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patients present with signs or symptoms of a visceral disorder
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and clinicians should refer patients for further diagnostic
assessment if uncertain if their origin is musculoskeletal in
nature.
Pain from a dissecting thoracic aneurysm is usually felt in
the chest and can radiate to the back if the descending aorta is
64,66
involved.
Pain is usually of sudden onset, often is unrelenting,
and is not relieved by position change. A dissecting aortic
aneurysm is a condition requiring emergent care due to the high
likelihood of mortality if this condition proceeds untreated.
Myocardial ischemia is accompanied by anterior chest pain
or heaviness, occasional nausea, and sometimes pain radiating
64
to the back.
Patients presenting acutely with this condition
require immediate medical attention. oracic or chest pain
may also be from exertional or variant myocardial ischemia,
also known as stable or unstable angina. In stable angina, pain
66
is related to exertion and relieved with rest.
Unstable angina
occurs in random or unpredictable fashion and is not related
to activity. Unstable angina is usually a progression of stable
angina and is a risk factor for pending myocardial infarction.
A clinical prediction rule was developed and validated to
67
rule out coronary artery disease in primary care.
Participants
were included in the study if they were greater than 35 years old
and reported anterior chest pain. e predictor variables in the
rule are: sex and age (female ≥ 65, male ≥ 55), known clinical
vascular disease (includes coronary artery, occlusive vascular,
and cerebrovascular diseases), pain worse during exercise, pain
not reproducible by palpation, and patient assumes pain is
of cardiac origin. e best overall discrimination, balancing
sensitivity and specificity, was presence of 3 predictor variables
with a sensitivity of 0.87 and specificity of 0.80, with a positive
likelihood ratio (LR) of 4.52. During external validation of
these predictor variables, the clinical predication rule was
89.1% sensitive.
67
A peptic ulcer of the posterior wall of the stomach or
duodenum can cause boring type pain from the epigastric area
to the middle thoracic spine. oracic pain either triggered
64
or relieved by eating is a sign of peptic ulcer disease.
Peptic
ulcer disease can result from prolonged use of nonsteroidal antiinflammatory drugs (NSAIDs). erefore, a history of extensive
NSAIDs use should raise suspicion for a peptic ulcer.
66
Pain from an inflamed gall bladder (cholecystitis) is usually
experienced in the right upper quadrant and right infrascapular
64
region.
e pain is often accompanied by a moderate fever,
nausea, and vomiting. Symptoms often occur 1 to 2 hours after
the ingestion of a heavy meal. e Murphy sign is performed
by palpating the right subcostal region and asking the patient
to take a deep breath. e sign is positive if the patient reports
68
pain with inhalation.
Patients with acute inflammation
of the pancreas (pancreatitis) can experience pain around
the thoracolumbar junction. Kidney or renal pain caused by
pyelonephritis (kidney infection) and renal stones is usually
66
referred to the costovertebral angle or flank area.
e flank
refers to the lateral region of the trunk between the rib cage
and iliac crest. Pain originating from the kidneys is typically
accompanied by fever, nausea, vomiting, and renal colic. Renal
colic is flank pain accompanied by lower abdominal pain
that spreads into the labia in women and into the testicles in
men. ose at risk for kidney infection either have a history of
urinary tract infections or currently have an ongoing urinary
tract infection.
Serious Causes of Thoracic Spine Pain
Pain from serious conditions emanating from the thoracic
spine includes infection, fractures, neoplasms, and inflammatory
disorders. Spinal metastases, usually secondary to a primary
breast, lung, or colon cancer, are the most common forms of
69
cancer in the thoracic spine.
Primary thoracic spine tumors
are less common. A previous history of a tumor in one of these
regions should cue the clinician to be mindful of potentially
non-musculoskeletal or serious pathologies in a patient with
thoracic spine pain.
69
Ozaki et al
reported on 22 cases of spinal osteoid osteoma
or osteoblastoma of which 6 were in the thoracic spine. Among
the common findings in these 6 cases were a painful scoliosis,
long-tract neurological signs, and leg pain. Deyo and Diehl
70
reported on 1975 patients in an outpatient primary care setting
with spinal pain of which 316 (16%) had thoracic spine pain.
Two (0.63%) of these patients had cancer as the cause of the
thoracic pain. is was similar to the 0.66% of cancer-related
pain for patients with LBP. Historical findings that carried the
most accurate diagnostic information for predicting cancer
were as follows: age over 50 (sensitivity 0.77, specificity 0.71,
positive LR 2.7, negative LR 0.32), history of cancer (sensitivity
0.31, specificity 0.98, positive LR 15.5), unexplained weight
loss (sensitivity 0.15, specificity 0.94, positive LR 2.5), and
failure of nonsurgical therapy (sensitivity 0.31, specificity 0.90,
positive LR 2.6). erefore, the greatest shift in probability of
cancer (positive LR 15.5) occurs when the patient reports a
history of cancer.
Ankylosing spondylitis is an inflammatory disease that can
affect the thoracic spine and rib joints. Ankylosing spondylitis
71
is estimated to have a prevalence of 0.18%.
Information from
the patient history can assist in guiding diagnosis. An initial
diagnostic criteria set was proposed with the following predictor
variables: morning stiffness of more than 30 minutes duration,
improvement in back pain with exercise but not with rest,
awakening because of back pain during the second half of the
72
night only, and alternating buttock pain.
is set was shown
to have reasonable diagnostic accuracy. If 2 of the 4 parameters
were fulfilled, the sensitivity was 0.70 and specificity 0.81. If
3 parameters were fulfilled, the sensitivity was 0.33 and the
specificity was 0.94. e key physical examination finding
implicating ankylosing spondylitis is limited chest expansion.
72
e normal expansion of the rib cage measured at the nipple
line is 5 cm. Chest expansion of less than 2.5 cm is considered
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17
pathologic. Other signs alerting the clinician to the possibility
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of ankylosing spondylitis include sacroiliitis, morning pain and
stiffness, and peripheral joint involvement. e ratio of those
affected by the disease is 3 to 1 for men to women, and age of
72
onset is between 15 and 40 years.
