96085 week 1 - Thoracic Pain_2024_BS.pptx

Thoracic Pain & Red Flag Screening A/Prof Bruno Saragiotto UTS CRICOS 00099F UTS TEQSA PRV12060 UTS CRICOS 00099F Learning Objectives At the end of this masterclass, you will be able to: Know the valid...

Thoracic Pain & Red Flag Screening A/Prof Bruno Saragiotto UTS CRICOS 00099F UTS TEQSA PRV12060 UTS CRICOS 00099F Learning Objectives At the end of this masterclass, you will be able to: Know the validity of red flags Describe common causes of pain in the thoracic region Provide condition-specific treatment for various thoracic pain disorders Prep Work JOSPT position paper Prep Work Mentimeter Quiz The Clinical Flags System Red: Signs and symptoms of serious pathology. Yellow: Indicators of psychological, social, and environmental factors that may influence the patient's recovery and prognosis. Orange: Indicators of serious psychiatric conditions that require immediate attention. Blue: Indicators related to the patient's perceptions of their work and occupational factors. Black: Indicators related to socio-occupational factors and system or contextual obstacles. Red Flags Signs and symptoms that raise suspicion of serious spinal pathology. Early detection is essential. Action: Immediate referral for further investigation! Red Flags General Characteristics Severe and/or progressive symptoms Non-mechanical pain Night pain or pain at rest Systemic symptoms (fever, weight loss) Most red flags are identified through comprehensive patient history and confirmed with imaging (e.g., MRI, CT scan) and lab tests (e.g., blood tests for tumour markers). Red Flags Cancer (Malignancy): incidence 0-5% Unexplained weight loss History of cancer Age over 50 Pain that is unrelenting and worse at night (night pain) Red Flags Infection (incidence 0.01-1.2% for spinal infection) Fever Recent bacterial infection Intravenous drug use Immune suppression Red Flags Fracture (incidence 0.7-10% for compression fracture of the spine) History of trauma or fracture (inc 50 Severe, localised pain Presence of contusion or abrasion Red Flags Cauda Equina Syndrome (incidence 0.002-0.4%) Severe low back pain Saddle anesthesia Bladder or bowel dysfunction (e.g., urinary retention, incontinence) Bilateral leg pain and weakness Neurological deficits (loss of sensation in the perineal area - saddle anesthesia, weakness in lower extremities, reduced or absent reflexes in the legs) Identifying Red Flags Does every patient over 50 represent a red flag for fracture and cancer? Does every history of trauma or cancer indicate a fracture or cancer recurrence? Does every fever indicate an infection? Identifying Red Flags The number of characteristics necessary for detecting a red flag is not fixed and can vary depending on the clinical context and specific condition. Single Characteristic: Usually, no single characteristic alone is sufficient to diagnose a serious condition, but in some cases 2 signs can be enough to raise concerns (e.g., unexplained weight loss in a patient with a history of cancer). Multiple Characteristics: The presence of multiple red flags increases the suspicion of a serious condition and may necessitate an action. For example, severe back pain accompanied by fever and a recent bacterial infection might strongly suggest an infection. Always consider the broader context and multiple indicators when evaluating potential red flags for spinal pain. Many red flags in current guidelines have little to no impact on diagnosing fractures or malignancies. The presence of multiple red flags increases the probability of serious conditions significantly. Downie 2013: Diagnostic Accuracy of Red Flags FRACTURE Feature Post-test Probability (95% CI) Older age 2-7% in primary care Prolonged use of corticosteroids 33% (95% CI: 10% to 67%) Severe trauma 11% (95% CI: 8% to 16%) Presence of contusion or abrasion 62% (95% CI: 49% to 74%) Downie 2013: Diagnostic Accuracy of Red Flags MALIGNANCY Feature Post-test Probability (95% CI) History 7% (95% CI: 3% to 16%) in primary care; 33% (95% CI: 22% to 46%) in emergency settings Older age Below 3% Unexplained weight loss Below 3% Failure to improve symptoms (1 month) Below 3% The origin of many red flags was unclear or was sourced from case