THORACIC PAIN ARISING FRO CERVICAL DISORDERS A CASE HISTORY Judith M usiker, BSc, BSc. (Physiotherapy) (W itwatersrand) Adapted from a p ro ject in partial fu lfil­ m ent of the post-grad uate cou rse on O r­ thopaedic M anipu lative Therapy. INTRODUCTION E xam ination using the M aitland con­ ce p t in volves re co g n isin g that a d isor­ dered jo in t m ay be responsible for both local and referred p ain 1. T he clinical pic­ ture becom es m ore confusing w h en a pas­ sive test m ovem ent, involving sim ultane­ ous m ovem ent o f jo in ts under the affected area and under the area o f referred pain, reproduces the p atien t's sym ptom s. D if­ ferentiation tests are special tests that are then ap p licab le1. T h e te st is th en p e r­ form ed in the reverse m anner. The pain response confirm s w hich jo in t is at fault. The d ifferentiation tests w ere o f particular value in this case study, w h ere a cervical disorder w as responsible for pain in the thoracic region. W ells2 relates "sh o u ld e r" dysfunction to cervical spine pathology. A lthough the sym ptom s appear to arise from the soft tissue o f the shoulder jo in t com plex, the origins are in the cervical spine. T he p res­ entation m ay be con fu sin g b ecau se the syndrom e does not p resent as an acute rad icu litis, w ith no n eurological sy m p ­ toms or irritability. The pain is usually a persistent dull ache deep in the shoulder, clavicular area, pectoral region or scapular area. There are often areas o f localised ten­ derness ("m y alg ic sp o ts") w hich m ay be located in the m uscles overlying the p ain ­ ful areas, including those ad jacent to the m edial b ord er o f the scapula . Experim ental studies on m an have p ro ­ duced referred pain into the scapular re­ gion b y irritation o f the cervical interspi- nous ligam ents, m u sculature and interver- tebral discs, as w ell as the connective tissue co v erin g them 2. F e in ste in 3 in je cte d the para-vertebral m u scles o f the neck and back w ith saline and reproduced a "b o r­ ing, heavy, cram py, d ee p " referred pain. A t the level o f the second and fourth cervi­ cal vertebrae, pain w as referred into the inferior angle o f the scapula. Although the skin over the vertebral bord er o f the scapula is supplied b y the second to the seventh thoracic nerve roots, the underlying m uscles are innervated by the low er cervical nerve roots o f the b ra ­ chial plexus. As a result o f the distal em- bryological m igration of the ventrolateral sheath of cervical m usculature, the para- scapular m uscles (subscapularis and latis- sim us dorsi) are innervated by the collat­ eral branches o f the posterior cord o f the brachial plexus, and the rhom boids b y the dorsal scapular nerve (C5). Clow ard d e­ scribes the scapular pain as a m otor rather than a sensory phenom enon, w ith reflex spasm o f the m uscles supplied b y the af­ fected cervical nerve roots4. The dorsal as­ pect o f the disc is innervated by the sinu- vertebral nerve5,6 and sensory receptors pass through the spinal cord as a reflex arc, sy nap sin g w ith the ven tral root to the para-scap ular m uscles. The intervertebral disc receptors can sense disc deform ation, effecting stim ulation o f the pathw ay. CASE REPORT The patient w as a fit 50 year old m ale w ho w orked as a technical supervisor. His jo b in volved read in g and w ritin g . His m ain recreation w as jo gging. Subjective Assessm ent The patient w as com plaining o f two m ain areas o f inter­ m ittent pain (Fig­ ure 1). The patient c o n s i d e r e d th e pain in Area 1 to be the m ost severe. It w as co n cen trated in the upper cervi­ cal region and ra­ d ia t e d i n to th e b ase o f his skull. H e rated the inten­ s it y o f th e d e e p pain as 3/5 and de­ scribed it as a "n a g ­ g i n g h e a d a c h e " w h ic h o c c u r r e d daily. T he pain in A rea 2 w as located in the m id -scapu­ la r r e g io n (b e ­ tw een the root o f ----- S U M M A R Y A case study is presented where a cervical dis­ order is responsible for thoracic symptoms. Mait­ land's differentiation tests become essential in clarifying which area of the spine is the source of the symptoms. The results of the treatment sug­ gest that intermittent cervical traction may be helpful in cases of this nature. O P S O M M IN G 'n Gevalle studie word aangebied waar 'n servi- kale kwaal verantwoordelik is vir torakale simp- tome. Maitland se differensiasie toetse is nodig om op te klaar watter deel van die werwelkolom die bron van die simptome is. Die uitslagte van die behandeling dui dat wisselende servikale traksie van hulp mag wees in sulke gevalle. V _____________________________________ y the sp ine o f -th e scap u la) and w as d e­ scribed as a "d u ll a ch e ". It occurred daily and w as rated as 3/5. T here w ere no neu­ rological sym ptom s. T he pain in Area 1 w as associated w ith stiffness and w as m o st intense on w aking in the m orning. It eased com pletely if the p atient took m ild analgesics. The patient slept on either side w ith on e pillow . D ur­ ing the day, the p ain w as aggravated by sustained neck flexion, and could not be eased b y any m ovem ent. The pain in Area 2 w as reproduced only by active cervical rotation to the right. It w as felt at the m id­ point o f the range and disappeared w h en Figure 1. Body chart of patient •b ru o ry 1995 P a g e 7 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) the head w as m oved back. The p atient's cond ition w as n ot considered to b e irrita­ ble. For the previou s tw o m onths, the pa­ tient had experienced a grad ual increase in the severity o f cervical and thoracic pain, w h ic h had b e g u n s im u lta n e o u s ly . H e could not relate the onset o f sym p tom s to any predisposing factors. The patient had su ffe re d a ce rv ica l w h ip la sh in ju ry 25 years previously. H e had had no treatm ent at the tim e. O nce the acute injury resolved, his neck becam e sym ptom -free. In 1989, physiotherapy treatm ent (ultrasound and cervical traction) w as given fo r "h e a d ­ ach es" sim ilar to those in Area 1. H e re­ sponded w ell and did not require further intervention until the present episode of pain. Special questions revealed noth in g of significance. The m ost recent X -rays, taken tw o years previously, show ed generalized cervical spond ylosis, m ore m arked at the C3/4 level. Objective A ssessm ent The patient had a good posture, but held his neck stiffly. C ervical flexion was full range, w ith pain in A rea 1 rated as 3/5 at the end o f range. U pper cervical flexion and extension w ere pain free w ith over­ pressure. Extension w as 3/4 o f the range o f m ovem ent and produced pain in Area 1 and 2 at the end o f range. C ervical rotation to the right w as full range and produced pain in Area 2, rated as 2/5, at the end of range. All other cervical m ovem ents were full range and pain free w ith overpressure. The p atient's verteb ral artery tests w ere negative. All m ovem ents o f the shou ld er jo in ts w ere full range and pain free w ith ov er­ pressure. Thoracic rotation to the right re­ produced pain in Area 2 at the end of range. M aitlan d 's test to d ifferentiate cer­ vical and thoracic ro tatio n 1 revealed an increase in pain in Area 2 w ith cervical rotation, and a lessen ing o f pain w hen cer­ vical rotation w as released, confirm ing the hypothesis that the pain w as partly o f cer­ vical origin. P alpation o f the cervical spine revealed a prom inent C4 sp inou s process. There w as thickening o f the C 3/4 and C 4/5 zy- gapophyseal jo in ts o n the right. M uscle spasm w as p resent on the right side o f the cervical spine. C entral and unilateral pos- tero-anterior pressures on the right, on C2, reproduced pain in A rea 1 w ith G rad e II p re s s u re s . U n ila te r a l p o s te r o -a n te r io r pressures on the right on C3 and C4 rep ro­ duced local pain w ith a G rad e II pressure. P alpation o f the thoracic spine revealed tenderness and spasm o f the rhom boid and erector spinae m uscles on the right side at the level o f T3 and T5. All thoracic intervertebral joints, costotransverse jo in ts and ribs in the area w ere full range and pain free w ith accessory m ovem ent test­ ing. O n reassessm ent the range o f cervical extension w as increased and the pain w as o f the sam e intensity. C ervical rotation to the right w as unchanged and continued to cause pain in Area 2. Treatm ent D ay 1 - Treatm ent 1 T reatm ent consisted o f three, 30 second sets o f G rade II unilateral postero-anterior pressures on the right on C2, C 3, and C4. Treatm ent w as ju st short o f pain. At the end o f the treatm ent session, cervical ex­ tension w as now 7/8 o f the full range of m ovem ent, w ith the intensity o f pain expe­ rienced in Area 1 and 2 unchanged. C ervi­ cal rotation to the right w as unchanged. T he patient w as advised to use tw o pillow s w hen sleeping in side-lying, so as to keep the neck in a neutral position, and to avoid long periods o f cervical flexion at work. D ay 2 - Treatm ent 2 The patient reported a slight headache in his occipital area on the evening o f the treatm ent, w ith no change in the pain in Area 2. H e had experienced very mild d is­ com fort in Area 1 on w aking that m orning and had not taken any analgesics. O n ex­ am