Ninety percent of patients
with ankylosing spondylitis are HLA-B27 positive. However,
only 10% to 20% of individuals who are HLA-B27 positive
develop ankylosing spondylitis; therefore, the false positive rate
for this test is high.
Infection is an uncommon cause of thoracic spine pain.
e pretest probability of infection as the cause of back pain in
63
general in the primary care setting is less than 0.01%.
Causes
of thoracic spine infection include osteomyelitis, diskitis, and
epidural injections. Fever is usually a hallmark sign in cases of
spinal infection.
Thoracic Vertebral Fractures
oracic spine pain secondary to fracture, can be divided
into traumatic fractures and osteoporotic fractures. Traumatic
fractures are usually a result of blunt trauma or injury.
Osteoporotic fractures represent an increasingly common
serious cause of thoracic spine pain in our aging patient
population. Osteoporosis is an age-related disorder characterized
by decreased bone mass and increased susceptibility to fracture.
Osteopenia is a generalized decrease in bone mineral density
appearing as excessive radiolucency on radiographs. Risk factors
for osteoporosis include Caucasian race, history of smoking,
early menopause, thin body build, sedentary lifestyle, steroid
treatment, and excessive consumption of caffeine or alcohol.
73
thoracic vertebral fracture was 6.2 per 1000 in men and 3.9 per
74
1000 in women.
e prevalence in men gradually increased
with age, and in women, it greatly increased over the age of
65. e majority of those with fractures in this study had no
symptoms despite having a fracture present. A hospital-based
study found that the majority of thoracolumbar compression
fractures occurred spontaneously or as a result of a trivial
75
e clinical implication is that in men or women age 60
strain.
or older presenting with acute thoracic spine pain, osteoporotic
fracture must be considered.
Vertebroplasty is minimally invasive and a commonly
used surgery to manage vertebral compression fractures.
Previously, it was thought that vertebroplasty had at least
short-term effectiveness in reducing pain and improving
function, but recent double-blind placebo-controlled trials
concluded that there was no significant difference between
vertebroplasty versus a sham procedure for pain, function,
disability, quality of life, and perceived improvement at 1- to
76,77
6-month follow-up.
ese results indicate that there is no
benefit of vertebroplasty over passage of time. A Cochrane
systematic review of 11 randomized clinical trials (RCTs) did
not recommend routine use of percutaneous vertebroplasty in
the management of osteoporotic vertebral compression fracture
78
regardless of the severity of a patient’s symptoms.
Although no
studies have directly compared surgery with physical therapy, it
is likely that physical therapy can serve as a low-cost alternative
to more invasive management, with little to no risk of serious
complications for patients with a stable fracture. ere is
currently limited evidence to guide nonsurgical management,
including exercise prescription, of patients who have sustained
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an osteoporotic vertebral fracture.
A pilot RCT compared
the effects of a multimodal physical therapy program to a
control group in 20 patients with a stable osteoporotic vertebral
80
compression fracture.
All patients were older than 50 and
had sustained at least 1 vertebral compression fracture between
the past 3 months and 2 years. e physical therapy program
took place once a week for 10 weeks. e program consisted
of education, postural taping, manual therapy, ROM exercises,
and back extensor strengthening. Manual therapy included
soft tissue massage and nonthrust grade II posterior to anterior
mobilization directed to the thoracic spine. At the completion
of the study, the physical therapy group reported decreased pain,
improved physical functioning, and displayed improvement in
physical impairments compared to the control group. No serious
adverse events were reported in the physical therapy group.
More research is needed to guide the nonsurgical management
of individuals with osteoporotic vertebral fractures.
CLINICAL EXAMINATION AND
DECISION-MAKING PROCEDURES
Diagnostic Imaging
Although requesting imaging studies is not currently
a standard part of most physical therapist’s practice, physical
therapists should be knowledgeable of when an imaging
study is indicated. In the absence of trauma, imaging of the
thoracic spine is indicated when investigating a serious cause
of thoracic spine pain. Individuals with acute thoracic pain
who are at risk for an osteoporotic fracture should have plain
63
radiographs to assess for the presence of a fracture.
In cases
where cancer or infection are suspected, MRI and bone scans
are typically the preferred initial imaging modalities due to their
high sensitivity in detecting these conditions. In the presence
of trauma, one guideline recommends plain radiographs for
patients with positive or equivocal clinical findings, such as
spinal tenderness and neurologic signs, and for those with
63
altered consciousness.
For those patients who are awake
and alert, and have no clinical findings, radiographs are not
indicated. In the absence of trauma or indications of serious
causes of thoracic spine pain, imaging studies, including MRI
and radiographs, are not useful in determining the source of a
patient’s pain. As discussed previously, MRI findings of thoracic
disc protrusions or degenerative disc disease are very common
29
in individuals without symptoms.
erefore, a routine MRI
for simple, mechanical thoracic spine pain is not warranted and
any supposed abnormal findings related to the thoracic disc on
MRI should be considered with these findings in mind.
18
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Patient History and Interview
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Patient profile and history of the current injury
e interview of the patient with primary thoracic spine
or rib cage related disorders should follow the same format
as for other musculoskeletal regions. Similar to other spinal
conditions, thoracic spine pain disorders can be associated
with trauma, such as a fall or motor vehicle accident, but more
commonly present without a history of trauma. Atraumatic
conditions may be associated with repetitive strain from workor sports-related activities such as those involving repetitive
trunk rotation as in golf and baseball. oracic pain aggravated
by static loading is not uncommon in students or sedentary
office workers who are required to sit for long periods of the day.
Older adults may develop thoracic spine pain with or without
trauma, and in particular, postmenopausal women are at risk
for thoracic spine compression fractures.
Area of symptoms and symptom behavior
As discussed in the pain mapping study section, thoracic
spine and rib cage pain has been reported to be experienced
in areas local to the involved thoracic spine or rib region.
21
However, this information is based on experimental studies
on asymptomatic individuals. Patients may report more vague
or distant referral of pain and this may become more likely in
individuals who have experienced pain for longer periods of
time. Some individuals with spinal pain may develop heightened
peripheral and central nervous system sensitization leading to
potentially more vague, less localized, and more widespread
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symptoms.
