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    Journal of Orthopaedic & Sports Physical Therapy2000;30(7) 401-409

    Thoracic Spine Dysfunction in Upper nmExtremity Complex Regional Pain Syndrome ;

    Type I 4Cu4l ean ine Y ip Menc k , D PTSusan M ais Requejo, DP T *Kornelia Kulig, PhD, PT

    Study Design: Case study.Objective: To demonstrate the importance of assessment and treatment o f the thoracic spinein the management of a patient with signs and symptoms of upper extremity ComplexRegional Pain Syndrome Type I (CRPS-I).Background:The patient was a 38-year-old woman who suffered a traumatic in jury to herleft hand. Five months after injury, she presented with severe pain, immobility of the leftarm, and associated dystrophic changes. She was unable to work and needed help in someactivities of daily living.Methods and Measures: The patient was treated for 3 months in 36 visits. Init ial treatmentconsisted of cutaneous desensitization, edema management, and gentle therapeuticexercises. However, further examination indicated hypomobility and hypersensitivity of theupper thoracic spine. Joint manipulation of the T3 and T4 segments was implemented. Thepatient's status was monitored and range of motion, strength, temperature, and skin moisturewere measured.Results: Immediately after the vertebral manipulation, there was a significant increase in theleft hand's skin temperature and a decrease in hyperhydrosis as measured by palpation.Shoulder range of motion increased from 135-175"nd the patient reported reduced painfrom 6/10 to 3/10 on a scale from 0 to 10, where 0 represents no pain. The decrease in thepatient's dystrophic and a llodynic symptoms permitted further progress in functional r eeducation. The patient was discharged with full return to independence and in itiation of avocational retraining program.Conclusion: Assessment and treatment of the thoracic spine should be considered in patientswith upper extremity CRPS-I. ) Orthop Sports Phys Ther 2000;30:401-409.Key Words:manipulation, manual therapy, reflex sympathetic dystrophy

    Student in the doctor of physical therapy program, University of Southern California, Los Angeles,Calif; is now staff physical therapist and research coord inator, Rancho Los Amigos National Reha-bilitation Center, Downey, Calif.Orthopaedic physical therapist resident and student in the postprofessional doctor o f physical ther-apy program, University of Southern California, Los Angeles, Calif; is now faculty at Mount St. Mary'sCollege, 10s Angeles, Calif.Associate professor of clinical physical therapy, Department of Biokinesiology and Physical Therapy,University of Southern California, Los Angeles, Ca lif.Send correspondence to leanine Yip Menck, DPT, 3610 Pdcific Avenue, Marina Del Rey, CA 90292.E-mail: [email protected],[email protected],or [email protected]

    B cause of its complexand poorly understoodnature, reflex sympa-thetic dystrophy hasrecently been reclassi-fied by the International Associa-tion for the Study of Pain (IASP)as Complex Regional Pain Syn-drome Type I (CRPSI).n CRPSI isdefined as "a pain syndrome thatusually develops after an initiatingnoxious event, is not limited to thedistribution of a single peripheralnerve, and is disproportional tothe inciting eventw2' t is associat-ed with altered sympathetic out-flow with "evidence of edema,changes in skin blood flow, abnor-mal sudomotor activity in the re-gion of the pain, or allodynia, orhyperalgesia. ~ 5

    Numerous authors have dis-cussed the possible causes andmechanisms for this complex syn-d r ~ m e . ~ . ~ ~ . ~o single model hasbeen universally accepted. Treat-ment approaches for patients withCRPSI in the upper extremityhave been diverX.5.7.9.14-IR.43.44.MSurgical intervention includessympathetic or somatic nerveblocks, sympathectomy, neurolysis,and decompression. Conservativetherapies for CRPSI have tradi-tionally focused on pain manage-

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    The thoracic sympathetic ganglia corresponding tothe T1 through the T9 segments lie against the ante-rior heads of the ribs, just lateral to the vertebralbodies.'"he sympathetic chain ganglia, which inner-vate the arm, lie in close proximity to the thoraciccostovertebral and zygopophoseal joints. Gonzalez-Darderl%as described compression of the dorsal ra-mus of the T4 nerve by a bone spur arising from theT4 inferior facet joint. Surgical decompression re-lieved a patient's pain and autonomic dysfunction inthe thoracic region, neck, and right arm. I t may bepossible that thoracic dysfunction resulting fromjoint or soft tissue restriction may compromise thesympathetic chain ganglia and may be linked to thedistal symptoms in CRPSI. Manual joint mobilizationmay in some cases have the same effect of increasingthe joint mobility and relieving the pressure on thesympathetic chain ganglia.

    We believe that evaluation and treatment in areasproximal to a patient's symptoms in CRPSI may benecessary. Both the hypomobility secondary to abnor-mal posturing and the anatomical proximity of thesympathetic ganglions to the thoracic spine may con-tribute to a unique link between upper quadrantCRPSI and thoracic joint dysfunction. Acting on thishypothesis, we assessed the thoracic spine in the cur-rent case and initiated manipulation. This treatmentwas an adjunct to the overall management of the pa-tient's symptoms of CRPSI.