ination, cervical extension w as 7/8 of the full range o f m ovem ent w ith a pain rating o f 2/5 at the end o f range. Cervical rotation to the right w as full range and produced a pain rating o f 2/5 in Area 2. T reatm ent w as repeated, progressing treatm ent tim e to three sets o f sixty sec­ onds. At the end o f the treatm ent, it w as possible to increase the am plitud e o f the m obilisation to a G rade III - w ithout cau s­ ing pain. Cervical extension w as full range and reproduced pain w ith overpressure, at an intensity o f 2/5. Cervical rotation to the right w as unchanged. D ay 7 - Treatm ent 3 The patient w as still experiencing pain in Area 2 w hile turning his head to reverse his car. Cervical extension w as full range and pain free w ith overpressure. Cervical rotation to the right w as full range and reproduced pain in Area 2, o f an intensity o f 2/5. U n ilateral p o stero -an terio r p ressures on the right on C3 and C4 w ere repeated as a G rade III pressure for 60 seconds. O n reassessm ent, the patient reported a slight d ecrease in the intensity o f pain experi­ enced in Area 2 (rated as 1/5). In view of the spondylitic changes on the X -rays, it w as decided to apply interm ittent variable cervical traction, in accord ance w ith M ait­ la n d 's su g g e ste d s e q u e n ce o f selectin g techniques fo r u n ilateral cervical pain1. M aitland suggests a three to five second hold period and a m inim al rest period if the con d itio n is sim p ly an ache, and a longer rest period if the cond ition is m ore severe. Ten k ilogram s o f cervical traction w ere given for five m inutes, w ith a hold period and rest period o f five second s each. There w as n o d iscom fort d uring the traction period, and no objective changes w ere noted after traction w as given. D ay 10 - T reatm en t 4 T he p atient felt "m u ch b e tte r" and w as experien cing very slight pain in Area 2 w h en turning his head to the right. O bjec­ tively, cervical rotation to the right pro­ duced a pain o f the intensity 1/5 in Area 2 at the end o f the range o f m ovem ent. T reatm en t consisted o f G rad e IV unilat­ eral p o stero -anterior pressures o n the right on C3 and C 4, w o rk ing into slight pain. Interm ittent variab le cervical traction w as applied for 15 m inutes, using the sam e p o u n d a g e as the p r e v io u s tre a tm e n t. There w as no objective ch an ge in signs and sym ptom s after the treatm ent. The d iffer­ entiation test show ed that cervical rotation w as still p rodu cing thoracic sym ptom s. Four days later, the p atient reported that there w as no fu rther thoracic pain. DISCUSSION C e rv ical p ath o lo g y rep ro d u cin g tho­ racic sym p to m s. T h e co n fu sin g clinical picture exhibited by the patient has im por­ tant im plications for the physiotherapist. W ells m aintains that w e m u st rem em ber that the cervical sp ine m ay appear to be asym ptom atic in the presen ce o f severe "s h o u ld e r" sym ptom s. Sch n eid er7 reports favou rable results obtained after treating subjects w ith ap p arent shou ld er jo in t pa­ thology w ith cervical m obilisation accord ­ ing to the M aitland concept. T he case stud y under d iscu ssion high­ lights the im portance o f q u estio ning for previous traum a w h en assessin g patients w h o com p lain o f thoracic pain that is exac­ erbated by cervical m ovem ents. The pa­ tie n t had s u ffe re d a w h ip la s h in ju ry . Q T w o m e y and T a y lo r d e s c r ib e th e s e ­ q u elae o f severe traum a to the cervical spine. These include trau m atic d isc ru p­ tures, clefts in the cartilage and plates and annu lu s fibrosis, and sev ere so ft tissue d am age to the facet jo in ts, w ith capsular and synovial tears. D isc d am age is associ­ ated w ith signs o f early disc d egeneration due to reduced nu trition. T he referred pain R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) could b e ascribed to anterior or anterolat­ eral disc pathology with pro lap se4, m uscle spasm 3 or z y g a p o p h y sea l jo in t p atho l- o gy 1- In the case under discussion, thoracic rotation to the right reproduced the tho­ racic pain. This m ight be explained b y vir­ tue o f the fact that there is reflex spasm o f the rhom boid and erector spinae muscles. R otation o f the thorax tow ards the painful side involves scapular retraction on that side, recruiting the affected m uscles and eliciting pain. Im plications for treatm ent M obilisation o f the cervical spine by direct pressure produced positive results. Schneid er7 a d v o c a t e s s u c h tre a tm e n t, m aintaining that repetitive passive m ove­ m ent o f the intervertebral jo in t decreases or blocks discharge from the jo in t afferent n e rv e s, in h ib itin g p ain s en sa tio n fro m these jo in ts and reducing referred pain. The patient responded rapidly to interm it­ tent variable cervical traction and it w ould be interesting to assess the value o f this m odality in other cases o f this nature. REFERENCES 1. Maitland G D. Vertebral Manipulation. 