In terms of aggravating factors, patients may report
that sustained thoracic loading, such as prolonged sitting or
stooping, or thoracic spine movement, such as trunk rotation,
lead to an increase in their symptoms. Patients who have rib
cage involvement may report that respiration and either deep
inhalation or exhalation is associated with their symptoms.
Patients who have constant, unrelenting pain that is not affected
by position or activity and is not relieved with lying down may
potentially have serious pathology such as cancer or infection.
66
Furthermore, patients whose symptoms vary with the function
of other body systems such as decreased or increased thoracic
pain after eating or chest wall pain associated with physical
exertion should be considered as potentially having a nonmusculoskeletal cause of pain. e 24-hour symptom behavior
also provides an indication of the potential causes. For example,
patients who wake with little pain that increases throughout the
day, especially if their job involves sitting, may have more of a
postural or loading mechanism associated with their symptoms.
Patients who awaken early in the morning or the second half
of the night and report the most symptoms at that time,
including pain and stiffness upon waking, may have ankylosing
spondylitis.
72
Red flag screening questions
Patients with primary thoracic spine pain should complete
a medical screening form as part of the initial intake forms. e
clinician can review the form and then carefully question and
follow-up on any concerning items. Red flag items for cancer,
which is most likely to be bony metastases from a primary
cancer, such as breast or lung cancer, includes personal or
family history of cancer, recent significant unexplained weight
loss, unrelenting night pain, history of or current smoking, and
70
age over 50.
Red flag items for infection include fever, chills,
or night sweats; known recent infection such as pneumonia;
current intravenous therapy or drug use; and recent surgery.
Red flags for visceral or gastrointestinal disorders include bowel
or bladder dysfunction, abdominal pain, reflux, excessive use
66
of NSAIDs, and alcohol abuse.
Cardiopulmonary red flags
include chest pain or shortness of breath with physical exertion,
personal or family history of cardiovascular disease, and thoracic
or chest wall pain described as throbbing or associated with
pulsatile sensations. Indications of a potential fracture include
history of osteoporosis and osteoporotic fractures, history
of significant trauma, and prolonged use of corticosteroids.
Neurological symptoms indicative of thoracic cord compromise
from a space occupying lesion or disease of the central nervous
system, such as multiple sclerosis, include bilateral upper or
lower extremity and trunk paresthesias, weakness, and sensory
loss.
Psychosocial factors
Although not studied specifically for the thoracic spine,
patients with spinal pain frequently present with multiple
82,83
contributing factors to their particular disorder.
ese factors
can include cognitive factors such as fear of movement, negative
beliefs associated with their condition, and pain catastrophizing.
Patients with spinal disorders can also present with psychological
conditions such as excessive stress, depression, or anxiety. ese
factors have been associated with a poorer response to physical
therapy and are risk factors for developing chronic pain and
disability. Lifestyle and social factors potentially associated
with thoracic spine pain can include tobacco or alcohol use,
lack of physical activity, work-related stress, and family issues.
Screening questionnaires have been developed, although not
specifically for patients with thoracic spine pain, that may be
a useful first step in identifying psychosocial factors. ese
questionnaires, among others, include the Depression Screening
Questionnaire, the Fear-Avoidance Beliefs Questionnaire,
Tampa Scale for Kinesiophobia, and the Pain Catastrophizing
84
Using multiple questionnaires may be burdensome
Scale.
to the patient and time consuming; one alternative is to use
the STarT Back Screening Tool (SBT). e SBT is a 9-item
questionnaire that includes biomedical and psychosocial
questions targeting prognostic factors for the development of
chronic pain and disability for patients with LBP. Based on the
patient’s SBT score, they are stratified into low-, medium-, and
high-risk prognostic categories. ese categories can serve as a
way to triage patients into receiving minimal care (low risk),
usual physical therapy (medium risk), and psychologically
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19
informed physical therapy (high risk). is questionnaire has
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been used in primary care clinical research for individuals with
neck and low back pain, with this type of stratified level of
care leading to significantly better clinical outcomes and cost-
84
effectiveness compared to usual care.
From the results of the
questionnaires, the clinician can gain an initial impression as to
the extent of psychosocial factors present. It should be noted
that the SBT was developed and validated for patients with
neck or low back pain attending primary care; therefore, further
research is needed to determine if it can be used effectively for
thoracic spine pain. e psychosocial screening questionnaires
should be considered as a starting point for discussion of these
topics with the patient during the interview. Simply having
the patient complete the questionnaire should not take the
place of discussing the potential psychosocial factors with the
85
patient.
During the interview, the patient should be invited to
share their thoughts, feelings, and beliefs about their disorder
in addition to discussing any ongoing psychological, social, and
lifestyle factors and how these might impact current symptoms.
Patient expectations and goals
Patients present to physical therapy with a variety of
opinions about what might be wrong with them, whether
they will recover or not, and what they think might help them
to recover. ese thoughts and opinions should be directly
explored with the patient. For example, it is not uncommon for
patients, who have had imaging of their spine showing typical
age-related degenerative changes, to focus on the imaging
findings and have negative and unhelpful beliefs about the
implications of those findings. ese beliefs may have been
perpetuated by other medical providers, the patient’s friends
or family members, and media sources such as internet sites.
Some patients may then consider their spine as vulnerable and
easily prone to damage or injury, making their expectations
of and response to physical therapy less positive. Patients
may present with specific expectations about what they think
might help them to recover. ese expectations could be based
on past successful or unsuccessful treatment experiences or
opinion from other medical providers, family and friends, or
the media. For example, a patient might have experienced a
reduction in pain for a similar injury after receiving therapeutic
ultrasound and feel that ultrasound should be given for their
current injury. e patient’s specific goals for physical therapy
should also be discussed as part of a comprehensive history
and interview. In summary, discussing the patient’s thoughts,
beliefs, and expectations about their injury, projected recovery,
and expectations for treatment can provide very valuable and
useful information and begin to establish a therapeutic alliance
with the patient.
e psychosocial factors in addition to the patient’s
beliefs and expectations should be considered alongside of the
biomedical factors such as the current stage of the disorder,
the presence or absence of specific thoracic spinal pathology,
the hypothesized dominant pain mechanism, the patient’s
specific activity limitations or participation restrictions, and the
associated movement-related impairments. At the end of the
interview, the clinician should have an idea of the degree of
complexity of the patient’s disorder based on the consideration
of the multiple associated factors. At that stage, the therapist
should have formulated several diagnostic hypotheses, have a
direction in mind for conducting the physical examination, and
have preliminary ideas for potential interventions.