reports. The incidence of malignancy in patients presenting with LBP in primary care varied between 0% to 0.7% A “history of malignancy” and “strong clinical suspicion” are the only red flags with empirical evidence of acceptable high diagnostic accuracy. The available evidence does not support the use of many red flags to specifically screen for vertebral fracture in patients presenting for LBP. Most red flags have poor diagnostic accuracy as indicated by imprecise estimates of likelihood ratios. When combinations of red flags were used the performance appeared to improve. Thoracic Pain Intervertebral Discs Facet Joints Thoracic Pain Epidemiology Thoracic pain accounts for approximately 15-20% of all spinal pain cases. 10-50% of chest pains are caused by musculoskeletal disorders (eg, fractures, muscle strains). More common in middle-aged and older adults, and children and adolescents. Risk factors include a sedentary lifestyle, limited neck ROM, previous cervicothoracic pain, emotional factors (eg, stress, anxiety), underlying medical conditions (e.g., osteoporosis, scoliosis), and poor posture (for acute temporary pain). Thoracic Pain Epidemiology Thoracic pain accounts for approximately 15-20% of all spinal pain cases. 10-50% of chest pains are caused by musculoskeletal disorders (eg, fractures, muscle strains). More common in middle-aged and older adults, and children and adolescents. Risk factors include a sedentary lifestyle, limited neck ROM, previous cervicothoracic pain, emotional factors (eg, stress, anxiety), underlying medical conditions (e.g., osteoporosis, scoliosis), and poor posture (for acute temporary pain). Thoracic Pain Muscular Strain Signs and Symptoms: Localised pain and tenderness in the thoracic muscles. Stiffness and limited range of motion. Pain exacerbated by movement or touch (always function-related). Imaging usually not required unless trauma is suspected. Thoracic Pain Facet Joint Dysfunction Degeneration or injury to the facet joints. Signs and Symptoms: Localised pain often described as aching or sharp. Pain worsened by twisting or bending movements. Possible referred pain to the shoulder or abdomen. Thoracic Pain Herniated Thoracic Disc Signs and Symptoms: Radicular pain radiating around the chest or abdomen is common. Numbness, tingling, or weakness in the affected dermatomes if radiating pain. Severe cases may involve myelopathy. MRI to confirm disc herniation and assess nerve compression. But unlikely to change treatment options. Thoracic Pain Osteoporosis and Vertebral Fractures Age-related bone density loss. Prolonged corticosteroid use. Signs and Symptoms: Sudden onset of severe pain. Worsen with activities and improve with rest. Localised tenderness and possible deformity. Pain upon palpation of the affected vertebrae. Height loss, reduced ROM and kyphotic posture. X-rays to identify fractures. DEXA scan to assess bone density. Thoracic Pain Thoracic Outlet Syndrome Compression of neurovascular structures in the thoracic outlet. Congenital anomalies, trauma, or repetitive activities. Signs and Symptoms: Pain, numbness, and tingling in the arm and hand. Weakness and swelling in the affected limb. Symptoms worsen with overhead activities. Positive Adson's test. Thoracic Pain Referred Pain from Visceral Organs (not to be missed) Cardiac conditions (e.g., angina, myocardial infarction). Pulmonary conditions (e.g., pneumonia, pleuritis). Gastrointestinal conditions (e.g., peptic ulcer, pancreatitis). Signs and Symptoms: Pain radiating to the thoracic spine. Associated systemic symptoms (e.g., fever, shortness of breath). Pain may vary with meals or respiratory movements. Require appropriate diagnosis. Thoracic Pain – Case 1 Ernesto, 39-year-old office worker reports mid-back pain after moving heavy boxes. He presents localised (right side of his mid-back) sharp pain (6/10) upon palpation and during spine flexion. No radiation of pain to the legs or arms. Muscle Strain or Facet Joint Dysfunction? Thoracic Pain – Case 1 Ernesto, 39-year-old office worker reports mid-back pain after moving heavy boxes. He presents localised (right side of his mid-back) sharp pain (6/10) upon palpation and during spine flexion. No radiation of pain to the legs or arms. Muscle