32 y.o. female of 5 foot 5 inches and 165 pound stature referred to skilled therapy with history of approximately 8 years of chronic mid back pain. Insidious onset with pain being isolated to the T 4- T 9 area. Pt reports daily pain that is best in the am and progresses throughout the day, can interrupt sleep, and is eased by 50-75% with resting on the couch for 30 minutes. She has a sitting profession and sits between 7-10 hours per day including her commute. Negative x-ray findings. She reports seeing 3 bouts of previous skilled therapy that included chiropractic (x 1) and physiotherapy (x 2). She states she had approximately 50% improvement in pain and no improvement in functional level with all therapies. Therapies that she described included: thrust joint manipulation, passive modalities, active weight-bearing and isotonic exercises focused on the parascapular area as well as stretching for the anterior chest wall. Denies smoking and 1-2 alcoholic drinks per week. Exercise regimen was 1-2x/ wk walking 2-3 miles with her neighbor. Patient is right handed. She was referred to my office via community recommendation.
The patient was not in distress, did not fear her condition, and did not report any signs associated with depression. She believed that her posture as some inclusion in her symptom presentation and reported that movement, heat, and over the counter anti-inflammatories did help, although minimally. She had sought consult with a cosmetic surgeon regarding breast reduction on the recommendation of her primary care as there was the possibility of her pain being correlated to her breast endowment size. She stated she viewed this as a last resort and was not actively seeking this surgical direction at the time of the evaluation.
Objective findings included:
- Resting HR: 74
- BP 124/ 88
- Tenderness to palpation
- VAS 3-5/10 report of pain to the T 5- T 9 area
- Range of Motion
- AROM screen – Pt willing to move
- Flexion: WNL – 42*
- Extension: WNL – 35*
- Lateral Flexion: WNL – Bilaterally 25*
- Limited and painful AROM Thoracic rotation performed in sitting with arms crossed and arms stacked extended held at 90 flexion (measured with iPhone inclinometer
- L: Arms X- 24* w/ central pain. Increased pain w/ overpressure
- R: Arms X- 18* w/ left sided pain. Increased pain w/ overpressure
- L: Arms extended – 18* with central pain
- R: Arms extended – 15* with left sided pain
- Resistive strength testing
- General screen performed in sitting
- Parascapular testing performed in prone
- Horizontal ABD: L 4/5 without pain; R 4-/5 without pain
- 90/90 ER: B 4/5 without pain
- Prone 135: L 4/5 without pain; R 4-/5 without pain
- Functional Movement Assessment
- Apply’s Scratch test: WNL
- Full Forward Elevation: WNL
- Hands behind head: WNL
- Passive joint motion exam
- Pain R2 with Central PA pressures: T 5- T 9
- Pain R2 with Left Unilateral Pressures: T 5 – T 9
- Pain 1 with R 1 with R Unilateral Pressures: T 5 – T 9
- AROM screen – Pt willing to move
After review of subjective and objective findings, Mobilization with Movement as the first attempt to address her comparable sign of thoracic spine symptoms and was selected for three main reasons:
- She presented with no red or yellow flags
- Her symptoms presented in what can be deemed a “mechanical” environment. They would be produced, altered or changed; she was not in distress, and her symptoms were stable
- Her previous experience with treatment suggested not attempting the same types of treatment. But rather, attempting treatments that had not been applied or focused on different comparable signs.
Treatment was applied as explained in Manual Therapy: NAGS, SNAGS, and more. 6th edition.
Treatment Session 1:
The treatment choice was explained to the patient and she consented for treatment. Six repetitions of through the full active range were achieved with overpressure provided and accepted during each repetition for both right and left rotation in sitting. Immediate post-treatment reassessment demonstrated right thoracic rotation with arms crossed 35* and left rotation with arms crossed 38*. The patient was then instructed in AROM exercises for 5 repetitions bilaterally every other hour until her follow up appointment. PILL response was explained to the patient.
Treatment Session 2:
Upon return to the clinic, patient reported compliance with the above program and demonstrated full maintained AROM bilaterally for thoracic rotation with mild pain report at end range of right rotation. Her VAS report was 0-2/ 10 for the past 48 hours. Three sets of 10 repetitions of symptom-free motion MWM’s were applied to both right and left rotation. The patient was then shown a self MWM technique utilizing a belt to mimic the manual application. Instructions for five repetitions each direction three times per day were given.
Treatment Session 3:
Patient returns 1 week after treatment session 2 and reported compliance with the instructed HEP and no pain for the past 5 days in her thoracic pain during ADL and work activities. A parascapular program with resistive bands and isotonics were issued in clinic including resistive rows, prone horizontal ABD, prone 90/90 ER, and serratus push ups. All exercises were tolerated with fatigue only in the clinic.
Treatment Session 4:
The patient returned to the clinic in 2 weeks reporting good compliance with the HEP and 0/10 pain since the complete of treatment session 3. Re-evaluation demonstrated full resolution of all objective findings mentioned previously. Spoke with patient for more than 10 minutes regarding future maintenance of exercises, prolonged posture considerations, education on poor likelihood of correlation with breast tissue endowment and returning to skilled therapy as needed. She was then discharged to her established program.