Physical Examination
Screening examination
Based on the patient’s history, a screening examination
can be used. Screening procedures for patients with thoracic
spine pain may include assessment of vital signs, abdominal
palpation, neurological examination, aortic pulse palpation
and auscultation, and chest auscultation. ese procedures,
aside from assessment of vitals, are not necessarily performed
routinely but may be used depending on if the patient history,
interview, and medical screening form indicates a potential need
for additional screening. e reader is referred to additional
resources for a full description of physical examination screening
procedures.
86
Functional examination
For patients with primary thoracic spine or chest wall pain,
it can be helpful to have them demonstrate a functional task(s)
that either increases their pain or they report as being difficult.
For example, for a golfer who reports thoracic spine pain during
their back swing, the clinician can have the patient mimic this
motion. e examiner can qualitatively assess the patient’s
movement and observe for the presence of aberrant motions,
altered breathing patterns, and guarding. e functional
assessment provides a means to recreate the patient’s symptoms,
analyze their movement patterns from a global perspective, and
tailor the examination to the patient. Functional examination
activities can be used to help design therapeutic interventions
and also serve as comparable sign that can be reassessed
following the intervention.
Observation
Global observation of the patient with thoracic spine pain
includes a scan of the patient’s posture. e reliability of postural
assessment in the CT spine has been studied by Griegel-Morris
87
ey visually assessed for the presence of a forward head
et al.
posture, the rounding of the right and left shoulders, and extent
of thoracic kyphosis against a plumb line. Using this method,
the intra- and inter-rater reliability across 3 therapists was κ =
0.825 and κ = 0.611, respectively. e primary purpose of the
study was to assess the association of postural abnormality and
a history of pain. In this group of 88 individuals aged 20 to 50
years, a relationship between pain frequency and severity and the
extent of postural abnormalities was not found. However, there
20
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was a significant increase in the incidence of pain, including
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interscapular pain, in individuals with the most severe postural
abnormalities. e majority of individuals displayed posture that
is traditionally considered abnormal, including a forward head
position (66% of participants), kyphosis (38%), right rounded
shoulder (73%), and left rounded shoulder (66%). In a smaller
88
study, Refshauge et al
did not find an association between CT
posture and pain. Based on this research, a clinician should
carefully consider whether an individual’s posture is relevant
to their current complaints as the link between thoracic spine
posture, pain, and injury is unclear.
One method to assess the potential influence of thoracic
spine posture on a patient’s chief complaint is using a symptom
89
modification procedure (SMP).
An example of an SMP is a
patient with an increased thoracic spine kyphosis who reports
thoracic pain at rest with sitting. e clinician can use either
active or passive (athletic or elastic tape) modification to
encourage a preferred thoracic spine posture and assess the
effects on the patient’s symptoms during the painful activity or
comparable sign. If the patient notes a reduction in symptoms,
this can help to confirm that the intervention will be useful for
this particular patient.
With the increased incidence of thoracic hyperkyphosis
due to osteoporosis and aging and the link between this
postural abnormality and function, it may be important to have
clinically efficient means of measuring thoracic kyphosis. One
such method is the use of 2 inclinometers placed over T1-2 and
90
T12-L1.
e higher location, T1-2, is identified by moving
down from the most prominent cervical spinous process, which
is assumed to be C7. e lower location, T12-L1, is found by
first identifying L4 spinous process at the level of the iliac crests
and counting-up from there. e patient is asked to stand in a
relaxed comfortable posture and the base of the inclinometers
are placed over T1-2 and T12-L1. e sum of these 2 angles is
a gross measure of thoracic kyphosis. is method has good to
excellent within and between rater reliability. For best reliability,
it is recommended that the measurement be performed 3 times
with an average of the 3 measurements used for recording.
e reference standard for measuring thoracic kyphosis is the
Cobb angle as seen on a lateral thoracic spine radiograph.
Hyperkyphosis is said to be a Cobb angle of greater than 50°.
e validity of the dual inclinometer method compared to the
Cobb angle requires further study.
Active range of motion
Patterns of active ROM impairments and pain provocation
at end range are helpful in determining diagnostic categories
and treatment interventions. Active ROM of the thoracic spine
is performed with the patient seated with the arms crossed in
front over the chest, preferably with their feet firmly on the floor.
In performing these procedures, the clinician will attempt to
determine the ROM present in each direction and the behavior
of the patient’s symptoms during and immediately following
the evaluated movement. e patient forward bends, backward
bends, side bends to the right and to the left, and rotates to the
left and to the right. e patient may require verbal or manual
lumbar spine and pelvis. If the patient reports no pain with
the active ROM, the clinician can provide passive overpressure
at end range to assess for both symptom response and end
feel. In addition to cardinal plane ROM, the clinician can also
use combined ROM. Combined motions are used when the
clinician is unable to reproduce the patient’s symptoms with
cardinal plane ROM. Combined motion quadrants include
flexion or extension with combined right or left rotation and
side bending. e patient actively performs these motions with
guidance from the clinician and the clinician may provide
overpressure at end range as needed. e clinician should also
consider using a combined motion if the position is similar to
a functional position during which the patient reports pain.
For example, if the patient is a right-handed tennis player and
reports middle-thoracic pain while reaching for an overhead
shot, the clinician could assess combined thoracic extension
with right rotation and left side bending.
Measuring thoracic range of motion
ere is moderate reliability for the quantification
of forward bending and right and left side bending using
91
inclinometers.
When using inclinometers for ROM
measurements, the examiner locates and marks the T1 spinous
process and places the inclinometer at the mark and zeros it.