    FIGURE 1. Radiograph of patient's left hand one month after injury. METHODSment and restoration of function of the hand andarm. Pain management includes pharmacology, de-sensitization therapy, transcutaneous electrical stimu-lation, and thermal modalities. Restoration of func-tion includes active and passive exercises, splinting,and progressive strengthening of the arm. Thesetherapies are well-accepted in the treatment of C R P SI; however, they focus on treating the distal extremitywhere the symptoms are primarily manifested. Evalu-ation and treatment of spinal dysfunction in CRPSIhave not been documented.

    The purpose of this case study is to demonstrate arelation between the distal symptoms of CRPSI andthe thoracic spine, and to describe the use of thorac-ic spine manipulation in the management of patientswith CRPSI in the arm. We also provide a conceptu-al framework for treatment of the spine in patientswith CRPSI symptoms. We have observed that pa-tients with CRPSI in the arm often exhibit posturaldeviations associated with a protective position of thearm. This position diminishes trunk motion duringall upright activities and if prolonged, may have con-sequences such as decreased thoracic intervertebralmobility. Joint hypomobility is the most salient fea-ture among thoracic spine pain syndromes, accord-ing to McNair and Maitland.!'"

    HistoryA 38year-old married, left-hand dominant woman

    sustained trauma to her left wrist and hand while us-ing a plastic-molding machine at work. On the day ofinjury, the patient underwent open reduction inter-nal fixation surgery with Kirschner wires placed inthe distal lateral carpal and proximal second andthird metacarpal bones. Figure 1 shows the radio-graph of the patient's left hand one month after in-jury. Her extensor tendons were also repaired. Shewas immobilized in a cast for 3 weeks, then receivedone month of occupational therapy that includedpassive and active range of motion of her left wrist,hand, and digits. Despite this intervention, the pa-tient developed an extensor lag of the middle andring fingers, with significant extensor tendon adhe-sions. Six weeks after the initial injury and repair,she underwent a second surgery consisting of remov-al of 4 Kirschner wires, tendolysis of the extensordigitorum communis of the left index, middle, andring fingers, and manipulation of the metacarpal-phalangeal joints. With the patient under anesthesia,the surgeon was able to passively flex the metacarpal-phalanx joints 45-60" and fully extend all the digitswith the wrist held in extension.

    J Orthop Sports Phys Ther.Volume 30.Number 7.July 2000

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    P3 =

    P2 =

    P I =

    FIGURE 2.cates pain.

    Body Chart of Patient's Symptomsheadache {

    swellingcold distal fingemnumbnessitchinesssharp painwith movementpurple discoloration

    Body chart of patient's symptoms at init ial evaluation. P indi-

    Two and one-half months after injury, the patientwas referred to physical therapy, where treatment in-cluded active and passive range of motion for thewrist and digits, joint and soft tissue mobilization,strengthening exercises, and a home program tomanage the pain and swelling. The patient reportedminimal changes in her status and one month intothe treatment, she accidentally hit her left hand on adoor and, consequently, discontinued therapy be-cause of increased pain.

    Six weeks later (5 months after the initial injury),the patient was reevaluated in our clinic by one au-thor (J.Y.M.). She received physical therapy 3 times aweek for 12 weeks and was discharged with a signifi-cantly improved functional status. Following is a de-scription of the patient's treatment in those 12weeks.

    Patient InterviewInitially, the patient complained of 3 types of pain

    (Figure 2). The primary pain (P l) was described assharp, was located at the dorsal aspect of her leftwrist and hand, and increased with any movement.The patient verbally rated this pain as a 6 on a scalefrom 0 to 10, where 0 represented no pain and 10represented the worse pain imaginable. The second-ary pain (P2) was along the posterior aspect of theentire left forearm, arm, and shoulder. This pain wasdescribed as dull and fatiguing. The third pain (P3)was a headache that affected the posterior and leftside of the occiput and temporal regions. In addi-tion, the patient reported that her left hand wascold, with numbness and tingling, and she com-plained of increased swelling. She had also experi-enced an itching of the hand in the previous 3J Orthop Sports Phys Ther.Volurne SOeNurnber 7.Julv 2000

    TABLE 1. Mobility, strength, and limb circumference from initial evalua-tion and at discharge.Ini tial status At discharge

    1. ROM:AROM (") PROM (") AROM ( W R O M 9

    Wrist:Flexion 0-6 0-10' 0-25 0-38Extension 0-10 0-40. 0-30 0-60Radial deviation 0-3 0-15 0-28 0-30Ulnar deviation 0-1 0-10' 0-1 5 0-30MCP flexion -10-30 0-45' 0-60 0-60MCP extension -3 0-5 0-1 0 0-25PIP flexion -10-45 0-90. 0-70 0-1 05DIP flexion -10-35 0-45' 0-45 0-90Shoulder flexion 0-125 0-1 35* 0-1 65 0-1 752. Strength:

    Left Grip: 4.05 g (right at 24.75 kg) 9.00 gLeft Pinch: 1.80 kg (right at 4.95kg) 4.95 kg3. Soft tissue swelling. Girth:

    Left Right Left girth measures at:distal radius 15 cm 14.5 cm distal radius 14.5 cmcarpal circumf. 17 cm 15.5cm carpal circumf. 15.0 cmmid hand 18.5 cm 17.0 cm mid hand 16.8cmROM indicates range of motion; AROM, active range of motion; PROM,passive range of motion; MCP, metacarpophalangeal; PIP, proximal inter-phalangeal; and DIP, distal interphalangeal. Subject was discharged 8weeks after initial evaluation.Endfeels were painfu l.

    weeks. Initially, the patient was taking the oral anal-gesics Daypro and Vicodin.

