MOBILIZATIONWEDGETHORACICDISCLESIONSPESTERPHYSIOTHERAPYBACK
MOBILIZATION WEDGE FOR THORACIC DISC LESIONS - Olive K. Pester, M.C.S.P. M.C.P.A.



MOBILIZATION WEDGE FOR THORACIC DISC LESIONS

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.

Conclusion
  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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