Her physician referred Mrs. T for a physiotherapy assessment. She was assessed first time on 8th April 2016.
Ms. T is a 55-year-old nurse who has long history of recurrent thorax pain past 15- to 20-years. She remembers her symptoms have been recurrent since teenage, but after her second pregnancy symptoms have started to appear more frequently. She has given birth to two children, both with C-section. Before her recurrent issue of back pain in mid thorax area, she remembers having at least two lumbagos before her first pregnancy. When she had the LBP episodes, she also had right knee pain that aggravated with running.
When she goes running, after few kilometers she experiences upper extremity numbness on both arms, she feels pain and discomfort in her cervical-thoracic junction and pain in left shoulder as well as in the mid thorax between her shoulder blades. After flaring up, pain symptoms can go on for 3-5 days. Her upper extremities numbness gets better when she stops running and shakes her arms for a while.
She also reported right arm numbness when not sleeping in her own bed.
She has tried different treatments on her symptoms such as dry needling, physiotherapy and various manual therapy treatments. All treatments have provided temporary or none relief on her symptoms.
She has taken painkillers for the pain, when pain is flared-up. Painkillers dulls the pain, yet won’t take it away completely.
She has been in a car accident 20-year-ago. She drove a car off the road ending upside down in a ditch. She had seatbelt on and she didn’t have any injuries due the accident based on the medical assessment after the accident.
There is a history of brain and heart diseases in her family. She has been in a heart assessment year 2010 where there were noted a small leak on aortic flap. She has had shorts episodes of chest pain, which concerns her.
She had a protrusion on L4 radiating symptoms on her right lower leg in 2006.
Her right knee was RTG-imagined in 2008 after period of pain and discomfort. In the assessment there was diagnosed knee hydrops, her knee was punctured at that time.
At the initial assessment, Mrs. T complained two areas of pain:
- Pain between shoulder blades, aggravated with running.
- Pain in the thoracic-cervical junction, aggravated with running.
She also reported numbness of her upper extremities while running and when sleeping somewhere else than in her own bed. Numbness starts from her arm going all the way to around her wrist. Her symptoms are clearly aggravated with activities and will go on for 3-5 days after flare-up.
In Mrs. T’s family women are prone to have same kind of symptoms as she does. Her mother and grandmother have had mid-thorax pain and upper extremity numbness, so she strongly feels that she is structurally prone to have back stiffness and other symptoms as noted before.
Based on Mrs. T’s story, the meaningful asks were identified as follows:
The screening tasks that were chosen to further assess were chosen from the requirements to perform the above meaningful task – running. Screening task side was determined by her subjective experience which side was harder to perform in terms of balance, effort and ease. They included: Standing postural screen, seated trunk rotation to the right, one leg standing on the left side.
Standing Postural Screen
This screen was chosen as a screening task to define starting position of other tasks, so that we can determine what changes in posture, alignment, control and biomechanics are relevant in other screening tasks.
There were no reported symptoms during evaluation of the static standing postural screen. Mrs. T stood with a left intrapelvic torsion (IPT) (added information after questions below – accompanied with left transverse rotation (TPR)). Right hip is anterior relatively to the right acetabulum. The low thorax is rotated to the left. Specifically, 9th thoracic ring is in right translated/left rotated position in standing. In the mid thorax 4th thoracic ring is left translated/right-rotated position and 5th thoracic ring is in right translated/left rotated position. Her C4-6 were left translated/right rotated.
Left one leg standing
This screen determines the ability to transfer load in one leg standing and is crucial assessment for her meaningful task of running, which requires single leg loading. Side was determined by asking her which side is more effortful. When she lifts her right leg, her pelvic girdle feels unstable.
In this screening task her pelvic girdle feels unstable. When she performs the screening task her 9th thoracic ring translates right/rotates left. 4th and 5th thoracic rings maintain its positions, 4th thoracic ring keeps rotated to the right and translated to the left and 5th thoracic ring keeps rotated to the left and translated to the right. C4-6 rotates even more to the right. At right SI-joint Ilium fails to rotate posterior in relation to sacrum. Left hip rotates internally and adducts.
Manual correction of the left hip resulted better mobility of the right SI-joint and partial control of the 9th thoracic ring. 4th thoracic ring keeps rotated to the right, translated to the left and 5th thoracic ring keeps rotated to the left, translated to the right. Correcting the left hip and 9th thoracic ring resulted best experience as task felt stable and easy. With 9th thoracic ring correction her cervical spine and thorax stays better aligned except 4th and 5th thoracic rings, which stays in the same position during the task. With 9th thoracic ring correction her left hip feels, in her words, “wobbly”.