To find the spinous process of T1, the examiner should first
locate C7 and move down a segment. To find C7, palpate
the lower cervical spinous processes while the patient actively
extends their neck. e spinous process that moves away from
the palpating finger is C6 and the one that stays stationary
below is C7. e examiner stabilizes the inclinometer against
the patient’s trunk with the thumb and index finger while
their remaining fingers rest on the upper trunk. e ROM is
measured for forward bending, backward bending, and right
and left side bending. e therapist can determine the ROM
and note any change in the patient’s symptoms resulting from
movement. e sequence is repeated with the inclinometer
located over the T12 spinous process. To measure rotation,
the patient assumes a quadruped position with the knees and
elbows at 90°, sitting back on the heels, the cervical spine in
neutral, and the hand of the direction to be measured placed on
top of the cervical spine. An inclinometer is placed over T1-2
level and the patient rotates as far as possible while the amount
of rotation is recorded. e standard error of measurement for
this procedure is 2° and the minimal detectable change is 6°.
Normative values for clinical measurement of thoracic spine
motion have not been investigated. e therapist needs to
clinically reason whether the patient has the requisite range of
thoracic motion to perform their individual functional tasks.
Additionally, measuring thoracic ROM along with associated
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21
symptoms at baseline and then after intervention can alert the
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clinician to objective changes in ROM and associated symptoms
and the potential success of the intervention. Although not
studied for the thoracic spine, clinical research has shown that
increases in cervical ROM within a treatment session predict an
increase in cervical ROM between treatment sessions.
92
Assessing for centralization
In addition to recording the ROM, it is important to
ascertain the effect of each movement on the patient’s status.
e patient’s status change with movement is assessed using
the following terms: peripheralizes, a neurological sign or
paresthesia is produced or the patient’s paresthesia or pain
moves distal to the thoracic spine, and the pain can radiate into
the upper or lower extremity, or wrap around the rib cage to
the anterior aspect; centralizes, a neurological sign is improved,
or paresthesia or pain is abolished or moves from the periphery
toward the thoracic spine; status quo, symptoms may increase
or decrease in intensity but do not centralize or peripheralize
and remain unchanged from the baseline assessment. e
judgment of a status change with movement testing may be an
important component for classifying patients. e presence of
centralization is a positive prognostic indicator in LBP and is
93
used in the cervical spine region as well.
e prevalence of
the centralization sign in patients with primary thoracic spine
pain has not been studied. A survey study of clinicians trained
in the McKenzie Mechanical Diagnosis and erapy (MDT)
system reported that the most common treatment direction
94
for individuals with thoracic spine pain was extension.
In
upper extremity symptoms and may have findings of weakness,
sensory loss, or reflex changes on the neurological examination.
95
Wainner et al
developed a test-item cluster that can assist the
clinician in determining the presence of a cervical radiculopathy.
e 4 items in the test-item cluster include cervical rotation
ROM to the painful side of less than 60°, a positive Spurling
A test, a positive upper limb neurodynamic test (ULNDT) A
(median nerve bias), and a positive cervical distraction test.
Positive findings on all 4 tests produce a positive LR of 30.3
for the presence of a cervical radiculopathy as determined
by positive electrodiagnostic testing. ree of 4 positive tests
produce a positive LR of 6.1. Furthermore, the ULNDT-A was
the single most sensitive test (0.97), with a resultant negative
LR of 0.12. erefore, a negative ULNDT-A effectively rules
out cervical radiculopathy.
Screening of other adjacent body regions
In addition to the cervical spine, the clinician may choose
to scan additional body regions for patients with primary
thoracic spine pain. is could include the upper extremities
and shoulder girdle, lumbar spine, pelvis, and lower extremities.
Hypotheses for involvement of adjacent regions may come
from the patient’s history, the patient’s specific functional or
movement related complaints, and the functional examination.
For example, if a patient’s chief complaint is mid-thoracic pain
involving trunk rotation, a clinician may elect to examine other
structures involved in whole body rotation (eg, the patient’s
hip rotation) to determine if an impairment in an adjacent
region is related to the chief complaint and overall movement
dysfunction.
patients and lateral (side) bend or rotation for 15% of patients
with thoracic spine pain who were classified in the derangement
category. It is important to note that this was a survey only,
no patient outcomes including the presence or absence of
centralization were reported, and all therapists were trained to
the credentialed level in the MDT system.
Cervical spine screening
Symptoms in the upper to middle thoracic spine may be
referred from the cervical spine. It can therefore be difficult
to differentiate between the lower cervical and upper thoracic
spine as the source of the patient’s symptoms. e clinician
should screen the cervical spine with active ROM testing,
repeated motion testing, and accessory mobility testing such
as posterior to anterior spring testing over the cervical spinous
processes and articular pillars. If the patient’s upper thoracic or
scapular symptoms are reproduced or decreased with cervical
ROM, repeated motion testing, or accessory mobility testing,
the symptoms are likely originating from the cervical spine. e
reader is referred to the cervical spine monograph for further
information on evaluation of the cervical spine. Patients with
upper thoracic and interscapular pain can also have a cervical
radiculopathy. Patients with cervical radiculopathy often report
Segmental examination of the thoracic spine
e physical therapist has several examination systems
and models to consider when assessing segmental motion or
segmental dysfunction in the thoracic spine. It should be noted
that in general, spinal segmental motion palpation procedures
96
have poor to fair reliability. Christensen et al
assessed the
reliability of a manual examination of the upper thoracic
spine by 2 experienced chiropractors. Participants included 29
patients with stable angina pectoris and 27 controls. Palpation
assessment, including seated and prone accessory motion
restriction and palpation for segmental paraspinal tenderness,
was performed from T1 through T8. Intrarater reliability was
superior to interrater reliability, and reliability for assessment of
tenderness was superior to motion palpation. For tenderness,
kappa scores for intrarater reliability were 0.63 to 0.77 and
for interrater reliability were 0.67 to 0.70. Kappa scores for
interrater reliability for motion palpation were 0.24 and 0.22
for the seated and prone examination, respectively, and ranged
from 0.59 to 0.68 for intrarater reliability. In a study involving
individuals without symptoms, reliability of segmental mobility
testing of the thoracic spine and ribs improved when an
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expanded definition of agreement was used.
e authors of
this study reported that most of the errors in measurement
22
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came from accurately identifying the same thoracic vertebral
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segment. In the expanded definition of agreement, the authors
allowed for agreement within and between raters to within ±1
thoracic vertebral level. More research is required; however,
one could conclude that reliability within and between raters
for thoracic segmental mobility testing is improved when
assessment is based on a region of the thoracic spine rather than
a specific segment.
e poor to fair reliability of the segmental examination
does not necessarily make these procedures obsolete or not
useful. Models or systems of manual therapy examinations allow
the therapist to assess spinal regions and, when coupled with
the history, form the basis of a movement–impairment-based
diagnosis. Furthermore, as part of a complete examination,
manually palpating tender areas and recreating the patient’s
pain can provide some therapeutic reassurance to the patient.
