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Olive K. Pester, M.C.S.P. M.C.P.A.

 Although  many  physiotherapists  are  able  to  diagnose  and 

effectively treat patients with cervical and lumbar disc lesions, patients having thoracic disc lesions may suffer unnecessary pain or receive misguided treatment when their condition is labelled as fibrositis of the chest wall, pleurodynia, inter-costal neuritis, and so forth.

 Diagnosis is not difficult,  however, if thoracic disc lesions 

are kept in mind. The influence of both posture and exertion, on the pain, should be elicited in the patient's history, and the movements of the thoracic spine should then be tested.

Evaluation of clinical data

 The only basis for deciding whether or not to manipulate is  a 

careful and informed evaluation of the clinical data. The articular, dural, root and cord signs should be carefully evaluated, and if there is any evidence of pyramidal pressure, manipulation is absolutely contraindicated.

 The  difficult  cases are those with a primary  posterolateral 

onset. Root pain is felt in the anterior thorax or abdomen, emerging without previous backache. A physician must examine these patients and rule out any involvement of the viscera (heart, lungs, stomach, and so on). Vertebral manipulation will relieve pains of spinal origin, but not those correctly ascribed to the viscera.

 In the orthopaedic department, most patients with spinal joint 

pain are suffering from a minor displacement of a fragment of disc. It is immaterial whether the disc is thin or thick, or whether osteophytes are present or not. X-rays are used to help rule out the pathologies not treatable by manipulation: osteoporosis, ankylosing spondylitis, rheumatoid arthritis, fractures, tumors, neoplasms, and so on.

 The  diagnosis  of thoracic disc problems is arrived at  by  a 

"Cyriax-type assessment" which involves examining for articular signs and for dural signs and symptoms.

Mobilization/manipulation technique

 The  simplest  and most effective method of treating  thoracic 

disc problems is by a mobilization/manipulation of the thoracic spine. The results of the treatment, for disc problems, are unusually excellent. Three hundred patients having thoracic disc problems were treated in this manner during a recent 12-month period at the author's clinic. Treatment ranged from two to eight sessions, depending on the number of levels involved in the spine and the degree of stiffness, pain and symptoms present. The success rate has been better than 90 per cent.

 The  main  problem is to inculcate in the patient a desire  to 

maintain the erect posture for much of his working day. Although slouching may be harmful for any areas of the spine, it is disastrous for the thoracic region. A follow-up program including swimming, walking, dancing, fencing - all activities that encourage an awareness of posture and relaxation - should be recommended to the patient.

The wedge: aid to mobilization

 A common problem of the  treatment,  mobilization/manipulation 

of the thoracic spine, occurs when a 5'4" female physiotherapist attempts to mobilize the thoracic spine of a 6'2", 200 pound patient. By the time the physiotherapist has placed her hand around the chest wall of the patient, to fixate the thoracic spine being treated, she frequently has no power and little leverage left with which to mobilize the offending joint.

 A  small  wedge  has therefore  been  developed  by  Norwegian 

physiotherapist Freddy Kaltenborn as an aid to the painless mobilization of the thoracic spine. It enables a physiotherapist to mobilize successfully, and with little physical effort, the thoracic spine of large, heavy patients.

 Construction: the wedge is made of molded polypropylene with a 

base measuring nine inches and a height of three and one-quarter inches. The central groove, in which the spinous process fits, is one inch across.

 Directions  for  use:  the patient lies supine and clasps  his 

neck in such a way that his elbows are brought together over his sternum. The therapist stands on the right side and grasps the patient's elbows with her left hand. She rolls him toward herself and firmly fixes the thoracic vertebrae to be mobilized within the groove of the wedge. The wedge now acts as a fulcrum and the physiotherapist, by leaning over the patient, can thrust through the patient's elbow in a downward direction. By altering the position of the wedge or by altering the degree of flexion of the thoracic spine, the physiotherapist can mobilize or manipulate all thoracic joints in this manner.


 The wedge has been used for over a year in the author's clinic 

and is recommended in the treatment of patients with thoracic disc problems. In cases involving the toracic spine, it is the maintenance of a reduction which is difficult. After the mobilization manipulation procedure, a program of extension exercises must be initiated.

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