    The patient's primary complaint was with her in-ability to perform selfcare activities of daily living(ADL) such as housework, driving, and writing. Shewas also unable to participate in sports and other rec-reational activities such as volleyball, softball, anddancing because of pain, numbness, and immobility(Table 1). In addition, she reported sleep distur-bances and emotional distress since the accident; shewas seeing a psychologist once a week. Before the ini-tial injury, the patient worked ICLhour days 5 days aweek, was independent in all ADL, and exercised reg-ularly in a gym or by playing team sports. She deniedany history of depression, trauma to the spine or u pper extremities, diabetes, drinking alcohol, or smok-ing. She lived with a supportive husband and 3 teen-age daughters; the oldest daughter had assumed re-sponsibility for the patient's normal household chores.

    Physical ExamOn initial evaluation, the patient held her left armin a very rigid, protective posture. This posture in-cluded shoulder elevation, adduction, internal rota-tion, elbow flexion, and wrist and finger flexion. Thepatient wore a glove because of her intolerance tocold and she supported the arm by holding her lefthand in her coat pocket. Compared with the righthand, the dorsal and ventral skin along the left distal

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    TABLE 2. Signs, symptoms, and functional status at initial evaluation andat discharge. DiagnosisInitial status at week 0 Status at week 10

    Abnormal skin temperaturewith left radial bursa warm totouch and lef t distal fingers coldto touch compared with righthand. Dorsal skin shiny andtaut, palmar discoloration.Allodynia along left radial bursato light touch and to pinwheelwith (t)ump signs. Allodynicto palpation of left lower cervi-cal and upper thoracic para-spinal skin, muscles, joints.Guarded posturing of en tire leftupper extremity in shoulder el-evation and internal rotation, el-bow and finger flexion. De-creased left arm swing in gaitwith tendency to sling left armin coat pocket. No initiation ofmovement with left arm.Unable to use left hand to write,type, perform ADLs and house-hold chores, play volleyball orsoftball, dance, or drive.

    Normalization of skin tempera-ture as well as skin color. Dorsalskin at wrist flexible, taut at postsurgical scar.

    No longer allodynic at left handor spine.

    Decreased guarding of left up-per extremity with use of arm ingait. Initiates activity such asreaching and writing with lefthand.

    Use of left upper extremity towrite and type 1 h/d. Resumedsweeping, combing her ownhair, cooking, dancing 2x1month, and driving. Limited en-durance wlabove.Pain rating 3/10.ain rating 6/10 (0 was no pain ,and 10 worst pain).

    phalanges were significantly colder to the touch,while the radial bursa was warm to the touch. Addi-tional examination of passive physiologic and acces-sory mobility revealed hypomobility of the T 3 and T4vertebrae and grea ter prominence of the left T3 andT4 transverse processes in neutral and flexed spine.Passive segmental upper thoracic flexion and exten-sion were painful, with extension being more restrict-ed and painful. The patient also demonstrated an al-lodynic response to light touch of her left lower cer-vical and upper thoracic vertebral column.

    The patient was hesitant to initiate any movementwith her left arm even when requested to d o so. Ini-tial physical examination findings are summarized inTable 1 and Table 2. Measures of treatment out-comes for impairments included the following: painassessment using a numerical scale (&lo), left armactive and passive motion measured with a goniome-ter,2"40s4'grip and pinch-strength measured with dy-n a m o m e t e r ~ , ~ ~ ~ ~iddle and lower trapezius

    as well as girth measured circumferen-cially with a tape measurem and segmental thoracicmobility. A questionnaire was used to assess the pa-tient's functional status, including ability to resumework, perform some ADL, drive, and engage insports and othe r recreational activities.

