Shoulder Breakout Hensley & Courtney Thoracic Skills · Shoulder)Hypomobility)Manual)Therapy) BreakoutThoracic)Skills))))) Craig)Hensley,)PT,)DPT,)OCS,)FAAOMPT)))))...

Shoulder Hypomobility Manual Therapy Breakout Thoracic Skills Craig Hensley, PT, DPT, OCS, FAAOMPT Carol Courtney, PT, PhD, ATC, FAAOMPT

April 22, 2017 Orthopaedic SecEon Annual MeeEng

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Orthopedic Manual Physical Therapy of

the Thoracic Spine for Shoulder Pain

Carol A. Courtney, PT, PhD, ATC, FAAOMPT Craig P. Hensley, PT, DPT, OCS, FAAOMPT

Objec&ves

1. Demonstrate examination of the thoracic spine and describe key determining factors guiding intervention targeting the thoracic spine in those with shoulder dysfunction. 2. Describe the evidence to support assessment and treatment of the thoracic spine in individuals with shoulder dysfunction. 3. Demonstrate manual intervention to the thoracic spine, including thrust and non-thrust mobilization/manipulation, to address mobility deficits in non-operative and operative patients with shoulder dysfunction.



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Key Points: Ac&ve and passive examina&on of thoracic spine •  Does a change to the thoracic spine (posture, mobility) alter paEent’s ability to perform a task, baseline pain?

•  To rule in/out cervical/thoracic dysfuncEon in paEents with shoulder pain/dysfuncEon, consider…

•  A/PROM •  Repeated movements •  Overpressure •  Combined movements •  Special tests •  Joint mobility tesEng •  (Bang & Deyle 2000)

•  Does movement produce familiar pain, other pain, spasm?

Key Points: Ac&ve and passive examina&on of thoracic spine • Passive joint movement exam begins with gentle palpaEon • Does baseline thoracic mobility maTer?

•  Are studies targeEng hypomobile segments? (Haik et al 2017, Mintken et al 2010) •  Central (Courtney et al 2010, Courtney et al 2016) vs mechanical (Campbell & Snodgrass 2010) effects

•  Joint mobility quanEty of movement: normal, hypomobile, or hypermobile? •  Pain versus resistance sequence helps determine irritability intervenEon-‐ Grade 1-‐2 vs 3-‐4 •  Anecdotally… Consider thrust in those who have higher irritability



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Posterior to anterior joint mobility: Central and Unilateral PA- T1-4 •  PaEent posiEon: prone, arms at side resEng comfortably, neutral c-‐spine

•  Physical therapist at head of bed in staggered stance •  Thumbs placed thumbnail to thumbnail on spinous process (SP) or onto transverse processes (TPs) (facet between TP and SP for unilateral PA)

•  oscillate 1-‐2x ((or more if needed) to appreciate Essue resistance and ROM

•  Of note SP of T2 at level of T3 TPs, and so on (T1 and 12 excepEons) (Geelhoed et al 2006)

Posterior to anterior joint mobility: Central and Unilateral PA-T5-12

•  PaEent posiEon: prone, arms at side resEng comfortably, c-‐spine neutral

•  Stand side of bed -‐ feet shoulder width apart

Pisiform Technique

•  IdenEfy T5 SP; apply hypothenar eminence

•  Opposite hand placed on top making a “C” with thumb and index finger

•  Apply anterior force

Alterna(ve method-‐ apply index and middle finger over TPs, then place opposite hypothenar eminence over distal phalanges

Unilateral PA-‐ consider flexing 2-‐5 digits to brace thumbs



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Evidence for non-thrust and thrust mobilization/manipulation directed at the thoracic spine for shoulder pain/dysfunction •  Peek et al 2015-‐ systemaEc review showing + effects from 3 RCTs •  Kardouni et al 2015-‐ RCT-‐ in those with impingement, 1 session of TJM had no effect on thoracic spine kinemaEcs, excursion, scapular kinemaEcs, pain and funcEon compared to sham

