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21.1, CERVICAL AND THORACIC PAIN:
EVIDENCE FOR EFFECTIVENESS OF PHYSICAL THERAPY
Table of Contents

ORIGINS OF CERVICAL PAIN

Abstract:

CONTENT: The authors introduce the readers to the morphology and innervation patterns of pain-producing anatomical structures within the cervical spine. During their discussion, they emphasize the diagnostic challenges of identifying pathoanatomic causes of nonspecific mechanical neck pain within the normal aging and degenerative process of the cervical spine. The authors then detail clinical presentation, diagnostic criteria, and review the concept of convergence as the proposed mechanism for referred pain and cervicogenic headaches. The next section of the paper discusses traumatic cervical pain, specifically whiplash associated disorders, cervical instabilities, and cervical fractures. The unique clinical presentations of cervical radiculopathy and myelopathy are then highlighted. The identification of nonmusculoskeletal causes for cervical pain and characteristic “red flag” signs and symptoms associated with each disorder are evident throughout the monograph. CASE ANALYSES: Two case studies complete the monograph. The first case study involves a 22-year-old female who presents with a chief complaint of acute neck pain. The second case involves a 67-year-old, African-American male, referred to physical therapy for cervical and periscapular muscle strain with accompanying upper extremity paraesthesias that has an underlying source of nonmuscular neck pain. Both cases use the Guide to Physical Therapist Practice format in framing and managing each case.

Keywords:​

differential diagnosis, spine, disease

References:​

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ORIGINS OF THORACIC PAIN

Abstract:

CONTENT: In the monograph, Ms. Goodman systematically details the Goodman/Snyder Screening model in evaluating thoracic pain. This 5-step screening process serves as an efficient method of directing and streamlining a therapist's decision-making process to quickly identify key data to aid in determining whether treatment, referral or consultation, or treatment and referral/consult is indicated. Ms. Goodman then discusses yellow and red flag findings and how they may assist the clinician in understanding the etiology of thoracic pain. Subsequently, the author details pain patterns referred to the upper back originating from each visceral organ system including cardiovascular, pulmonary, renal, and gastrointestinal. The information ultimately allows the therapist to interpret pain symptoms with a greater degree of confidence by providing a systematic model of information gathering and interpretation. Throughout the paper, Ms. Goodman successfully provides differentiation between thoracic pain patterns attributed to neuromusculoskeletal system and those originating from other sources that require referral. A well-developed section on guidelines for physician referral offers excellent strategies that will assist the therapist in establishing a productive line of communication with other medical professionals. An evidence-based approach is threaded throughout the text in an attempt to validate the content and provide scientific rationale. Even when we refer without treatment, Ms. Goodman helps demonstrate the pivotal role physical therapists provide in making sure a patient gets the appropriate care. CASE ANALYSES: Ms. Goodman challenges the reader with 5 excellent case studies to facilitate application of the Goodman/Snyder model. Topics of each case are corticosteroid use tosteoporosis, midthoracic back pain, disk versus metastases; skin lesions, and finally early satiety and weight loss. The cases highlight effective decision-making and also how to key in on the most critical information.

Keywords:​

differential diagnosis, disease, musculoskeletal

References:​

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BEST EVIDENCE FOR EXAMINATION AND TREATMENT OF THE CERVICAL SPINE

Abstract:

CONTENT: In their monograph, Drs. Leal and Dennison introduce the reader to the epidemiology and prevalence of cervical spine pain as well as the financial impact of cervical spine pain. Current evidence supporting the need for subgrouping patients with neck pain and assigning specific treatments to optimize treatment success is then promoted using a treatment-based classification scheme. The importance of conducting a thorough history and clinical examination, as well as identifying the presence of red or yellow flags, is then detailed. In addition, key information and research regarding self-report measures are presented. Throughout the paper, the authors provide current evidence in support of interventions using each of the 5 treatment-based classifications proposed. CASE ANALYSES: The two case studies at the end of the paper will assist the reader in applying the information presented by the authors. The first case involves a 48-year-old female receptionist referred to physical therapy for the examination and treatment of neck stiffness and right arm and hand symptoms. The second case is a 28-year-old internet Web site designer referred to physical therapy for neck pain, tightness, and stiffness. The case presentations help clarify the role of classification and subgrouping methodology in the evaluation and treatment of cervical spine pain.