Strain or Facet Joint Dysfunction? Have you had similar pain before? If so, how was it managed? Does the pain change with specific movements or positions? Have you experienced any recent trauma or injury other than lifting the box? Do you have any pain or stiffness in the morning that improves with movement? What other physical examination can you perform? Thoracic Pain – Case 2 Tania, A 28-year-old professional swimmer reports experiencing pain and tingling in her right arm for the past month. Pain onset was gradual, worsening with overhead activities like swimming. She describes the pain as aching (5/10), accompanied by numbness and tingling in the right hand. She also presents mild weakness in the right hand grip strength. Pain usually improves with rest. Thoracic Outlet Syndrome or Herniated Disc? Thoracic Pain – Case 2 Tania, A 28-year-old professional swimmer reports experiencing pain and tingling in her right arm for the past month. Pain onset was gradual, worsening with overhead activities like swimming. She describes the pain as aching (5/10), accompanied by numbness and tingling in the right hand. She also presents a mild weakness in the right-hand grip strength. Pain usually improves with rest. Thoracic Outlet Syndrome or Herniated Disc? Do you experience any colour changes or swelling in your hand (vascular symptoms)? Have you noticed any loss of muscle mass in the affected arm? Do you have any neck pain or stiffness? What specific physical examination tests would you perform to support your diagnosis?  Thoracic Pain Conditions – Summary Condition Onset Signs and Symptoms Muscle Strain Sudden, often after specific Localised pain and tenderness, stiffness, pain activity or injury with movement, no neurological deficits Facet Joint Dysfunction Gradual or sudden, often Localised sharp or aching pain in the facet associated with repetitive joints, worsened by twisting or bending, no movements or poor posture neurological deficits Herniated Thoracic Disc Gradual or sudden, often after a Radicular pain around chest or abdomen, specific movement or trauma numbness, tingling, weakness, confirmed by MRI Osteoporosis and Sudden, often after minor trauma Pain that worsens with activities and upon Fractures or spontaneous in severe palpation of the affected vertebrae. Limited osteoporosis ROM, and improve with rest Thoracic Outlet Gradual, worsens with repetitive Pain, numbness, tingling in arm and hand, Syndrome overhead activities worsened by overhead activities, positive Adson's test Thoracic Pain General Assessment History & Red flags o Are the symptoms caused by musculoskeletal structures? Severity, prognostic factors (work, psychosocial), outcome measures Physical examination (neck and back assessment) Observation AROM & PROM Palpation PAMs MMT Thoracic Pain Outcome Measures NRS or VAS Patient-Specific Functional Scale (0-10) Roland-Morris Disability Questionnaire (RMDQ) or Oswestry Disability Index (ODI) Quality of life Psychological & behaviour symptoms (anxiety, fear-avoidance, self-efficacy) Thoracic Pain General Assessment Don’t forget about the ICF Thoracic Pain Active Movements of the Thoracic Spine Forward flexion (20° to 45°) Extension (25° to 45°) Side flexion, left and right (20° to 40°) Rotation, left and right (35° to 50°) Costovertebral expansion (3 to 7.5 cm) Rib motion (pump handle, bucket handle, and caliper) Combined movements (if necessary) Repetitive movements (if necessary) Sustained postures (if necessary) (Magee textbook) Thoracic Pain Movements Pain Suggests dysfunction of movement Directs further assessment to isolate the problem Absence of pain = assess the quality of movement Quality Free movement with normal control and co-ordination Range Too much or too little can indicate a dysfunction Compare during treatment sessions Note symptoms during movement Joint Play MMT/Resistance Action Muscles Acting Nerve Root Flexion of thoracic spine 1. Rectus abdominis T6-T12 2. External abdominal oblique (both sides acting together) T7-T12 3. Internal abdominal oblique (both sides acting together) T7-T12, L1 Extension of thoracic spine 1. Spinalis thoracis T1-T12 2. Iliocostalis thoracis (both sides acting together) T1-T12 3. Longissimus thoracis (both sides