Correcting 4th and 5th thoracic ring was impossible due stiff end-feel on thoracic rings when correcting the thoracic rings. With a manual hip correction 5th thoracic ring could be corrected a little, 4th thoracic ring did not correct with any manual correction.
Primary driver for this task is left hip and secondary driver is 9th thoracic ring. It is still unclear what is driving the 4th and 5th thoracic rings, yet I found no correction to correct the site in initial assessment. Area is to be assessed further.
Seated trunk rotation to the right
Screen determines ability to perform normal biomechanics, control and alignment during her meaningful task of running, which requires trunk rotation on the opposite side of the loaded leg when performed optimally. As stated before, this task was performed seated due the experience of the movement.
In the screening task (seated trunk rotation to the right), she reports familiar stiffness in her mid thorax at T4-T5 area. When she rotates to the right C4-6 keeps rotated to the right, 4th thoracic ring maintains rotated right and translated left. 5th thoracic ring keeps rotated left and translated right.
9th thoracic ring rotates left and translates right even more when she rotates right. After 9th thoracic ring fails to transfer load optimally, she reports stiffness at 4th and 5th thoracic ring area. 9th thoracic ring correction results more range of motion and no symptoms in mid thorax area.
Screening Task Summary
Findings suggest areas of the body where to start the treatment. The primary driver is an area of the body that results the best total response in the task. The secondary driver is an area of the body that results partial improvement in the body, not fully correcting other site of failed load transfer. This knowledge helps to coordinate what areas of the body need to address treatment.
- Right OLS primary driver – Left hip secondary driver: 9th thoracic ring
- Seated trunk rotation: Primary driver – 9th thoracic ring
4th and 5th thoracic rings were glued together and couldn’t be corrected in any position. This site will be assessed in further appointments. 4th and 5th thoracic rings felt to be compressed, meaning no joint play and no movement of the thoracic rings when correcting the area. With 9th thoracic ring correction and in child pose 4th and 5th thoracic rings could be corrected partially but they moved together implicating that area should be assessed further.
Her lower cervical spine correct itself with 9th thoracic ring correction suggesting it doesn’t need to be addressed at this time.
Manually correcting the 9th thoracic ring made right hip to feel unstable during one leg standing on the left side and correcting the left hip partially corrected 9th thoracic ring. Correcting manually the left hip to the centered position and keeping it corrected with 9th thoracic ring partial correction made best result of experience in the initial assessment on the one leg standing on the left side. This suggested that ability to coordinate deep muscle system was to be tested.
Motor control was tested supine with lower extremities flexed.
We initially tested Mrs. T’s ability to recruit pelvic floor muscles and transversus abdominis muscle in supine with external palpation. Tests showed that she had poor recruitment response over her pelvic floor on her left side. The clinical palpation tests were confirmed via ultrasound imaging examination.
During lying in prone, legs flexed, she was able to recruit transversus abdominis muscle with a verbal cue, but she was unable to maintain contraction on her transversus abdominis muscle at the level of 9th thoracic ring while breathing normally. Optimally a person should be able to keep the contraction of transversus abdominis muscle while breathing normally. She had a proper recruitment response over transversus abdominis muscle with verbal cue, but she held her breath while doing so. When she was asked to maintain contraction and breath normally, she failed to do keep the contraction during a verbal cue.
Inability to control lower thorax may result in excessive tone in superficial muscles i.e. QL, EO, IO, IC and so could relate to pelvic control by creating a pull to the pelvic girdle and/or affect lower abdominal pressure.
With the pelvic floor, she had no recruitment response over her left ischiocavernosus muscle and left transverse perineal muscle.
After releasing 9th thoracic ring and left hip, we assessed her deep muscle system again with following findings:
- Transversus activation was still the same, but with 9th thoracic ring correction she had better contraction and she was able to breathe normally while maintaining the contraction.
- With the pelvic floor findings were the same as before, but with 9th thoracic ring correction she had better resting activation over her left ischiocavernosus muscle and left transverse perineal muscle, but recruitment response was still weak.
We tested active straight leg raise test resulting left leg to be harder to lift. With 9th thoracic ring correction and a verbal cue to connect with her pelvic floor lifting left leg was easier. Suggesting better recruitment patterns for the task.