5th ed. London: Butterworths, 1986. 2. Wells P. Cervical dysfunction and shoulder problems. Physiotherapy 1932;68(3):66-73. 3. Feinstein B, Langton J, Jameson R M, et al. Experiments on pain referred from deep so­ matic tissues. Journal o f Bone and Joint Surgery 1954;36A(5):981-997. 4. Cloward R B. Cervical discography. Ann Surg 1959;150(6):1052-1064. 5. Bogduk N. The innervation of the lumbar spine. Spine 1983;8(3):286-293. 6. Wink C S, M endel T, Zimny M L. Neural elements in human cervical intervertebral d is c s . O r th o p a e d ic D iv is io n R e v ie w 1992;Sept/Oct:5-7. 7. Schneider G. Restricted shoulder movement: capsular contraction or cervical referral. Aust J Physio 1989;35(2):97-100. 8. Twomey L T, Taylor J R. Damage to the cervi­ cal discs and facet joints following severe trauma. Seventh Biennial Conference of the M T T A 1991. PHYSIOTHERAPY ON THE INTERNE by Larry Ian Cohen Introduction T h e n u m b e r o f c o m p u t e r u s e r s throughout the w orld is increasing rap­ idly, as are the nu m ber o f fu nctions that the com puters are able to perform . The linking o f com puters is term ed netw ork­ ing and can involve a local area netw ork (LAN), a larger m etropolitan area netw ork (M A N ) and even a w id e area netw ork (W A N ). W hen com p u ters are netw orked users can "ta lk " to others, send m essages and share files and program s, and is the principle o f the Internet, a global internet­ w orking o f com puter system s. The exact nu m ber o f users on the In ­ ternet is increasing exponentially b u t cu r­ rent estim ates place usage at 34,000 n et­ w orks, 5 m illion com puters and 20 m illion u sers1. The m ain key feature o f the Internet is that it allow s heterogeneous com puters to com m unicate w ith each other using a "co m m o n langu ag e", transm ission control p r o to c o l/ In te r n e t p ro to c o l (T C P / IP )2. This allow s A pple com puters, IBM m a­ chines, v ario u s m ainfram es and super­ com puters to com m unicate w ith one an­ other. Electronic mail (e-m ail) The m ost basic use o f the Internet in­ volv es electronic m ail (e-m ail) w hereby user x at com puter a is able to send a m essage to user y at com puter b. C om ­ puter b could b e in the room n ext d oor or halfw ay across the w orld, and the time it takes for m essages to travel across the net­ w ork can be m easured in seconds. Like ordinary m ail (snail m ail), e-m ail requires an Internet address so that it can reach its d estination. Internet addresses follow a logical pattern : person@ m achine.sitenam e.sitetype.coun try (eg: 0571arry@ w itsvm a.w its.ac.za) where: • person is the userid of the person on the netw ork eg. 0571arry • m achine is the com puter's nam e on the internet eg. w itsvm a • sitenam e is the nam e o f the institution eg. wits • sitetype is the type o f institu tion eg ac (academ ic) • cou ntry eg. za (South A frica) M ailing lists are a slight variation on e-m ail. T hey allow users w ith sim ilar inter­ ests to subscribe to a list. M ail is forw arded to all thfe m em bers o f the list w ho can then decide w heth er to act, store, o r discard the message. Y ou m ay be w ond ering w h at this h as to do w ith p h y sio th e ra p y , w e ll the good new s is that physiotherapists now have their ow n m ailing list (PH Y SIO ) w h ich is based in the UK. P H Y SIO aim s to provide a global forum fo r everybody interested in p h y s io th e ra p y , n a m e ly u n d e rg ra d u a te students, researchers, edu cators, clinicians and adm inistrators. How to subscribe to PHYSIO: You need a com p u ter that is connected to the Internet, via a direct link or via a m odem . T h e re are co m m ercial b u lle tin b oard s in Sou th A frica that act as gatew ays onto the Internet. M em bers o f the public can subscribe to the b u lletin b o ard s for a nom inal annual fee. O nce you are ab le to connect to the Internet and have a personal Internet address, send a m essage to: m ailbase@ m ailbase.ac.u k w ith the fo llow ing instruction in the bod y o f the m essage: • jo in physio firstnam e lastnam e (eg. jo in p hysio Jo h n D oe) T h e m a ilb a s e s y s te m a u to m a tic a lly R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:0571arry@witsvma.wits.ac.za mailto:mailbase@mailbase.ac.uk