However, the authors caution that explanation of any palpation
findings during the examination should be made using simple,
non-threatening language. Given the research evidence, it is
highly unlikely that positional faults of the spine can occur.
Use of language or diagnostic terminology that equates spinal
alignment and position with pathology could potentially lead to
increased fear avoidance and pain catastrophizing.
During the first step in the thoracic spine segmental
examination, the therapist assesses for tenderness and tissue
reactivity by palpating the patient’s spine in the medial gutter
between the spinous process and the transverse process, from T1
to T12. Segmental mobility testing of the thoracic spine is then
performed with posterior to anterior spring testing, conducted
with the patient prone. e clinician screens the thoracic spine
for mobility and pain by applying their hypothenar eminence to
the thoracic spinous process and producing a graded posterior
to anterior force. e examiner records the presence or absence
of pain and notes whether mobility is perceived as normal,
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hypomobile, or hypermobile for each thoracic segment.
e
clinician can spring unilaterally over the region of the thoracic
transverse processes in a similar fashion using their thumbs.
Segmental examination of the chest wall
Chest wall range of motion
oracic spine ROM as described above also involves rib
cage motion. In addition to those tests, the clinician can also
assess rib cage ROM visually and manually as the patient is
breathing. Assess the first rib by sitting at the head of the table
with the patient lying supine. e therapist’s palpating fingers
should be just inferior to the sternoclavicular joint. Instruct
the patient to take a deep breath and then exhale completely.
Monitor the motion for right to left symmetry and for the
presence of pain. Perform a similar assessment on the remaining
rib segments by standing at the side of the patient and testing
the remaining ribs in groups: upper (ribs 2-5), middle (ribs
6-10), and lower (ribs 11-12). For the upper and middle ribs,
the examiner can assess both the bucket-handle and pumphandle motions. is is accomplished by placing the fingertips
on the lateral aspect of the ribs for the former and the anterior
aspect for the latter, while the patient fully inspires and then
expires. Recall that ribs 11 and 12 move in a caliper fashion.
To assess ROM of these ribs, the examiner palpates the lateral
aspect while the patient fully inspires and expires.
Rib cage static positioning and segmental mobility
Following the general assessment of overall rib cage
ROM, the ribs are palpated for tenderness and symmetry
anteriorly at the costochondral junction and posteriorly at
the rib angle and the intercostal spaces. Rib cage dysfunction
may present with tenderness at the rib angle, pain or reduced
or increased movement during inspiration or expiration, and
pain with spring testing over the involved rib(s). e ribs may
be assessed for segmental mobility and pain using posterior to
anterior spring testing with the patient prone. Using a crosshanded technique, the clinician stabilizes the opposite side of
the thoracic spine with their hypothenar eminence positioned
lateral to the spinous process and springs over each rib, just
lateral to the transverse process, using the hypothenar eminence
of their opposite hand. e clinician can also perform passive
accessory mobility of the anterior ribs by springing in an
anterior to posterior direction over the costosternal joints using
their thumbs. e clinician records the presence or absence of
pain and notes whether mobility is normal, hypomobile, or
hypermobile for each rib.
First rib testing using the cervical rotation lateral flexion test
First rib dysfunction can be present in many upper
quarter clinical syndromes. e cervical rotation lateral flexion
(CRLF) test is an additional method that has been reported to
assess for the presence of an elevated first rib in patients with
53
brachialgia.
e test is performed with the patient in a sitting
position. e cervical spine is rotated passively and maximally
away from the side being tested (rotation to the right to test the
left side) (Figure 1). In this position, the cervical spine is gently
side bent as far as possible, moving the ear toward the chest. A
test is positive when the side bending movement is limited or
blocked. A reduction of side bending mobility is suggestive of
an elevated first rib on the side opposite from which the cervical
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spine was rotated. Lindgren et al
reported excellent interrater
reliability (κ = 1.0) and good agreement with findings from
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cineradiography (κ = 0.84). Lindgren et al
suggest that the
cervical side bending movement during this test is limited due to
the transverse process of T1, on the contralateral side, contacting
and being blocked by the relatively superior positioning of
the first rib. However, additional and independently verified
research is required to substantiate this claim.
Multifactorial Clinical Diagnosis
It is recommended that the diagnosis and evaluation
of patients with spinal disorders is approached from a
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biopsychosocial multidimensional framework.
For the patient
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23
Figure 1.
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e Cervical Rotation Lateral Flexion Test
Assessing the Left First Rib
with thoracic spine pain, the first step for the clinician, is to
consider whether a specific pathology is present that could
influence the management of the patient. For example, a patient
presenting with multiple signs or symptoms of serious or visceral
pathology would best be referred for additional diagnostic
work-up and medical management. Patients with specific
musculoskeletal thoracic spine disorders, such as osteoporotic
vertebral compression fractures, will benefit from physical
therapy management and the specific pathology will guide or
inform the management of that patient. But, the majority of
spinal disorders, including those involving the thoracic spine,
are deemed as nonspecific. is implies that there are no serious
conditions or relevant pathology that will directly inform the
management of the patient.
Another important factor is the current stage of the
disorder. Acute to subacute spinal conditions tend to have a
favorable recovery, and in the acute stage, physiological tissue
healing timeframes should be considered. Chronic disorders,
often regarded as existing for more than 12 weeks, may have a
less favorable prognosis for natural recovery, have more complex
central pain mechanisms, and tend to involve more psychosocial
factors.
e hypothesized dominant pain mechanism involved
in the patient’s disorder may also guide management. ree
proposed categories include peripheral neurogenic, peripheral
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nociceptive, and nociplastic.