Keywords:​

differential diagnosis, neck, musculoskeletal

References:​

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BEST EVIDENCE FOR EXAMINATION AND TREATMENT OF THE THORACIC SPINE

Abstract:

CONTENT: In the monograph, Dr. Austin first provides perspective on the epidemiology of thoracic spine pain. He then offers a comprehensive review of the clinical anatomy and biomechanics of the thoracic spine and rib cage. Key elements of the examination process are then introduced to provide the reader with a solid understanding of the unique aspects of evaluating the patient with thoracic pain. A variety of thrust and nonthrust interventions are explained as well as specific therapeutic exercises for this population. This monograph complements another monograph in this series, Origins of Thoracic Pain, by Catherine Goodman. Both authors have succeeded, in providing useful information and best evidence on each topic. Supporting best practice is especially pertinent to a topic within orthopaedic physical therapy that is often misunderstood. CASE ANALYSES: Two case studies conclude the monograph. The first case involves a 37-year-old woman who suffers from left cervicobrachial pain. The second case is a 49-year-old man referred to physical therapy for bilateral arm pain.

Keywords:​

differential diagnosis, mobilization, trunk

References:​

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CLINICAL DECISION MAKING IN THE APPLICATION OF CERVICAL SPINE MANIPULATION

Abstract:

CONTENT: In the monograph, Drs. Wise and Schenk discuss cervical spinal kinematics, the relationship between structure and function, and implications for the management of neck pain. They present the value of diagnostic classification and current impairment-based classification systems in evaluating and treating the cervical spine. Differential diagnosis to guide interventions and its role in premanipulative screening procedures are presented to insure safety and effectiveness. A critical analysis of the efficacy and safety of cervical spine nonthrust and thrust manipulation techniques as part of a comprehensive plan of care are contrasted. Throughout the paper the current best evidence related to the use of cervical thrust manipulation for the management of neck pain support the authors' reasoning. By the end of the monograph, you should be familiar with an essential skill set of effective nonthrust and thrust cervical spine manipulation techniques that can be immediately incorporated into clinical practice. The authors systematically present their scheme to properly apply best practice for justification of cervical spine manipulation. Not only have the authors provided perspective on its use but also have specifically detailed techniques within the monograph and how such intervention can be a vital part of a comprehensive plan of care when applied correctly. CASE ANALYSES: Application of the material is presented through 3 varied case reports. The first is a 62-year-old woman who suffers from chronic neck pain with accompanying radiculopathy. The second is a 19-year-old man who is evaluated 1 year after the accident and has a previous diagnosis of whiplash-associated disorder with subcranial mobility impairment. The third case is a 45-year-old woman who suffers from neck and shoulder pain during golfing.

Keywords:​

manual therapy, mobility, screening

References:​

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CERVICAL AND THORACIC PAIN: EVIDENCE FOR EFFECTIVENESS OF PHYSICAL THERAPY

Abstract:

CONTENT: In the monograph, Drs. Schenk and Wise analyze the current literature regarding cervical and thoracic spine surgery and present the criteria for which patients may be candidates for cervical and thoracic spine surgery. Common surgical approaches according to diagnoses for each of these regions of the spine are then discussed. Physical therapy examination tests and measures for the postoperative patient are then reviewed, along with intervention strategies to optimize recovery and function. The authors have compiled a nice comprehensive monograph to help the clinician thoroughly understand the essentials of patient pathology, surgical options, and treatment progressions for the patient with cervical and thoracic pathology. CASE ANALYSES: Application of the material is highlighted through 2 interesting case reports. The first is a 57-year-old male who was referred to physical therapy following an anterior cervical discectomy and fusion 6 weeks earlier. The second case is a 37-year-old female who presents with intermittent and improving thoracic pain and bilateral lower extremity pain and weakness following a thoracic laminectomy and fusion. Each case is thoroughly described to allow the reader insight into the authors' clinical decision-making process.

Keywords:​

spine, surgery, rehabilitation

References:​

Click here.

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