Many people suffer from thoracic pain. Our osteopaths work in our specialist rehabilitation clinic for pain in Cambridge, with pain management treatment and rehabilitation therapy, for mid back pain, and other thoracic spine pain conditions. Working with a vast range of physical capabilities, allows us to have very positive contact with such pain symptom sufferers. This is why we provide some of the most effective Cambridge Osteopath treatments.
In fact, Thoracic pain (including middle back muscle pain, upper back pain, intercostal strain, or similar pain syndromes and muscle strain) is currently a common musculoskeletal disorder, and the burden is most likely underestimated. The ‘physical and personal impact’ of musculoskeletal illnesses are believed to generate some of the highest costs to society, by threatening ‘efforts to support healthy ageing’. Thoracic spine pain seems to have large effects on disability levels and quality of life. This risk of spinal pain increases incrementally with ‘comorbidity’ levels.
Some of the most commonly ‘diagnosed’ issues leading to an episode (acute), or multiple episodes (chronic), of thoracic pain, with or without ‘swelling’ (filling of the joint’s and capsule’s or fluid around the joint’s area) are:-
Functional spinal instability, structural back instability, mid back pain, intervertebral joint sprain, thoracic spine pain, thoracic subluxation, ‘disc’, ‘zygapophyseal joint pain’, paraspinal muscle strain, costotransverse joint sprain, middle back muscle pain, back pain, strain, sprain, motor control imbalances, tendonitis, ligament sprain, muscle strains, muscle spasms, over use syndromes, degeneration, arthritis, cartilage injury, ‘inflammation’, ‘wear-and-tear Injuries’, ‘Tendonitis’, ‘wear and tear’, mechanical back pain, back stiffness, rib pain, spine swelling, costovertebral joint sprain, spinal ‘restriction’, ligament injury, costochondritis, rib fracture, stress fracture, ‘slipping rib syndrome’, intercostal muscle strains, muscle strains, pectoralis muscle injury, ‘myofascial pain’, ‘fibromyalgia’, scheuerman’s disease, ‘postural imbalance of the neck and shoulders and upper thoracic spine’, ‘T4 Syndrome’, ‘rib stress reaction / fracture’, thoracic disc prolapse, ‘tendinitis’ (tendonitis), trigger points, fracture of the rib posteriorly, trapped nerves, ‘nerve entrapment’, ‘sprains and strains’, osteoarthritis, ‘arthritis of the spine‘.….The list goes on!
The quality of some of these diagnosis concepts, and the actual correlation to your pain, are even more fascinating!
How This May Affect People
When this doesn’t go well, it often leads to a very dissatisfying outcome. This can manifest itself as: deconditioning, disability development, depression, loss of confidence in yourself and your body, which ultimately often leads to a dependency on pain altering medications, and poorer physical health. This can even affect the health related quality of life among adolescents, which then runs the risk of developing into adulthood.
So, what are we to do? Are we to:- be immobile?, be mobile?, be active?, or minimally active?, train into pain (‘no pain no gain’)?, or train avoiding pain?, stretch the spine?, or no stretching of the spine?, use medication management?, topical or oral?, use massage?, use mobilisation?, Osteopathy or chiropractic or physiotherapy?, use prescriptive exercise?, regular treatments or minimal treatments?, have imaging or not to have imaging?, surgery?, should we focus on structure or function?, or is it just age?!!!
I started seeing Michael due to my fatigue and back problems. I see him regularly and keep in contact via emails between this. I have found Michael to have a wide knowledge base, and feel he has helped me more than other professionals have. I feel that since my first visit, Michael has helped me improve at lot.
Our knowledge and understanding of the body, and mechanical anatomy of the thorax, its associated structures and the muscles used for stability and injury prevention, are still being updated and evolving. This allows for constantly changing assessments, treatment and rehabilitation techniques.
Sometimes additional investigations are needed. However, for ‘non-specific mid back pain’, they are rarely needed as a primary input into your assessment and treatment.
Imaging was originally seen by most, as a tool to rule out pathology or disease states, and less to diagnose specific musculoskeletal causes. Often this was due to a poor correlation of images and symptoms. New imaging approaches have developed, and our dependency on them has increased!
However, recent studies show that by performing a thorough clinical case history and physical examination you can often, very effectively decide if MRI or additional imaging or other investigations are needed.
Ultrasound imaging, may actually not be superior to manual palpation for identifying intervertebral level.