Peripheral neurogenic conditions
involve direct injury or pathology of the peripheral nervous
system such as radiculopathy. is type of pain mechanism
is relatively uncommon in the thoracic spine. Peripheral
nociceptive refers to conditions in which nociceptive signals
from peripheral tissues are the dominant driver of the disorder.
Patients with peripheral nociceptive pain present with more
discrete regions of symptoms and mechanically patterned
symptom behavior. Patients with nonspecific thoracic spine or
rib cage pain seem to most often have this as the dominant pain
mechanism. A small minority of patients may present with a
dominant pattern of nociplastic pain. e term nociplastic is the
term currently used by the IASP instead of central sensitization.
Currently, the term nociplastic is not widely adopted and central
sensitization may be used more often. Nociplastic pain (or
central sensitization) can have many definitions. In this clinical
model, it refers to the pain mechanism in which the patient’s
symptoms are predominantly perpetuated and mediated within
the central nervous system. Patients with dominant nociplastic
pain tend to report less discreet and more widespread pain
of a more constant or unpredictable pattern in addition to a
host of additional comorbid symptoms such as sensitivity to
temperature, smells, chemicals, or light; extreme fatigue;
gastrointestinal complaints; and mental health disorders. It
is important to note that all pain, regardless of the stage or
region of the disorder, will involve both peripheral and central
pain mechanisms. Patients can present with findings along a
spectrum from peripheral to more central. However, it can be
helpful, for the purpose of guiding management, to hypothesize
as to the patient’s dominant pain mechanism.
Cognitive and psychological factors are important
considerations for all patients with pain. Negative beliefs,
worrying thoughts, or emotional distress may all serve as barriers
to recovery or factors that could add to the sensitization of the
patient’s condition. Psychological factors such as depression, fear
of movement, and pain catastrophizing are also potential risk
factors for poor recovery especially if all 3 factors are involved.
83
In addition, social, work, and lifestyle factors should be
considered as part of the multifactorial clinical diagnosis. A high
stress job, family or marital issues, sedentary lifestyle, substance
abuse, and poor sleep have all been found to be potentially
associated with a poor recovery from a pain disorder.
Finally, the specific movement-related impairments
found during the physical examination will also contribute
to the multifactorial diagnosis. In the thoracic spine, due
to the anatomy and function, impairments or restrictions
of movement seem to be most common. Patients who are
fearful of movement or loading their spine can present with
movement-related behavior such as guarding and breath
holding that leads to a restriction in movement. It is important
to note that a significant functional movement involving the
thoracic spine and rib cage is respiration. Restriction of thoracic
spine and rib movement during respiration can be an important
and potentially functionally disabling impairment. Another
common impairment is a postural loading impairment,
where the individual becomes sensitized to static loading (eg,
prolonged sitting) as a result of a posture that tends to load the
spine toward its end of range. Motor control impairments seem
to be less common but can occur after traumatically induced
24
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thoracic spine injuries or be associated with repetitive activities
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such as sports or job-related tasks. Individuals with motor
control impairments do not usually present with a restriction
of movement in the direction that increases their pain and
may present with aberrant motions or demonstrate frequent
loading in end range positions during the functional movement
examination.
In formulating the clinical diagnosis, the therapist will
consider all relevant factors as described above. A targeted, goaloriented intervention program that addresses the modifiable
factors can then be formulated. Particularly for those patients
with more chronic and complex disorders, constructing a
pictorial diagram of the multiple factors involved can be helpful
as a discussion and teaching tool.
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CONDITION-SPECIFIC EVIDENCE-BASED
REHABILITATION CONCEPTS
A patient-centered, individualized rehabilitation program
for people with primary thoracic spine is recommended. Similar
to neck pain and LBP, the majority of primary thoracic spine
conditions do not involve a specific pathobiological diagnosis.
For individuals with these nonspecific thoracic spine disorders,
the range of factors discussed in the examination section need to
be considered in developing a plan of care. For individuals with
specific thoracic spine disorders, the same factors are considered
in addition to potential multidisciplinary management for
diagnostics and treatment.
Primary Thoracic Spine Disorders and Rib Cage
Pain with Low to Medium Risk of Prolonged Pain
and Disability
Individuals with mechanically-patterned acute to subacute
pain and without significant psychosocial factors or signs of
central sensitization can be considered low to medium risk of
prolonged pain and disability. ey are expected to respond well
to a rehabilitation program of education and advice, exercise,
and potentially manual therapy. Education and advice should
include reassurance of a positive prognosis and guidance to
remain active as tolerated. Depending on the acuity and severity
of the complaints, temporary activity modification may be
recommended to allow sensitized or overloaded tissues in the
thoracic spine to recover. For patients with primary impairments
of movement due to pain and or stiffness, exercise and manual
therapy interventions are devised to target these impairments in
movement. Specific exercise and manual therapy interventions
are outlined below. For individuals with primary symptoms
associated with static positioning or loading, impairments in
movement may also be addressed. Additionally, these patients
may benefit from advice to alter and vary their posture and
positioning throughout their day and activities. Patients who
are load sensitive can also benefit from resistance exercise to
progressively load their spine and supporting musculature to
increase strength, endurance, and load tolerance.
Primary Thoracic Spine Disorders and Rib Cage Pain
with High Risk of Prolonged Pain and Disability
People in the high-risk category tend to have a greater
extent of psychosocial factors (depression, fear of movement,
pain catastrophizing) and may have signs of central sensitization
(non-discrete, widespread pain; non-mechanically patterned
pain; sensitivity to temperature, light, smells; co-morbid
gastrointestinal distress). Personal and lifestyle factors such
as job stress, family stress, poor sleep, poor diet, and lack of
exercise/activity may also be involved. ese patients may also
display more maladaptive movement behaviors such as trunk
muscle co-contraction/guarding, breath holding, avoidance
of certain movements or positions, and rigidly held postures.