    At the initial examination, our diagnosis of CRPSIwas based on the IASP Committee on Taxonomy,which states that "to satisfy a diagnosis of CRF'SI, theclinical findings include regional pain, allodynia, ab-normalities of temperature, edema, abnormal sudom-otor activity that occurs after a noxious event anddoes not involve a peripheral nerve."J5 Very recentwork regarding internal validity of these criteriafound the sensitivity to be quite high (0.98). howev-er, specificity was poor (0.36). This suggests the pos-sibility of false positives in diagnosing CRPS versusneuropathic pain with established nonCRPS etiolo-gy."n addition, Sandroni et a142 ound that usingthe above composite autonomic clinical features ofCRPS is both a sensitive and reliable tool with whichto formulate a correct diagnosis of CRF'SI. We fur-ther classified the patient's symptoms as moderateand in the second (dystrophic) stage of the course ofthis pain syndrome. Although there have been no re-liability o r validity studies on this staging, Bonica4 de-scribed "moderate" as characterized by throbbing,aching diffuse pain and moderate or mild vasomotorand sudomotor disturbances. He classified the dys-trophic stage as characterized by cold skin and tro-phic changes that develop from 3-6 months after on-set.4 Our patient had a classic cold, purple, and pale-colored edematous wrist and hand, characteristic ofCRF'SI, which appeared to have been progressingsince the initial traumatic injury to the hand 5months earlier. Allodynia, defined by Gracely et a1 as"pain due to a stimulus, which does not normallyprovoke pain,"4 suggested sympathetic dysfunction.However, the pain was not limited to the left upperquadrant. T he patient also had signs of thoracicspine dysfunction, including abnormal posturing andpalpable joint stiffness at the T3 and T4 segments.Thoracic spine dysfunction has not previously beenassociated with CRPS.

    INTERVENTION AND OUTCOMEThe initial treatment objective was pain manage-

    ment and edema control. The long-term goal was toachieve the functional range of motion and strengthnecessary to resume using the left arm, shoulder gir-dle, and trunk in work, and to permit the patient toengage in ADL.Treatment 1 consisted of gentle active and passivewrist and finger range of motion and tubagrip foredema management. A home program of desensitiz-ing techniques was implemented because of the pa-tient's allodynic response (Table 3). The patient's ac-tive participation in therapy was limited because thepain was highly irratable and because she was unwill-ing to move her left arm.

    Treatment 2 included evaluation and manipulationJ Orthop Sports Phys Ther-Volume 30.Number 7.Jnlv 2000

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    TABLE 3. Summary of therapeutic management at initia l (week 11 middle (week 4) and final (week 10) stages of treatment.Type of intervention Week 1 Week 4 Week 10

    Movement re-education Genera lized posture education. Facilitation of left upper extremity Use left upper extremity for all activi-Facilitation of left upper extremity during gait. ties of daily living.during transitional movements. Writing 5 midd . Writing 30 midd.Aerobic conditioning Treadmill, 5 minld. Bike or treadmill, 10 min ld with left Bike, 15 midd .hand on the handrail. Walk at home 45 midd.Walk at home 15 midd.Dynamic strength and Co- Proprioceptive Neuromuscular Facili- PNF D I D 2 patterns with red thera- PNF D I D 2 with green theraband.ordination Exercises tation (PNF)'.47 ncluding D I D 2 band. Throw and catch softball. Bicep curlspatterns wi th active assistance. Throw and catch tennis ball. 6 Ib. Scapular retraction with 40 Ib.Wall reach with towel. Wrist flexion/extension/ulnar radialBiceps curls 4 Ib medicine ball. Scap deviation with 2 Ib.ula retraction 20 Ib. Isometric wrist Resisted mid4ow trap w ith red thera-flexionlextension and ulnar and ra- band.dial deviation. Active strengtheningfor m id and lower trapezius with-out resistance.Passive ROM Splint wear for finger flexion stretch, Splint for finger flexion. Upper limb tension test mob iliza tion10 min. PROM for wrist and fingers Mob ilization of the wrist to gain flex- in radial nerve bias (ULTT#2).7beyond per tolerance. ion and extension: Grade Illand IV. Stretch upper quadrant with weight-Mobiliza tion of scaphoid on trapezi- bearing on gym ball (see Figure 5).urn to gain wrist extension. Manipulation: T31415 to gain shoulderManipulation: T3 and T4 to gain ex- flexion and elbow extension.tension and rotation.Desensitization Gentle towel rub 5 timedd, gentle Soft tissue mobil iza tion at the dorsum Thera-putty with increased resistance.

    self light touch massage 5 timedd of the hand. Resisted grasp withof the left hand. Warmkold con- thera-putty.trast baths 3 timedd. AROMPROMper above.Edema management Tubagrip. Tubagrip as needed.

    of the upper thoracic spine, as described by Kalten-b0rn,2~Maitland,27McGuckin,3' and 0'Malley.38 Theobjective was to place traction on the left T3 and T4facet joints to gain thoracic extension and right rota-tion. The clinician used her manipulating hand as afulcrum by placing it under the supine patient at thelevel of thoracic joint dysfunction (Figure 3).Athrust was delivered through the patient's foldedarms as she exhaled and there was an audible click.There was immediate normalization of skin tempera-ture and color, as well as a significantly decreased al-

    lodynic response to light touch along the left armand left upper thoracic vertebral column (Figure 4).The segmental thoracic mobility improved and therewas an immediate increase in shoulder flexion afterthis treatment. This reduction of signs and symptomsof CRPSI made it possible to proceed with function-al rehabilitation. The improvements were maintainedand functional retraining, progressive strengtheningand use of the left arm in activities were possible insubsequent visits. A stress loading program of thearm as described by Dzwierzynski and Sangerlowasimplemented.