acting together) T1-T12 4. Semispinalis thoracis (both sides acting together) T1-T12 5. Multifidus (both sides acting together) T1-T12 6. Rotatores (both sides acting together) T1-T12 7. Interspinalis T1-T12 (Magee textbook) MMT/Resistance Action Muscles Acting Nerve Root Rotation and side flexion of thoracic spine 1. Iliocostalis thoracis (to same side) T1-T12 2. Longissimus thoracis (to same side) T1-T12 3. Intertransverse (to same side) T1-T12 4. Internal abdominal oblique (to same side) T7-T12, L1 5. Semispinalis thoracis (to opposite side) T1-T12 6. Multifidus (to opposite side) T1-T12 7. Rotatores (to opposite side) T1-T12 8. External abdominal oblique (to opposite side) T7-T12 9. Transverse abdominis (to opposite side) T7-T12, L1 (Magee textbook) Common questions in spinal pain How much does posture matter in spine pain? Is it necessary to correct every postural abnormality in patients with thoracic spine pain? Thoracic Pain There is a moderate level of evidence of no significant difference in thoracic kyphosis between groups with and without shoulder pain. Common questions in spinal pain Can psychological factors influence thoracic spine pain? Are imaging findings always correlated with symptoms? Does manual therapy provide long-term relief for spine pain? Can spine pain always be attributed to a specific cause? Is medication or injections the primary treatment for thoracic spine pain? Is spinal pain self-resolving? Thoracic Pain Case: John (Consolidation case on Canvas) John is a 39-year-old office worker and regular gym goer. 3 days ago, he felt a sharp pain in his right mid back doing a military press. This has been a recurring issue for John and has happened 3 times in the last year. He has attended physiotherapy before but feels the hands-on treatment helps but doesn’t fix the issue. He has no discomfort with activities that involve reaching above shoulder height. What’s the possible diagnosis? Thoracic Pain Case: John (Consolidation case on Canvas) John is a 39-year-old office worker and regular gym goer. 3 days ago, he felt a sharp pain in his right mid back doing a military press. This has been a recurring issue for John and has happened 3 times in the last year. He has attended physiotherapy before but feels the hands-on treatment helps but doesn’t fix the issue. He has no discomfort with activities that involve reaching above shoulder height or extension. Facet joint? “sharp pain”, “happened 3 times”, “hands-on treatment helps but doesn’t fix the issue”, “He has no discomfort with activities that involve reaching above shoulder height or extension” Muscle strain? “sharp pain”, “doing a military press”, “hands-on treatment helps but doesn’t fix the issue”, “3 days ago” Thoracic Pain Case: John (Consolidation case on Canvas) John is a 39-year-old office worker and regular gym goer. 3 days ago, he felt a sharp pain in his right mid back doing a military press. This has been a recurring issue for John and has happened 3 times in the last year. He has attended physiotherapy before but feels the hands-on treatment helps but doesn’t fix the issue. He has no discomfort with activities that involve reaching above shoulder height. What other physical assessments are important to rule in/out diagnosis? Thoracic Pain Case: John (Consolidation case on Canvas) John is a 39-year-old office worker and regular gym goer. 3 days ago, he felt a sharp pain in his right mid back doing a military press. This has been a recurring issue for John and has happened 3 times in the last year. He has attended physiotherapy before but feels the hands-on treatment helps but doesn’t fix the issue. He has no discomfort with activities that involve reaching above shoulder height. What other physical assessments are important to rule in/out diagnosis? AROM/PROM? MMT? PAMs? Thoracic Pain Case: John (Consolidation case on Canvas) AROM Pain Response PROM Pain Response Condition Pain with movements that Pain with passive movements contract or stretch the affected that stretch the affected muscle Muscle Strain muscle (e.g., lifting, pushing, (e.g., passive bending, reaching) bending, reaching) Pain with movements that load Pain with passive movements Facet Joint Dysfunction or stress the facet joints (e.g., that