Furthermore, all patients should have a physical consultation in person, having the most suitable assessments for their case, and ensuring no non-musculoskeletal causes to their chest pain are indicated or identifiable. Perhaps verbal conversation alone without physical examination, may lack the diagnostic accuracy.
Ultrasound assessment, may hold more value in structural assessments of the chest wall, than is typically indicated. However, there are also recent studies that show that MR Imaging (MRI), may actually increase the patient’s likelihood of continuing in pain or disability status, and elongate their symptom picture.
Degeneration and Osteoarthritis
Then there are studies showing that degeneration changes, are just a part of function and use. These however, have no correlation with pain, or perceptions of illness, or illness behaviour i.e. age and degenerative changes have no clear causal link with pain.
In fact, some degenerative changes, such as osteophytes (small bony growths) seem to have a protective role against compressive fractures of the vertebrae in age.
Thoracic spine kyphosis severity, seen in static postures, is ‘not associated with subsequent physical function’. This led to the researchers concluding, ‘Individuals at risk of functional decline cannot be targeted based on supine CT thoracic curvature measures alone’. This leads towards the approach used for dynamic exercise therapy, that function is even more important than structure.
Imaging diagnosis is as difficult in thoracic spine pain cases, as it is in other regions. With ‘difficulties in efficiently correlating a pathologic imaging finding with clinical neurologic symptoms and signs, as well as the value of a thorough clinical neurological evaluation.’. They continue with saying ‘clear discrimination of a causal relationship against an incidental co-existence of a radiological finding and a specific symptom is not always possible.’
Physical assessment by a clinician is vital in all cases of mid back pain.
Muscle Strain and Muscle Pain
Functionally there are differences in muscle use of the thoracic spine, such as the deep and superficial muscles functioning differently, throughout different parts of the thorax. Some of these muscles may also be those which are commonly seen as lower back muscles. Which is why pulled muscle treatment, relies on as accurate a diagnosis as possible.
One of the easiest ways to assess how a person is functioning is looking at the level of ‘slump’ when seated. This will also show you if they are responding to stress and similar excitatory mechanisms. This may even affect the response of approaches towards motor control of muscle spasm treatment back pain.
Luckily it seems that increased activity of the thoracic paraspinal muscles, can usually be identified with the use of palpation. Palpation is a trained skill, use by osteopathic practitioners to help aid their diagnostic reliability. Interestingly, it seems it really does matter who is performing the examination, in regards to what the diagnostic reliability of your pain. This will certainly affect how people may approach your chronic pain management.
General Rib Conditions
Rib injuries can occur in many ways, and to variable levels of injury.
Slipped Rib Syndrome
Conditions such as slipped rib syndrome (a condition of instability), can be common among the more youthful age ranges, and can be sub classified if preferred, between different regions. Symptomatic sternocostal slipping rib syndrome is a lot less common.
This indicates that structural and function insufficiencies, do not always guarantee pain, and that pain doesn’t always present with physical changes.
Costochondritis can be assessed using physical examination and impairment based examination, which aids focusing of treatment. By assessing reproduction of pain with deep inhalation, range of motion and restricted motion of the cervical spine, thoracic spine, ribcage and shoulders, along with increased tone of the muscles indicating an increase in Sympathetic tone and perhaps Sensory overload.
Associated with costochondritis, is tietze syndrome, which is a rare, benign pain the chest, from localized inflammation, of costosternal, sternoclavicular, or costochondral joints, typically of the 2nd and 3rd ribs, which is normally managed with conservative treatments
Vitamin D deficiency, it seems can present with flank pain, vitamin D deficiency is common. It can also present as flank pain associated with tenderness over the tips of the lowermost ribs, over the costal margins, and renal angle proper. In these symptom cases vitamin D status perhaps should be assessed.
In the workplace, a lack of ergonomic principles can lead to postural changes, which have an effect on upper extremity (arm, shoulder and shoulder blade) and thoracic spine use, which can be less energy efficient and cause physical and health difficulties.
What Can Help
Transcutaneous electrical nerve stimulation (TENS) machine use, does not have enough good evidence for neuropathic pain treatments.
Pre-Surgery and Post-Surgery Rehabilitation
Osteopathic manipulative treatments, may improve post-surgical outcomes, Such as pain post chest surgery. Especially when performed in conjunction with standard care, and rehabilitation. Pain relief and functional recovery improvements are induced, perhaps aiding post-surgical sensitisation.