    Mobilization was also used to address the pain local-ized at the left lateral epicondyle region. This painwas specifically reproduced by the Upper Limb Ten-sion Test #2 (ULTT2) with a radial nerve bias de-scribed by B ~ t l e r . ~utler suggests using the ULTT2when treating thoracic syndromes by combining thetest with thoracic rotation and lateral flexion to placethe thoracic spine on tension. Thoracic manipulationdirected at the patient's T3T5 facet and cost-trans-verse joints resulted in gains of both left shoulderflexion and decreased sensitivity to the ULTI'2. Forexample, in treatment session 20, the patient demon-strated limited passive left shoulder flexion to 135'with a painful end-feel. In the ULTT2, left lateral el-bow pain was reproduced with scapula depression and

    FIGURE 3. Thoracic manipulation with the therapist's hand as a fulcrum elbow extension to 90' with neutral shoulder rotationat T3-T4. and wrist position. Following thoracic manipulation toJ Orthop Sports P hp Ther .Volume SO Number 7 .July 2000 405

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    headache b headache:r. (no change)

    cold I f ' 1swellingpainfulpurple

    \ resolved

    temperatureand color

    FIGURE 4. Signs and symptoms before (A) and after (El) manipulation. P indicates pain.

    the left T3, T4, and T5 facet and costo-transversejoints with the patient prone and head rotated right,left shoulder flexion increased to 175" with no pain atend-range. Reexamination of the ULTT2 showed anincrease in left elbow extension range to 16". Therewas decreased pain at the end-range of elbow exten-sion. Treatment included passive stretching of thearm in external rotation and active stretching mobili-zation while in the sitting position, including weightbearing onto a gym ball (Figure 5).

    The patient's progression of therapeutic exercisesand desensitization therapy is summarized in Table 3.Five weeks after the thoracic manipulation, Neuron-tin was prescribed for left elbow pain; the patient re-ported that she took it on an irregular basis to "helpher sleep."RESULTS

    The patient's status at 10 weeks is summarized inTables 1 and 2. She showed significant improvementsin range of motion and pain levels, as well as a nor-malization of autonomic activity. Functionally, the pa-

    tient resumed use of the left arm in activities such ascooking, cleaning, driving, and writing. Emotionally,she showed anxiety in initiating activity with the lefthand and upon discharge, she was considering re-joining a gym club and enrolling in a program totrain for return to work.DISCUSSION

    Manipulation of the thoracic spine may have re-sulted in improvements in distal upper extremitypain, skin color, and temperature in a patient withCRPSI. We hypothesize that there is a unique linkbetween symptoms of upper quadrant CRF'S and thethoracic spine. One explanation is that disuse of thearm and abnormal posturing may contribute to tho-racic hypomobility. Furthermore, the anatomic prox-imity of the sympathetic chain to the dysfunctionalthoracic joints may predispose the ganglions to me-chanical pressure. Therefore, we concluded that e d -uation and treatment of areas proximal to the pa-tient's symptoms were necessary.

    Our patient was evaluated 5 months after initial in-406 J Orthop Sports Phys Therevolume 30-Number 70July 2000

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    --- " thoracic h hos i s . which then allowed an im ~rove-

    FIGURE 5. Functional retraining with patient sitting and weight bearingarm extremity on gym ball. The therapist is standing.

    ,ment in shoulder elevation. However, we did not ex-pect an additional immediate change in the sympa-thetic symptoms. Possible explanations for thosechanges include: neurogenic stimulation to the sympa-thetic nervous system, relief of mechanical pressure tothe sympathetic trunk, reduction of thoracic z y g a pphyseal referred pain, reflexive inhibition of muscleguarding, and possibly a placebo effect.

    Neurogenic Stimulation to the Sympathetic NervousSystem

    Kornberg and McCarthy2"resented a study inwhich a slump stretch resulted in a significant short-term temperature increase of the mobilized extremi-ty compared with a control. They attributed the tem-perature change to an intraneural stretch stimulusthat caused an afferent barrage to the system. In anin vitro study, Sato and S w e n ~ o n ~ ~eported sympa-thetic nervous system responses to applied forces tothe lateral aspect of two mobile vertebral segments inrats. They identified large changes in blood pressureand smaller decreases in heart rate. The thoracic ma-nipulation in our patient may have also caused animmediate afferent stimulus ;hat altered sympatheticoutflow; however, the exact nature of the mechanism1 is uncertain.

    jury and after having had one month of occupationaltherapy and one month of physical therapy that pro-duced little change in symptoms. Therefore, the ini-tial objective was to evaluate the possible sources ofsymptoms. Immobility of the trunk with restrictedthoracic intervertebral motion was observed. Wechose to manipulate the most restricted and sympto-matic thoracic vertebral segment (T3T4). This re-sulted in improved joint mobility and sympatheticoutflow. We were then able to proceed with a proto-col suggested by Stanton- hick^,^" which focuses onthe distal extremity symptoms and functional re-edu-cation. Concurrent with physical therapy, the patientwas receiving psychological and drug therapies. Wecannot discount the possibility that the overall im-provement in status was due to the multidisciplinaryintervention.

