LAS VEGAS—Using a case study—a 25-year-old woman with thoracic outlet syndrome—Erica L. Sigman, DPT, OCS, demonstrated how joint mobilization/manipulation can decrease chronic pain, underscoring the role of physical therapy in managing such pain.
Dr. Sigman, an instructor of clinical physical therapy at the USC Division of Biokinesiology and Physical Therapy, Los Angeles, California, said the patient presented with an average pain score of 7 (out of 10), with a range from 4 to 8. The pain was located in the periscapular region on the right and extended down the posterior aspect of the brachium to the medial aspect of the forearm and the last two digits of the hand, with allodynia of the right medial forearm and last two digits.
Dermatomal and myotomal testing were within normal limits, and symmetric bilaterally. The patient’s cervical spine active range of motion, in degrees, was flexion, 60; extension, 50; and bilateral rotation, 70; with pain into flexion and right rotation. Her DASH (disabilities of the arm, shoulder, and hand) score was 58.3%.
The patient underwent a total of six, 30-minute, physical therapy visits over the course of 2.5 months. Included were postural education (desk ergonomics), activity pacing, postural strengthening/endurance training, cardiovascular exercise, diaphragmatic breathing, and movement re-education.
Cervico-thoracic junction mobilization/manipulation (including first rib mobilization) was performed and the patient was instructed in self-mobilization techniques using a towel, foam roll, and tennis balls.
After completing therapy, the patient reported her average pain had decreased to 3 (out of 10), ranging from 0 to 4. The pain is located in the periscapular region on the right and stays proximal. Her DASH score is now 20%. Her extension and flexion cervical spine active range of motion was unchanged from the initial evaluation and bilateral rotation to 80 degrees was pain free.
Dr. Sigman explained that mobilization/manipulation is defined as “a manual therapy technique comprised of a continuum of skilled passive movement to the joints and/or related soft tissues that are applied at varying speeds and amplitudes, including a small amplitude high velocity therapeutic movement.”
This technique uses the Maitland Joint Mobilization Grading Scale, ranging from Grades I to V. Movement comprising Grades I and II activate type I and cutaneous mechanoreceptors; Grade III activates more of the muscle and joint mechanoreceptors as more resistance is encountered; Grade IV changes joint capsule tension with more sustained motion; and Grade V, or joint manipulation, results from a high velocity, low amplitude thrust technique.
Dr. Sigman said studies have shown manipulation can either facilitate or inhibit muscle function. For example, lumbar multifidi thickness during a submaximal contraction was shown to increase after spinal manipulation and was associated with an improvement in low back pain-related disability. One mechanism of manipulation may be the removal of subthreshold stimuli induced by changes in joint play, she said, and many studies have supported the notion that manipulation can increase pressure/pain thresholds.
Prior to using physical therapy to care for patients with chronic pain, an evaluation should be performed that is subjective as well as objective. A subjective evaluation comprises a history of the condition, prior and current level of function, aggravating and easing factors, the nature and irritability of symptoms, an assessment of fatigue, and patient goals. Neurologic status, assessments of function and balance, and an analysis of posture and movement that includes strength, endurance, flexibility, joint mobility, and pain sensitivity should be objectively evaluated.