Similarly, for other chronic health changes, osteopathy may help manage / decrease the associated mechanical symptoms associated with such conditions in outpatient communities.
Manipulation as performed by a chiropractor or Osteopath, of the cervical and upper thoracic spine, helps increase extension and rotation ability of the spine, perhaps helping reduce the experience of stiffness of the spine.
This back pain relief may be occurring, by thoracic spinal manipulation of the T4 area, which then includes articular cavitation (joint popping sounds), decreased temporal summation of pain (inhibitory effects of pain information collection, which affects afferent drive), which is consistent with spinal anti-nociceptive mechanisms in clinical pain relief.
Reviews of osteopathic manipulative medicine, show it is an approach used for decades, on hospitalized and current inpatients, diagnosing and treating ‘somatic dysfunction’, associated with their other comorbidities. The most common condition consulted on was chest / rib pain, spinal pain. Techniques used include myofascial release, balance ligamentous tension, muscle energy techniques, and osteopathic manipulative treatment.
Rib related acute pain, may lead to chronic pain, such as biomechanically complex rib-related chest wall pain. Diagnosis can be assisted by using osteopathic palpatory (manual diagnosis) and physical examination techniques. Multi-modal treatment approaches can be applied clinically, with an emphasis on effective manual manipulative techniques of mechanically displaced ribs, and seem to help painful rib syndrome (mechanical rib-related pain), rib related chest wall pain (rib-related pain), and mechanical chest wall pain (mechanical rib pain), in combination with other approaches.
Costochondritis similarly has seen benefit and resolution, from manual therapy and therapeutic exercise used in combination, when treatment was directed at the cervicothoracic spine and ribcage.
Other techniques used are non-thrust manipulation, and manual therapy, for treatment of back pain, thoracic pain and rib dysfunction. These have been shown to have immediate decreases in tenderness on palpation of thoracic erector spinae musculature (muscle strain treatment) and associated intercostal spaces and ribs, with increase in active thoracic spinal motion and chest expansion capacity. The case study reports this ‘demonstrates the use of a spinal non-thrust manipulation’ with return to pain free sports, and no return of reported symptoms.
Chronic Nerve Pain and Middle Back Pain
Some pain conditions of the thorax, such as chronic sensory neuropathy, cause upper to middle back issues, typically below the shoulder blade. Symptoms include pain, pins and needles, and increases sensitivity to stimulus of the skin and tissues, and itching sensations, along with some possible pigmentation changes of the skin. These are believed to have correlations with degenerative spinal changes, and similar spinal nerve impingements,
Osteopathic manipulative treatment, of the thoracic spine and rib somatic dysfunctions, may help with patient reported improvements of symptoms.
Interestingly there are indications that spinal manipulation treatments of the thoracolumbar junction, may help symptoms management of organ health issues, such as kidney stone pain symptoms.
Costochondritis and associated pain, can be a painful and persistent inflammation of costochondral or costosternal junction.
Conservative treatments of NSAIDs, local splinting, local heat, local injections or anaesthetics, are sometimes disappointing in results.
The goal of treatment is to reduced inflammation and pain.
Mobility exercises for costochondritis pain, seem to show progressive significant amelioration (symptom reduction).
Rib Fracture Rehabilitation
Later, after rib fractures have healed and been managed medically, people may still find it challenging to regain pre-injury fitness, even after full healing and pain reduction / subsides.
Too often people just ‘make do’, and often believe there is nothing they can do..
A rehabilitation intervention, for pain, normalises trauma, and helps restore physical activity, and may improve recovery.
Education and rehabilitation helps contribute to achieving a full recovery, when focusing on pain management, respiratory fitness, and emotional wellbeing, as provided in our clinic for conditions related to pain Cambridge.
For some sports, serratus anterior fatigue seems to be associated with rib stress fractures mechanism of injury, and recurrent back strains (recurrent muscle spasm treatment). Strengthening the serratus anterior is recommended as rehabilitation after injury, and in conditioning programmes associated with risks of specific sports.
Degeneration and Arthritis
Such exercise treatments (middle back pain exercises), are safe for patients with osteoarthritis, rheumatoid arthritis and ankylosing spondylosis, when focusing on range of motion, strengthening and aerobic conditioning exercises. This can help to reduce pain, improve muscle strength, assist cardiovascular health, and improve endurance for physical activities. Additionally, spinal mobility exercises seem to decelerate loss of mobility, while assisting sustained independent living and function.