    Identifying the specific mechanism responsible forchanging the distal symptoms after thoracic manipula-tion is difficult. We hypothesize that there may havebeen both mechanical and neurologically mediatedmechanisms. The immediate increase in shoulderflexion after manipulation was likely due to a mechan-ical change in the tissue. We may have reduced the

    Relief of Mechanical Pressure to the SympatheticTrunk

    We believe that in addition to the neurogenic re-sponse, the thoracic manipulation in our patient mayhave also relieved a mechanical pressure on the adja-cent paravertebral sympathetic chain ganglia in thesympathetic nervous system, causing the long-termchanges we observed. In a comprehensive study of1000 cadavers, Nathan3' found that 65% had osteo-phytes compressing the sympathetic chain. In an earli-er study, Nathanw found that 100% of the 400 verte-bral columns studied had evidence of osteophytes bythe fourth decade. Furthermore, Gilesa2 krformed ahistologic investigation of 3 cadavers, which showedevidence of the osteophytes deforming the paraspinalchain ganglia. Finally, Gonzalez-DarderI3 eported thatthe surgical removal of osteophytes compressing theT4 nerve relieved a patient's chronic back pain in thedistribution of T3T5 dorsal rami. The patient alsohad autonomic symptoms of pallor, sweating and syn-cope, which were relieved with the surgery. In addi-tion, Weinbergw observed degenerative arthritis in theupper costovertebral oint in all 40 patients who werediagnosed with thoracic outlet syndrome. He attribut-ed the radiating pain of these patients to the patho-logical joint changes, which affected the sympathetictrunk. Stellate ganglion blocks in the area of these ar-

    J Orthop Sports Phys Ther-Volum e 30-N umber 7.July 2000 40 7

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    thritic joints completely relieved symptoms in 25 pa-tients and gave partial relief in 14.Reduction of Thoracic Zygapophyseal Referred Pain

    While we have assumed that sympathetic distalsymptoms in our patient were a result of the distaltrauma, we cannot discount the possibility of re-ferred peripheral pain from the thoracic zygapophy-seal joint. In a study of pain patterns in normal s u bjects, Dreyfuss et a19 administered provocative intra-articular injections of the thoracic joints. They re-ported symptoms of unilateral glove paresthesias ofthe upper limbs and headaches after injection of theT3T4 or T5T 6 joints, in addition to the expectedintrascapular pain. Therefore, the manipulation inour patient, which was directed to the zygapophysealjoint, may have affected the joint mechanics and re-sulted in a reduction of the patient's distal symptoms. The immediate relief of the distal symptomsmay indicate that there was a possible direct link be-tween the apophyseal joints and the patient's painpattern.Inhibition of Muscle Guarding

    Pain inhibition after spine manipulation has beens u g g e ~ t e d . ~ ~ . ~ ~erzog et a120 reported a sharp de-crease and cessation in the electromyographic signalof hyperactive muscles after manipulation and sug-gest that the motor neuron drive to the spastic mus-cles was eliminated because of the treatment. Theyconcluded that the reflex response was associatedwith a multitude of mechanoreceptors and propri*ceptors in the muscles, tendons, skin and joint c a psule underlying the treatment area. The specificmechanisms included an interruption of the trans-mission of pain, a reflex response in the target mus-culature, and reflex relaxation of spastic muscles.This muscle response is similar to the reflexive inhi-bition first described by Sherrington in 1906 wherecontraction of a muscle will be immediately followedby inhibition of that muscle.45Furthermore, the re-duction in pain may be secondary to the increase insensory input of the manipulation. MelzackM ntro-duced the gate theory, which states that any increasein sensory input, whether cutaneous, muscular, artic-ular, visual or auditory, will block the afferent trans-mission of pain pathways. It is possible that the ma-nipulation provided a sensory input, which either in-hibited the muscle or blocked the pain.The Placebo Effect

    The psychological effect of the clinician's hands iswell-accepted in the medical community and cannotbe discounted as a factor influencing the patient's re-sponse to thoracic manipulation. It is known that af-

    ter a treatment in which there is an audible pop orsnap, the placebo factor is undeniably high.39 Howev-er, studies have been done to determine whether theeffects of manipulation are due to the treatment ef-fects or the "laying on of hands." Hoehler and To-bis2' did a double-blind study of manipulation versussham in which the manipulation group reported sig-nificantly greater relief compared with patients expe-riencing "laying on of hands." They concluded thatsomething intrinsic to the manipulative thrust couldreduce spinal pain. While we cannot dismiss the pla-cebo effect of pain reduction, we did observe objec-tive signs of change in skin temperature.CONCLUSION

    Chronic and heightened perception of pain aftertrauma or surgery is a common but poorly under-stood impairment. The Guide to Physical TherapistPractice2 (consensus of experts), suggests that for adiagnosis of reflex sympathetic dystrophy, the prog-nosis for return to highest level of function is up to4 months, and 80% of all patients are expected toachieve the desired outcome in 3 to 21 visits. Ourpatient was treated for 3 months; however, her 36treatments exceeded the expected number of visits.Factors that may have increased the number of treat-ments beyond the number specified in the guide in-cluded chronicity and severity of her symptoms, aswell as continued emotional distress. In addition, thetreatment we have described was delayed until 5months after the initial injury.