Individuals deemed high risk may benefit from more intensive
education, including a discussion about the multiple factors
involved in their pain, in addition to pain neurophysiology
education. is should include a candid discussion about the
influence of the specific multiple factors on the patient’s pain
experience and how these factors continue to lead to a cycle of
pain and poor recovery. is cognitive intervention can take
place across multiple treatment sessions, should be tailored to
target the patient’s specific factors, should consider the patient’s
individual learning style, and can be facilitated by diagrams,
videos, and written materials. Although not researched for the
thoracic spine, this type of education has been shown to lead
to favorable outcomes in patients with chronic spinal disorders
when used alongside more traditional physical therapy such as
100
manual therapy and exercise.
Multidisciplinary referral may
be useful including to mental health counseling and medical
physicians for pharmacological management or diagnostic
work-up. Exercise interventions may be directed toward
reducing the maladaptive movement behaviors by addressing
general relaxation through diaphragmatic breathing and graded
exposure type exercise program to address avoided and painful
movements and activities. Manual therapy may be considered
for pain modulation, but care would be needed for individuals
displaying significant mechanical hypersensitivity (allodynia) or
reporting previous poor response to manual therapy.
Rehabilitation for Older Adults
with Thoracic Spine Disorders
Older adults with vertebral compression fractures are at
significant risk for subsequent fractures and further morbidity
and mortality. Due to the increasing incidence of osteoporotic
vertebral compression fractures and also increased thoracic
kyphosis in older adults, research has been conducted on
exercise interventions for these conditions.
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Based on this
research, it appears that exercise programs involving spinal
extensor musculature strengthening, upper and lower quarter
stretching, postural awareness exercises, balance activities, and
thoracic spine mobilization exercises have led to improvements
in pain, health-related quality of life, strength, thoracic spine
posture, and thoracic spine mobility. ese programs have
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25
involved both individual and group exercise programs and have
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generally been of short to medium time duration. e challenge
is to identify cost effective means by which individuals with
age-related thoracic spine disorders can maintain a long-term
exercise program. A recent, large scale RCT assessed the effects
of a manual therapy program, exercise program, or a single
session of physical therapy with advice. e authors reported
improvement in the primary outcome measures of pain, selfreported function, and the Time Loaded Standing (TLS) test of
back muscle endurance in the groups receiving manual therapy
or exercise compared to a single physical therapy session at 4
months but not at 12 months. An example of an exercise is the
102
prone trunk lift (Figure 2).
In this exercise the patient lays
prone with a pillow placed under the abdomen. e patient
lifts the chest up and squeezes the shoulder blades together and
holds this position for 5 seconds. e exercise is performed for
10 repetitions daily and can be progressed using a weighted
backpack. In an RCT involving postmenopausal women, this
exercise was performed daily, and results showed a reduction
in the incidence of vertebral fracture at 10-year follow-up. In
addition to a rehabilitation program, individuals with thoracic
vertebral compression fractures should undergo diagnostic
work-up to assess bone mineral density and vitamin D levels, to
determine if pharmacotherapy to address bone mineral density
and vitamin D or calcium supplementation is needed.
Chest Wall Pain
Individuals reporting chest wall pain can present a
diagnostic challenge. Non-musculoskeletal conditions including
cardiac, pulmonary, inflammatory, infectious, cancerous, and
visceral should be considered as part of a medical screening
process. Individuals with musculoskeletal chest wall pain often
report pain along the involved rib cage area and the costosternal
or costochondral region. If these symptoms arise after trauma,
such as a motor vehicle accident or other blunt force, and there
Figure 2.
oracic Spine Extensor Muscle
Strengthening
is specific tenderness over a bony rib area then a rib fracture
should be considered with appropriate referral for radiographs.
Chest wall pain can arise after a chest infection involving
significant coughing and resulting in pain along the costosternal
region. Chest wall pain can also arise insidiously or after repeated
loading from athletic or occupational activities. If the pain is
unilateral and involves a specific upper rib (typically the second
or third) and there is visible swelling at the costosternal region,
103
it is often diagnosed as Tietze syndrome.
If it is bilateral or
involving multiple ribs without swelling, it is often diagnosed
as costochondritis.
For individuals with chest wall pain from repeated loading,
especially if they report a rapid increase in activity level over
a short period of time, a rib bone stress injury should be
considered. Rib bone stress injuries are not uncommon in elite
rowing athletes due to the amount of force placed on the rib cage
and the thousands of loading cycles occurring with rowing.
104
Individuals with rib bone stress injuries, aside from this specific
history, will have specific rib bony tenderness with palpation
and compression over the involved rib region. is most often
affects the 6th rib in the mid-axillary line region. Referral for
imaging should be considered if suspected and imaging may
include radiographs, bone scans, and MRI.
Slipping rib syndrome causes pain in the lower chest wall,
usually the 9th or 10th rib, and is most common in children
103
and young adults.
e typical presentation is a young female
involved in athletics who reports lower, anterior chest wall pain
that is sharp and may involve a clicking sensation. Slipping rib
syndrome is thought to arise from injury to the interchondral
fibrous attachments causing the involved rib to slip under the
superior rib resulting in pain and possibly irritation of the
intercostal nerve. A ‘hooking maneuver’ has been described
in the diagnosis of slipping rib syndrome. With the patient
supine, the clinician attempts to hook their fingers under the
lower anterior costal margin and pulls anteriorly (Figure 3).
A positive test is reproduction of the patient’s symptoms and
possibly a painful click. e hooking maneuver has not been
researched so its diagnostic accuracy is unknown.
Finally, chest wall pain can arise after thoracic surgery such
as coronary artery bypass or thoracotomy. Individuals who have
undergone these procedures often report chest wall pain of
varying severity and rehabilitation for post-surgical chest wall
pain is likely underutilized despite its potential benefits.
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Rehabilitation for chest wall pain should consider the
stage and irritability of the disorder. For individuals presenting
with more acute and irritable conditions, interventions should
involve activity modification to unload sensitized and healing
tissues and gentle thoracic mobility exercise with an emphasis
on incorporating breathing to mobilize the ribs. Manual
therapy treatment directed toward the involved ribs can be
considered but often targeting the thoracic spine at this stage is
better tolerated and can lead to adequate pain modulation. As
symptom severity and irritability decrease, direct mobilization
26
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