• Thoracic Outlet Syndrome: A Functional Dysfunction of the Upper Thoracic Aperture?
• The Effect of Back Injury and Load on Ability to Replicate a Novel Posture
• The Value of Pain Drawings in the Care of Neck and Back Pain
• EMG Activity of the Medial and Lateral Hamstrings at Three Positions of Tibial Rotation During Low-Force Isometric Knee Flexion Contractions
• Applications of Physical and Occupational Therapy in Chronic Pain Syndrome

Karl-August Lindgren, Hannu Rytkonen

Purpose of the study: To determine possible malfunction of the upper thoracic aperture (an upward displacement of the first rib at the costotransverse joint) as the cause of thoracic outlet syndrome (TOS) symptoms among consecutive TOS patients admitted for conservative treatment.

Basic procedures: 15 consecutive TOS patients, with a positive TOS index, admitted for conservative treatment were investigated with a 3-dimensional CT scan of the upper thoracic aperture. A rehabilitation program was administered at a rehabilitation ward.

The CT scans were evaluated for a possible upward displacement of the first rib at the costotransverse joint. The outcome of conservative therapy was classified as good if the patient was symptom free and poor if loading of the upper limbs still produced symptoms. Outcome follow-up time was 1 year.

Main findings: An asymmetry of the first rib was shown on the symptomatic side, indicating an upward displacement of the first rib at the costotransverse joint, in 12 of the patients. Only three patients did not respond to therapy. Eleven patients were engaged in sedentary work.

Conclusion: Malfunction of the upper thoracic aperture especially among patients doing sedentary work, seems to cause TOS symptoms. A carefully planned conservative therapy program based on the functional findings of the individual patient is recommended.

Keywords: Thoracic outlet syndrome, Computerized tomography, First rib.

The purpose of this study was to investigate the effect of back injury and load on the ability to replicate a target standing posture. Subjects included 16 back-injured males and 16 age-matched controls. Subjects were asked to reproduce a target standing posture and to repeat this task while holding a weight. Trunk inclination was measured using an electrogoniometer. Analysis of variance indicated that back-injured subjects were less accurate in reproducing the target posture than were control subjects. Back-injured subjects typically overestimated how much they had moved and therefore underestimated the target position. Both groups demonstrated a small but statistically significant difference between the load and no-load condition with greater degrees of trunk inclination under the load condition. Analysis of covariance indicated that neither self-reported pain level nor maximum voluntary range of motion contributed to significant differences between the two groups. These data indicate that, following injury to the back, individuals may develop an inaccurate perception of body position. This study has implications for training the injured worker.

Keywords: Back-injury, posture, biomechanics, proprioception.

The magnetic resonance imaging (MRI) reports and pain questionnaires of 100 patients with complaints of lower back or neck pain were reviewed. Prior to physician examination, each patient had completed a questionnaire which included pain drawings and a rating on a pain scale. The information given on the drawings and questionnaires was compared to the MRI reports. The levels of agreement between them were analyzed. The results show that the pain questionnaire with drawing is a useful tool in the evaluation of patients when the diagnoses of herniated nucleus pulposis (HNP) or spinal stenosis are in question. The levels of agreement between the pain drawings and the MRI findings were stronger for the cervical spine than for the lumbar spine and also stronger for the presence of HNP than for central canal spinal stenosis. Particularly useful was the negative predictive power for ruling out cervical and lumbar pathology.

Keywords: Clinical Diagnosis, Pain Drawings, Pain Scale, Herniated Nucleus Pulposis, Spinal Stenosis

The purpose of this investigation was to determine how the position of tibial rotation effects the EMG activity of the medial and lateral hamstrings during low-force isometric knee flexion contractions. Forty-five subjects (ages 18-35) with no history of lower extremity injury or disease volunteered for this study. While lying prone, and with surface EMG electrodes secured to the bellies of their right medial (semitendinous and semimembranosus) and lateral (long head of the biceps femoris) hamstring muscles, each subject held the knee in 45 degrees of flexion for 8 seconds against 5% of their body weight. This was performed 3 times in each of the positions of neutral tibial rotation, external tibial rotation, and internal tibial rotation. The root-mean-square (RMS) of the EMG activity from these muscles was determined for each of the contractions. A repeated measures ANOVA was used to compare the RMS values of the two muscle groups in the 3 positions. The average RMS values (in V (microvolts)) obtained were (means and standard deviation): medial hamstrings in external rotation: 50.74 + 23.11; in neutral: 65.57 + 25.35; in internal rotation: 70.73 + 31.86; lateral hamstrings in external rotation: 66.08 + 46.99; in neutral: 46.18 + 39.34; in internal rotation: 27.68 + 17.86. A statistically significant interaction was found between tibial rotation and hamstring muscle (p < .0001). These results are consistent with the presumed function of these muscles in that EMG activity in the medial hamstrings increased when the tibia was rotated internally, whereas the lateral hamstring EMG activity increased when the tibia was rotated externally.

Keywords: Isometric, Hamstrings, Electromyography, Manual muscle test

This article will describe how to approach the prescription of physical therapy for 'chronic pain syndrome'. Initial sections will describe script writing for physical and occupational therapies, and review types of exercise and physical therapeutics. Exercise regimens that the literature supports for patients with chronically painful syndromes will also be discussed. The author emphasizes that the practitioner cannot write a therapy script for 'chronic pain syndrome.' Instead, the practitioner should understand that physical and occupational therapy can remedy impairments of flexibility, strength and endurance and the patient should be examined to identify these impairments. When the practitioner has identified poor flexibility or contracture, weakness or loss of strength, or poor endurance in the patient with chronic pain, the practitioner can then write a physical therapy or occupational therapy script with goals to improve these impairments. It is not necessary for the practitioner to be familiar with the nuances of exercise application; it is only necessary for the practitioner to identify contracture, weakness, and poor endurance, and to direct the therapist's attention to these deficits via a therapy script. The practitioner should include precautions on a script to a therapist. These precautions are based on the patient's concurrent medical and surgical diagnoses. Lastly, the literature describing therapeutic interventions in patients with chronic pain syndromes is poor because the painful conditions are poorly characterized and the therapeutic interventions are poorly described; however, where specific exercise programs for specific diagnoses were identified, the exercise regimens are discussed.

Keywords: Chronic pain syndrome; Script writing; Physical and occupational therapies