    We believe that there may be a link between thethoracic spine and distal symptoms in patients withCRPSI. Thoracic joint manipulation appeared to im-prove spinal mobility, and also appeared to relievedistal and autonomic symptoms. These improvementsallowed for functional rehabilitation of the affectedarm. Therefore, it is our opinion that mobility of thethoracic spine should be evaluated for patients withautonomic dysfunction diagnosed with CRPSI. Fur-ther research is warranted to help define the rela-tionship between neurogenic symptoms and musculo-skeletal pathology. In addition, the physiologic re-sponses of manual therapy in patients with CRPSIshould continue to be documented and reported.

    REFERENCESAdler S, Beckers D, Buck M. PNF in Practice: An Illus-trated Guide. Berlin, Germany: Springer-Verlag; 1993.American Physical Therapy Association. Guide to Physi-cal Therapist Practice. Phys Ther. 1997;77:1264-1275.Bennett G, Roberts W Animal models and their contri-bution to our understanding of complex regional painsyndromes I and II. In: Janig W Stanton-HicksM, eds.Reflex Sympathetic Dystrophy: A Reappraisal. Seattle,Wash: IASP Press; l996:lO7-12 1.Bonica J. The Management of & in. 2nd ed. Philadelphia,Pa: Lea & Febiger; 1990.

    J Orthop Sports PhysTher *Volume SO. Number 7.July 2000

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    5. Bowsher D. Neurogenic pain syndromes and their man-agement. In: Wells JCD, Woolf CJ, ed ~ . ain Mechanismsand Management. Br Med Bull. 1991 47:644-666.6. Bruehl S Harden RN, Galer BS, et al. External validationof lASP diagnostic criteria for Complex Regional Pain Syn-drome and proposed research diagnostic criteria. Inter-national Association for the Study of Pain. Pain. 1999;81:147-1 54.7. Butler DS. Mobilization of the Nervous System. Mel-bourne: Churchill Livingston; 1991.8. Charlton JE. Management of sympathetic pain. In: WellsJCD, Woolf CJ, eds. Pain Mechanisms and Management.Br Med Bull. 1991;47:601-618.9. Dreyfuss P Tibiletti C, Dreyer SJ.Thoracic zygapophysealjoint pain patterns. A study in normal volunteers. Spine.1994;19:807-811.10. DzwierzynskiWW, Sanger JR. Reflex sympathetic dystro-phy. Hand Clin. 1994;10:2944.11. Frese E, Brown M, Norton BJ. Clinical reliability of man-ual muscle testing. Middle trapezius and gluteus mediusmuscles. Phys Ther. 1987;67:1072-1076.12. Giles LGF. Paraspinal autonomic ganglion distortion dueto vertebral body osteophytosis: a cause of vertebrogenicautonomic syndromes?)Manipulative Physio Ther. 1992;15:551-555.13. Gonzalez-Darder JM. Thoracic dorsal ramus entrapment.Case report. ) Neurosurg. 1989;70:124-125.

    14. Gracely R Price D, Roberts W, et al. Quantitative sensorytesting in patients with complex regional pain syn-drome(CRPS) I and II. In: JanigW, Stanton-Hicks M, eds.Reflex Sympathetic Dystrophy: A Reappraisal. Seattle,Wash: IASP Press; 1996:151-172.15. Harding VR, Williams A. Extending physiotherapy skillsusing a psychological approach: cognitive-behaviouralmanagement of chronic pain. Physiotherapy. 1995;81:681 688.16. Hardy MA, MoranCA,Merritt WH. Desensitization of thetraumatized hand. Va Med. 1982;109:134-137.17. Hardy MA, Hardy SG. Reflex sympathetic dystrophy: theclinician's perspective. ) Hand Ther. 1997;10:137-150.18. Hassenbusch SJ, Stanton-Hicks M, Schoppa D, et al. Long-term results of peripheral nerve stimulation for reflex sym-pathetic dystrophy. )Nemurg. 1996;84:415423.19. Headley B. Historical perspective of causalgia. Manage-ment of sympathetically maintained pain. Phys Ther.1987;67:1370-1374.20. Herzog W, Conway PJ, Zhang YT, et al. Reflex responsesassociated with manipulative treatments on the thoracicspine: a pilot study. )Manipulative Physiol Ther. 1995;18:233-236.21. Hoehler FK, Tobis JS, BuergerAA. Spinal manipulation forlow back pain. IAMA. 1981;245:1835-1838.22. Janig W. The puzzle of "reflex sympathetic dystrophy":mechanisms, hypothesis, open questions. In: Janig W,Stanton-Hicks M, eds. Reflex Sympathetic Dysthropy: AReappraisal. Seattle, Wash: IASP Press; 1996:l-24.23. Kaltenborn F The Spine: Basic Evaluation and Mobiliza-tion Techniques. Minneapolis, Minn: OPTP; 1993.24. Kendall FP, McCreary EK, Provance PG. Muscles: Testingand Function. 4th ed. Baltimore, Md: Williams and Wil-kins; 1983.25. Kornberg C, McCarthy TM. The effect of neural stretchingtechnique on sympathetic outflow to the lower limbs. )Orthop Sports Phys Ther. 1992;16:269-274.26. LaStayo PC, Wheeler DL. Reliability of passive wrist flexionand extension goniometric measurements: a multicenterstudy. Phys Ther. 1994;74:162-174; discussion 174-1 66.27. Maitland GD. Vertebral Manipulation. 5th ed. Oxford:Butterworth-Heinemann; 1986.