Also, improvements in respiratory function with exercise, are believed to be from ‘improvements in diaphragmatic respiration rather than to changes in thoracic cage mobility’.
In adults with scoliosis, rehabilitation treatments have been of secondary prevention, while countering curve progression, while improving functional impairments, and pain. Therapy has been shown to increase vital capacity, rib mobility, cardiopulmonary functioning, and reducing pain complaints such as, addressing muscle spasm treatment back.
Whole Body Integration
Then we can start to look at a more global pattern, and treatment plan.
Neck related issues, from postural overuse in overhead work and sport, can cause alterations in nerve health, including the nerves which innervate the upper back, and shoulder blade. This can cause cervicogenic dorsalgia (neck generated back pain). These injuries can cause pain, atrophy, scapular winging, dysesthesia, mid-thoracic pain, stiffness, and dysfunction. This can occur down over the back, away from the site of mechanical generation.
Thoracic spine stiffness and reduced motion, such as extension mobility and the sum of mobility in the thoracic spine being reduced, is associated with back pain.
Thoracic spine and rib manipulation, offers immediate relief and increases mobility for sufferers of shoulder pain.
Methods, designed by manual therapists, which can be performed similarly by other therapists, such as our high trained osteopaths Cambridge. These may utilize techniques with emphasise on optimal posture and spinal alignment as the primary goals of care, while simultaneously improving pain and function (structural rehabilitation of the spine and posture). These may also non-invasively assist with reduction of thoraco-lumbar curves.
Integrated post manipulation, and corrective core exercise, performed while assessing spinal deformation and lumbar strength, showed significant pelvic tilt changes, and corrections of spinal deformation. This shows that more global treatments, can affect an area positively.
Lower back, radiating flank pain, from a vertical compression injury (impacts and falls on to the pelvis), can cause ‘lower thoracic syndrome’. Symptoms of tenderness, local muscle activity, and functional leg length discrepancy may be present. Mechanical dysfunction addressed with manual therapy, spinal manipulation, and therapeutic exercises, of the thoracic spine, assisted in pain relief, reduced local tenderness, and also reduced back and radiating flank pain, in addition to resolution of persistent short leg findings. This all aided potential symptoms mediators, with a possible need of future strength training.
This may show why whole body assessment and treatment, is reported anecdotally to be so effective in clinic.
These positive effects from manual therapy and exercise, may be due to the increasing body of evidence, that pain is a brain interpretation of data, and the local structure itself, cannot be consistently linked with pain or general function.
Additionally, manual therapy by an osteopath including the use mobilization and manipulation, and prescription exercise therapy, are all safer than long, or even short term medication treatments, such as non-steroidal anti-inflammatory drugs (NSAIDs). Additionally, these are statistically safer than surgical intervention.
The point here is that there are many opinions and many solutions, to treating thoracic pain (spinal pain / thorax pain / rib pain / costo-cartilage joint pain). Perhaps some, in our opinion, are more rational than others and some statistically safer than others, and some more empowering than others.
With all treatments, it’s important to get the diagnosis, advice, and treatment programme from people who are trained, skilled and prepared to aid your musculoskeletal needs, such as at our Cambridge Osteopath Clinic.
The guidelines for ‘thoracic pain’, includes the guidance to remain as active as possible, seek support and advice at a specialist clinic, for, diagnosis, education, management advice, manual therapy including mobilisation and manipulation, and soft tissue treatment, hydrotherapy application, increase in muscle strength (strength training) and specialist exercise therapy for rehabilitation.
At Elementary Health, our Cambridge Osteopath Clinic, we provide a seamlessly layered combination approach, of diagnosis, education and therapeutic application. This includes education of anatomy and pain theories, manual therapy, osteopath for back pain, posture advice and training, lifestyle advice, hydrotherapy guidance, dietary overviews, and dynamic exercise therapy with motor control training rehabilitation. All of these work together to provide a uniquely structured approach, towards the aim of restoring your brain’s interpretation, or ‘mapping’ of your healthy functioning body, giving you back the control!
If there are any other questions, or, you wish to book a consultation with Michael Parr the consulting osteopath in Cambridge, based at Elementary Health. Please don’t hesitate to call or email.