•  Mintken et al 2016-‐ RCT-‐ in those with shoulder pain, 2 sessions of TJM + exercise no different than exercise for pain and disability

•  GROC and PASS scores favored TJM at 4 weeks and 6 months

•  Mintken et al 2017-‐ validity of CPR from Mintken et al (2010) not supported • What about a pragmaEc approach? (Mintken et al 2016)

Precautions/Contraindications to manual therapy directed at the thoracic spine

Gatterbauer 2009 Precau&ons (Maitland reference) •  Currently pregnant •  Children

Contraindica&ons •  AcEve cancer of the spine •  Fracture/mechanical instability •  Spinal infecEon •  AorEc aneurysm •  Signs/symptoms of worsening neurologic funcEon at site, thoracic myelopathy

•  Hypermobility syndromes (including RA) •  SpondyliEs •  Fusion/ankylosis at joint •  AnE-‐coagulant therapy •  Uncontrolled hypertension •  PaEent posiEon cannot be achieved •  Osteoporosis or in a paEent with suspected low bone mineral density without bone density tesEng



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Thrust mobilization/manipulation: safety Puentedura and O’Grady 2015

• 7 case reports detailing 10 cases of serious adverse events following thoracic thrust joint manipulaEon

•  SCI • Pneumothorax • CSF fluid leakage

•  Insufficient evidence to show whether or not the TJM was contraindicated (was the TJM the cause, or was the problem already there?)

•  Rib/vertebral fractures are other potenEal problems

Non-thrust joint mobilization/manipulation Mobilization with movement: Extension

• PaEent posiEon: seated at end of bed, forehead resEng on folded arms

• PT off to side with leg up on chair • PaEent forearms rests on paEent thigh, supported with PT’s forearm and/or quad

• Provide PA while moving leg away and mobilize into thoracic extension

• Oscillatory technique



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Non-thrust joint mobilization/manipulation Mobilization with movement: Rotation with or without unilateral PA on rib

•  PaEent posiEon: seated at foot of bed, arms folded

•  Therapist stands to one side •  1 hand reaches across chest to opposite shoulder

•  Other hand applied to hypomobile thoracic segment

•  Assist with thoracic rotaEon while applying transverse glide to hypomobile segment in opposite direcEon of rotaEon

•  Rota7on+ Unilateral PA on rib

Thrust mobilization/manipulation: Supine gapping/Flexion gliding/Central PA- Midthoracic spine •  PaEent posiEon: supine scooted toward therapist, arms folded across chest securely

•  *Arm of painful shoulder should be placed closest to paEent’s chest

•  Roll paEent toward you •  IdenEfy SP of segment above (goes between DIPs of 3-‐5 and thenar eminence)

•  IdenEfy TPs (thenar eminence and 3rd DIP will go there)

•  Index finger will be towards PT •  PaEent elbows should be near lateral trunk •  Support head and flex thoracic spine unEl tension localized

•  Ojen performed with exhalaEon, ~75% into resistance

•  May place a towel roll under the paEent’s arms on top of his/her chest if unable to get good tension

•  Also consider towel/chapsEck under your 3-‐5th digits

•  Alternate therapist hand:



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Thrust mobilization/manipulation: Supine gapping/Flexion gliding/Central PA- Alternative: mid-upper thoracic spine

• Alterna7ve: paEent clasps hands behind neck

• Use elbows as fulcrum to develop tension

• Can have paEent bridge up to beTer target segment

•  Thrust through elbows •  Should we doing this in those who are post-‐op TSA, RTC repair, any shoulder surgery for that maJer?