Motor control is an important part of the physiotherapy, and it is crucial to assess deep muscle systems endurance and ability to contract or relax it with intention. Tests suggest that motor control should be included on treatment plan. Motor control should be assessed more after release.
Mrs. T’s primary driver is 9th thoracic ring with vector analysis suggesting visceral vector coming from anterior part of the right the thorax, more specifically liver and/or gallbladder. My hypothesis is that her body has had to compensate different stresses over time, suffering car accident and two pregnancies. For this reason she has learn thigh gripping strategy to maintain hip control. Pelvic floor contains muscles that control hip joint as well. If femur head loses centered position in the hip socket, it will change relations of the pelvic floor muscles.
Diane’s response: Above you state: “Correcting manually the left hip to the centered position and keeping it corrected with 9th thoracic ring partial correction made best result of experience in the initial assessment on the one leg standing on the left side.” Therefore this would be defined as a co-driver or secondary driver as you mention below. Depends if they are related 50/50 or if one has more precedence which it seems like the 9th thoracic ring does.
Thoracic-cervical junction and 4th and 5th thoracic rings should to be assessed later on. With no possibility to correct the area and no change in the areas alignment with other corrections suggest that there are still drivers to be found.
Initial treatment session (RACM)
Primary driver (9th thoracic ring) (see video 3Release&align_TR9): Secondary driver (hip):
- Release adductor longus and adductor brevis muscles of the left hip, using positional release with awareness and trigger points.
- Release of 9th thoracic ring with ring stack and breathe, combining it with vector specific stretch. Correcting 9th thoracic ring alignment as much as possible, then rotating thorax to find the specific vector, in this case rotating thorax upward and lateral (see video 4Seated_rotation_re-test for post release improvement in seated right rotation). After local release, rotating lower extremities were used with 9th thoracic ring alignment to find vector pulling to the 9th thoracic ring.
- 9th ring alignment corrected left hip alignment after release. Best cue: let your thoracic rings float. 9th thoracic ring and left hip was first released manually.
- Pelvic floor contraction was evaluated with ultrasound initially and after release of the left hip and 9th thoracic ring
- Pelvic floor contraction was possible after hip release, but she was unable to maintain contraction. – This suggests an endurance deficit.
Relationship between the 9th thoracic ring alignment and hip alignment and impact on pelvic floor recruitment were assessed both manually and with ultrasound imaging. 9th thoracic ring alignment cue (let your thoracic rings float) clearly restored her hip alignment to neutral. This was felt manually (femoral head centered) and her pelvic floor ability to recruit and relax was seen via ultrasound imaging and felt manually externally.
She was given three home exercises:
- Maintaining of left hip abductor range of motion moving lower extremity passively in supine using strap while maintaining 9th thoracic ring alignment. Breath 3-4 times at the end – Lateral costal breath, which gave the best sensation of release perform 2-3 times before other exercises.
- Supine 9th thoracic ring alignment combined with Pelvic floor activation three second hold 10 times a day 2-3 times a day to work on pelvic floor endurance.
- Left one leg standing 10 high quality repetitions, using mirror and/or her hands to ensure optimal thorax and optimal hip alignment, three times a day. Palpating thoracic rings and hip was taught to her step by step, finding out the easiest way for her to be sure she is maintaining optimal strategy for the task.
Exercises was to be done in given order concentrating on increasing pelvic floor endurance and control, maintaining hip range of motion and promoting brain plasticity to create better movement strategy for meaningful task.
After the initial treatment session she reported ease of her mid-thorax symptoms. After two week after the first visit she was able to run half marathon without flaring up any symptoms. She still had some feeling in her cervical-thoracic junction and arm numbness while running, but symptoms didn’t stay for days. She felt she could run more effortless as before.
In the follow up treatment sessions left hip needed less of releasing and needed more concentration on control. 9th thoracic ring needed releasing on every session, but on third session we noted that 4th and 5th thoracic rings could be partial corrected manually. With 4th and 5th thoracic ring correction range of motion in thoracic rotation increases flaring up cervical-thoracic junction stiffness and pain. 4th and 5th thoracic ring relationship with shoulder girdle and cervical spine is to be assessed later on.
In the follow up treatment sessions home exercises were progressed to thoracic rotation in sitting and in lunge, one leg standing with partial one leg squat and hip rotation via trunk and pelvic.