    28. Marieb EN, Mallett J. Human Anatomy. 2nd ed. MenloPark, Calif: Benjamin Cummings; 1997.29. Marks GC, Habicht JP, Mueller WH. Reliability, depend-ability, and precision of anthropometric measurements.The Second National Health and Nutrition ExaminationSurvey 1976-1 980. Am )Epidemiol. 1989;130:578-587.30. Mathiowetz V, Kashman N, Volland G, et al. Grip andpinch strength: normative data for adults. Arch Phys MedRehabil. 1985;66:69-74.31. McGuckin N. The T-4 syndrome. In: Grieve GP, ModernManual Therapy of the Vertebral Column. 2nd ed. NewYork: Churchill Livingston; 1986:37&376.32. McMahon SB. Mechanisms of sympathetic pain. In: WellsJCD, Woolf CJ, eds. Pain Mechanisms and Management.Br Med Bull. 1991 47:584-599.33. McNair J,Maitland G. Manipulative therapy techniquesin the management of some thoracic syndromes. In: GrantR ed. Clinics in Physical Therapy: Physical Therapy of heCervical and Thoracic Spine. New York: Churchil l Living-stone; 1988:243-269.34. Melzack R. The Puzzle of Pain. London: Penguins; 1973.35. Merskey H, Bogduk N. Classification of Chronic Pain:Pescriptions of Chronic Pain Syndromes and Definit ion o fPain Terms. Seattle, Wash: IASP Press; 1994.36. Nathan H. Osteophytes of the vertebral column: an ana-tomical study of their development according to age,race, and sex with considerations as to their etiology andsignificance. )Bone oint Surg [Am]. 1962;44:243-265.37. Nathan H. Osteophytes of the spine compressing the sym-pathetic trunk and splanchnic nerves in the thorax. Spine.1987;12:527-532.38. O'Malley T Kamkar A. Manual examination and treat-ment of the cervicothoracic region. In: Erhard R, lglarshA, RichardsonJ, eds. Orthopedic Phys Ther Clin NAmer;1998:499-523.39. Paris S. Spinal manipulative therapy. Clin Ortho Re1 Res.1983;179:55-61.40. Riddle DL, Rothstein JM, Lamb RL. Goniometric reli-ability in a clinical setting. Shoulder measurements. PhysTher. 1987;67:668-673.41. Rothstein JM, Miller PJ, Roettger RF. Goniometric reli-ability in a clinical setting. Elbow and knee measure-ments. Phys Ther. 1983;63:16ll-1615.42. Sandroni P, Low PA, Ferrer T, Opfer-GehrkingTL, WillnerCL, Wilson PR. Complex regional pain syndrome I (CRPSI): prospective study and laboratory evaluation. Clin )Pain. 1998,14:282-289.43. Sato A, Swenson RS. Sympathetic nervous system re-sponse to mechanical stress of the spinal column in rats.

    )Manipulative Physiol Ther. 1984;7:141-147.44. Schwartzman RJ, Liu JE, Smullens SN, Hyslop T Tah-moush AJ. Long-term outcome following sympathectomyfor complex regional pain syndrome type 1 (RSD).)Neu-rol Sci. 1997;150:149-152.45. Sherrington C. Integrative Action of the Nervous System.New Haven, Conn: Yale University Press; 1906.46. Stanton-Hicks M, Baron R, Boas R et al. Complex re-gional pain syndromes: guidelines for therapy. Clin) Pain.1998;14:155-166.47. Voss D, lonta M, Myers B. ProprioceptiveNeuromuscularFacilitation: Patterns and Techniques. 3rd ed. Philadel-phia, Pa: Harper and Row; 1985.48. Wadsworth CT,Krishnan R Sear M, Harrold J Nielson DH.lntrarater reliability of manual muscle testing and hand-helddynametric muscle testing. Phys Ther. 1987;67:1342-1371.49. Watson HK, Carlson L. Treatment of reflex sympatheticdystrophy of the hand with an active "stress loading" pro-gram. ) Hand Surg [Am]. 1987;12:779-785.50. Weinberg H, Nathan H, Magora F Robin GC, Aviad I.Arthritis of the first costovertebral joint as a cause of tho-racic outlet syndrome. Clin Orthop. 1972;86:159-163.

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