Thrust mobilization/manipulation: Prone Central PA •  Arms resEng at paEent’s side •  R pisiform/hypothenar eminence applied at TP on L

•  L pisiform/hypothenar eminence applied at TP on R

•  Take up soj Essue slack by rotaEng the hands so that are facing in a cephalad and caudal direcEon respecEvely

•  PaEent takes a deep breath and exhales •  As paEent exhales, apply addiEonal PA force with elbows straight ~75% into resistance

•  Apply thrust in PA direcEon



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Thrust mobilization/manipulation: Seated Gapping/Extension Gliding/Longitudinal •  PaEent posiEoned towards edge of bed •  PaEent interlaces fingers behind neck with elbows together

•  Therapist in staggered stance •  Arms wrapped around paEent to get to paEent elbows, interlace fingers

•  IdenEfy SP below segment you are trying to gap with sternum

•  Flex thoracic spine to localize tension •  Thrust applied with cranial posterior force

•  Can also use towel between paEent arms and chest

Thrust mobilization/manipulation: Seated CT junction technique •  PaEent posiEoned towards edge of bed

•  PaEent interlaces fingers behind neck with elbows separated

•  Therapist in staggered stance •  PT weaves arms through paEent arms and places fingers at and above C7

•  Compress paEent forearms •  Lean paEent back unEl CT juncEon perpendicular to floor

•  Provide thrust in cephalad direcEon



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References •  Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for paEents with shoulder impingement syndrome. J Orthop Sports Phys Ther.

2000;30:126– 137.

•  Campbell BD & Snodgrass SJ. The effects of thoracic manipulaEon on posteroanterior spinal sEffness. J Orthop Sports Phys Ther. 2010;40:685-‐93.

•  Courtney CA, Steffen AD, Fernandez-‐de-‐Las-‐Penas C, Kim J, Chmell SJ. Joint mobilizaEon enhances mechanisms of condiEoned pain modulaEon in individuals with osteoarthriEs of the knee. J Orthop Sports Phys Ther. 2016;46:168-‐76.

•  Courtney CA, White PO, Chmell SJ, Hornby TG. Heightened flexor withdrawal response in individuals with knee osteoarthriEs is modulated by joint compression and joint mobilizaEon. J Pain. 2010;11:179-‐85.

•  GaTerbauer A. ContraindicaEons in osteopathy. Vienna: Vienna School of Osteopathy, Danube University Krem; 2009.

•  Geelhoed MA, McGaugh J, Brewer PA, Murphy D. A new model to facilitate palpaEon of the level of the transverse processes of the thoracic spine. J Orthop Sports Phys Ther. 2006;36:876-‐81.

•  Haik MN, Alburquerque-‐Sendin F, Camargo PR. Short-‐term effects of thoracic spine manipulaEon on shoulder impingement syndrome-‐ A randomized controlled trial. Arch Phys Med Rehabil. 2017 Mar 1. epub ahead of print

•  Mintken PE, et al. ExaminaEon of the validity of a clinical predicEon rule to idenEfy paEents with shoulder pain likely to benefit from cervicothoracic manipulaEon. J Orthop Sports Phys Ther. 2017;47:252-‐60.

•  Mintken PE, et al. Cervicothoracic manual therapy plus exercise therapy versus exercise therapy alone in the management of individuals with shoulder pain: A mulEcenter randomized controlled trial. J Orthop Sports Phys Ther. 2016;46:617-‐28.

•  Mintken PE, et al. Some factors predict successful short-‐term outcomes in individuals with shoulder pain receiving cervicothoracic manipulaEon: a single-‐arm trial. Phys Ther. 2010;90:26-‐42.

•  Peek AL, Miller C, Heneghan NR. Thoracic manual therapy in the management of non-‐specific shoulder pain: A systemaEc review. J Man Manip Ther. 2015;23:176-‐87.

•  Puentedura EJ, O'Grady WH. Safety of thrust joint manipulaEon in the thoracic spine: a systemaEc review. J Man Manip Ther. 2015;23:154-‐61.

Shoulder Breakout Hensley & Courtney Thoracic Skills · Shoulder)Hypomobility)Manual)Therapy) BreakoutThoracic)Skills))))) Craig)Hensley,)PT,)DPT,)OCS,)FAAOMPT)))))...

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