stress the facet joints, extension, rotation, lateral especially with overpressure flexion) (e.g., extension, rotation) Thoracic Pain Case: John (Consolidation case on Canvas) MMT PAMs (joint play) Condition Pain may not be as pronounced Pain is typically elicited during during isolated muscle strength passive accessory movements Muscle Strain tests unless they involve that stress the facet joints, such significant spinal extension or as joint play tests involving rotation extension and rotation Pain is typically felt during Pain is usually not elicited during muscle strength tests that passive accessory movements Facet Joint Dysfunction contract the affected muscle, unless the movement indirectly such as resisted movements stretches or compresses the (e.g., lifting, pushing) affected muscle Thoracic Pain Case: John (Consolidation case on Canvas) John is a 39-year-old office worker and regular gym goer. 3 days ago, he felt a sharp pain in his right mid back doing a military press. This has been a recurring issue for John and has happened 3 times in the last year. He has attended physiotherapy before but feels the hands-on treatment helps but doesn’t fix the issue. He has no discomfort with activities that involve reaching above shoulder height. How to treat John? Thoracic Pain Treatment Thoracic Pain Treatment Four main types of exercises Mobility Strength Work Capacity Motor control Thoracic Pain Treatment Manual Therapy Not a long-term solution! Useful for pain relief and mobility No difference in effectiveness between thrust or non-thrust manipulations Thoracic Pain Treatment In Summary Exercise should be the main focus of treatment Manual therapy can help relieving pain and improving mobility Pain education should be provided to all patients Passive interventions should be avoided Thoracic Pain Treatment – Case Study Tania Tania, A 28-year-old professional swimmer reports experiencing pain and tingling in her right arm for the past month. Pain onset was gradual, worsening with overhead activities like swimming. She describes the pain as aching (5/10), accompanied by numbness and tingling in the right hand. She also presents mild weakness in the right hand grip strength. Pain usually improves with rest. She received the diagnosis of Thoracic Outlet Syndrome (TOS) Thoracic Pain Treatment – Case Study Tania Physical Examination: Forward head posture and rounded shoulders. PSFS: 6/10 (Swimming 7/10, Reaching overhead objects 7/10, Driving 4/10) Palpation: Tenderness over the scalene muscles and pectoralis minor. ROM: Limited cervical and shoulder AROM/PROM, pain with neck rotation and shoulder abduction. Neurological Examination: Decreased sensation in the right arm and reduced grip strength. Special Tests: Positive Adson's test (diminished radial pulse with head rotation to the affected side). She received the diagnosis of Thoracic Outlet Syndrome (TOS) She wants to try conservative treatment before considering surgery Thoracic Pain Treatment – Case Study Tania What are the main goals of Tania’s treatment? Thoracic Pain Treatment – Case Study Tania What are the main goals of Tania’s treatment? Reduce pain and tingling in the right arm Improve ROM and strength in the shoulder and neck (focus on functional activities) Prevent recurrence of symptoms Thoracic Pain Treatment – Case Study Tania What is the treatment plan for Tania? Thoracic Pain Treatment – Case Study Tania What is the treatment plan for Tania? Stretching Exercises (scalene and pectoralis minor) Strengthening Exercises Reduce activities that exacerbate symptoms and modify training Address contributing factors to reduce symptom exacerbation (education and stress management) Soft tissue mobilisation and mobilisation for pain relief Continuous reassessment during 4-6 weeks of treatment Thoracic Pain Treatment – Case Study Tania When to consider surgery? Thoracic Pain Treatment – Case Study Tania When to consider surgery? Persistent symptoms despite an adequate trial of conservative treatments, typically lasting 3 to 6 months Progressive neurological symptoms such as muscle weakness, atrophy, significant numbness, or tingling that impair function – Neurogenic TOS Vascular symptoms (claudication, ischemia) – Venous TOS Thank you 