Editor's Note: In part 1 (April issue), Dr. Heller discussed other areas he suggests evaluating when dealing with chronic thoracic pain.
6. Postural Distortions
Many patients have an anterior carriage of their head and their shoulders are rotated forward. Even if this is not the singular cause of their pain, correcting this can improve their pain patterns. I say to these patients, especially the older ones, "Even a 10% change in your posture may make a significant change in your pain pattern."
7. Scapular Motion
By the time you see a chronic thoracic patient, their scapular motion is disturbed. Their scapula is not gliding smoothly over the rib cage. Correcting this dysfunction involves restoring endurance, strength and mobility to the scapula area.
This correlates with Janda's upper crossed syndrome, with tightness of the levator scapula and pectorals, and weakness of the middle trapezius and serratus anterior. If the shoulder on the symptomatic side is depressed, look for a weak upper trapezius, which allows downward scapular rotation.
8. Muscular or Fascial Knots
Significant muscular or fascial knots are often found in the infraspinatous, teres minor, subscapularis and pectoral muscles.
9. Viscero-Somatic Referral
My filter is the French osteopathic technique, visceral manipulation. Yours may be acupuncture meridians or another reflex system. However you assess, look for connections to visceral organs and their function.
The common patterns I find include a lack of motion of the pericardium (the sack around the heart). For right-sided thoracic pain, common patterns include liver, gallbladder, and bile duct problems. For left-sided thoracic pain, gastro-esophageal problems (functional hiatal hernia) or any stomach / esophageal irritation may be present. The pleura of the lungs can impact function of the intercostal region.
Cautions: Working on Sensitive Areas
I always use proper caution in approaching any sensitive area, which includes the anterior chest wall. I tell the patient what I am going to do and why I am going to touch their chest. I ask their explicit permission, and I ask them to tell me if my touch feels inappropriate, unsafe or not OK.
Another useful tip: If the area where you need to work is under the breast, use body positioning (such as side-lying) and the patient's own hands to get the breast tissue out of the way.
Expand Your Search
If the patient is not responding, expand your search! In this article and the previous one, I've outlined a series of patterns, a laundry list, to assess. Do you have a written or unwritten algorithm? Can you touch the pain? Use provocation testing, both through functional testing and palpation for tenderness, as indicators.
On palpation for a tender point, be as specific as possible. Is it the side of the spinous process; is it over the transverse? Is it more lateral, over the rib-vertebrae junction? Mark the spot. However you mark it, recheck it in the same body position as the skin moves. Don't blindly trust your AK muscle testing or leg checks. Intuition is great, but back it up with more concrete evidence. Remember that same-session changes are most significant.3-4
Do not assume the fifth or 10th adjustment of the same painful place is going to change the pattern. If you are releasing the same muscles over and over, you are not likely to get a different response. Do your corrections, whether they are adjustments, soft-tissue release and/or exercises and patient movements. And recheck your indicators.
When you are dealing with a chronic pain patient, you rarely will have a one-session, one-cause fix. You are building a picture of the whole pattern. As always, find a way for the patient to reinforce your work via self-mobilization and exercise. Any chronic pattern is just that: an ongoing pattern of how they have gotten used to using their body. Help them change the pattern.
References
3. Tuttle N. Do changes within a manual therapy session predict between session changes for patients with cervical spine pain? Aust J Physiother, 2005;20:324-330.
4. Tuttle N. Is it reasonable to use an individual patient's progress after treatment as a guide to ongoing clinical reasoning? Aust J Physiotherapy, 2009;32:396-403.
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