Journal of Orthopaedic & Sports Physical Therapy 2000;30(7):401-409

Thoracic Spine Dysfunction in Upper Extremity Complex Regional Pain Syndrome Type I
leanine Yip Menck, DPT Susan Mais Requejo, DPT * Kornelia Kulig, PhD, PT

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ecause of its complex and poorly understood nature, reflex sympathetic dystrophy has recently been reclassified by the International Association for the Study of Pain (IASP) as Complex Regional Pain Syndrome Type I (CRPSI).n CRPSI is defined as "a pain syndrome that usually develops after an initiating noxious event, is not limited to the distribution of a single peripheral nerve, and is disproportional to the inciting eventw2'It is associated with altered sympathetic outflow with "evidence of edema, changes in skin blood flow, abnormal sudomotor activity in the region of the pain, or allodynia, or hyperalgesia. " ~ 5 Numerous authors have discussed the possible causes and mechanisms for this complex synKey Words: manipulation, manual therapy, reflex sympathetic dystrophy dr~me.~ No .~ single ~ . ~model has been universally accepted. Treatment approaches for patients with Student in the doctor of physical therapy program, University of Southern California, Los Angeles, CRPSI in the upper extremity Calif; is now staff physical therapist and research coordinator, Rancho Los Amigos National Reha- have been diverX.5.7.9.14-IR.43.44.M bilitation Center, Downey, Calif. Orthopaedic physical therapist resident and student in the postprofessional doctor of physical ther- Surgical intervention includes apy program, University of Southern California, Los Angeles, Calif; is now faculty at Mount St. Mary's sympathetic or somatic nerve College, 10s Angeles, Calif. blocks, sympathectomy, neurolysis, Associate professor of clinical physical therapy, Department of Biokinesiology and Physical Therapy, and decompression. Conservative University of Southern California, Los Angeles, Calif. Send correspondence to leanine Yip Menck, DPT, 3610 Pdcific Avenue, Marina Del Rey, CA 90292. therapies for CRPSI have tradiE-mail: yipmenck@aol.com,smais@msmc.la.edu,or kulig@hsc.usc.edu tionally focused on pain manage-

Study Design: Case study. Objective: To demonstrate the importance of assessment and treatment of the thoracic spine in the management of a patient with signs and symptoms of upper extremity Complex Regional Pain Syndrome Type I (CRPS-I). Background: The patient was a 38-year-old woman who suffered a traumatic injury to her left hand. Five months after injury, she presented with severe pain, immobility of the left arm, and associated dystrophic changes. She was unable to work and needed help in some activities of daily living. Methods and Measures: The patient was treated for 3 months in 36 visits. Initial treatment consisted of cutaneous desensitization, edema management, and gentle therapeutic exercises. However, further examination indicated hypomobility and hypersensitivity of the upper thoracic spine. Joint manipulationof the T3 and T4 segments was implemented. The patient's status was monitored and range of motion, strength, temperature, and skin moisture were measured. Results: Immediately after the vertebral manipulation, there was a significant increase in the left hand's skin temperature and a decrease in hyperhydrosis as measured by palpation. Shoulder range of motion increased from 135-175"nd the patient reported reduced pain from 6/10 to 3/10 on a scale from 0 to 10, where 0 represents no pain. The decrease in the patient's dystrophic and allodynic symptoms permitted further progress in functional r e education. The patient was discharged with full return to independence and initiation of a vocational retraining program. Conclusion: Assessment and treatment of the thoracic spine should be considered in patients with upper extremity CRPS-I. ) Orthop Sports Phys Ther 2000;30:401-409.

The thoracic sympathetic ganglia corresponding to the T1 through the T9 segments lie against the anterior heads of the ribs, just lateral to the vertebral bodies.'"he sympathetic chain ganglia, which innervate the arm, lie in close proximity to the thoracic costovertebral and zygopophoseal joints. GonzalezDarderl%as described compression of the dorsal ramus of the T4 nerve by a bone spur arising from the T4 inferior facet joint. Surgical decompression relieved a patient's pain and autonomic dysfunction in the thoracic region, neck, and right arm. It may be possible that thoracic dysfunction resulting from joint or soft tissue restriction may compromise the sympathetic chain ganglia and may be linked to the distal symptoms in CRPSI. Manual joint mobilization may in some cases have the same effect of increasing the joint mobility and relieving the pressure on the sympathetic chain ganglia. We believe that evaluation and treatment in areas proximal to a patient's symptoms in CRPSI may be necessary. Both the hypomobility secondary to abnormal posturing and the anatomical proximity of the sympathetic ganglions to the thoracic spine may contribute to a unique link between upper quadrant CRPSI and thoracic joint dysfunction. Acting on this hypothesis, we assessed the thoracic spine in the current case and initiated manipulation. This treatment was an adjunct to the overall management of the patient's symptoms of CRPSI.
FIGURE 1. Radiograph of patient's left hand one month after injury.

METHODS
ment and restoration of function of the hand and History arm. Pain management includes pharmacology, desensitization therapy, transcutaneous electrical stimuA 38year-old married, left-hand dominant woman lation, and thermal modalities. Restoration of funcsustained trauma to her left wrist and hand while ustion includes active and passive exercises, splinting, ing a plastic-molding machine at work. On the day of and progressive strengthening of the arm. These injury, the patient underwent open reduction intertherapies are well-accepted in the treatment of CRPS nal fixation surgery with Kirschner wires placed in I; however, they focus on treating the distal extremity the distal lateral carpal and proximal second and where the symptoms are primarily manifested. Evalu- third metacarpal bones. Figure 1 shows the radiograph of the patient's left hand one month after ination and treatment of spinal dysfunction in CRPSI have not been documented. jury. Her extensor tendons were also repaired. She was immobilized in a cast for 3 weeks, then received The purpose of this case study is to demonstrate a one month of occupational therapy that included relation between the distal symptoms of CRPSI and the thoracic spine, and to describe the use of thorac- passive and active range of motion of her left wrist, ic spine manipulation in the management of patients hand, and digits. Despite this intervention, the pawith CRPSI in the arm. We also provide a conceptu- tient developed an extensor lag of the middle and al framework for treatment of the spine in patients ring fingers, with significant extensor tendon adhewith CRPSI symptoms. We have observed that pasions. Six weeks after the initial injury and repair, tients with CRPSI in the arm often exhibit postural she underwent a second surgery consisting of removdeviations associated with a protective position of the al of 4 Kirschner wires, tendolysis of the extensor arm. This position diminishes trunk motion during digitorum communis of the left index, middle, and all upright activities and if prolonged, may have con- ring fingers, and manipulation of the metacarpalsequences such as decreased thoracic intervertebral phalangeal joints. With the patient under anesthesia, mobility. Joint hypomobility is the most salient feathe surgeon was able to passively flex the metacarpalphalanx joints 45-60" and fully extend all the digits ture among thoracic spine pain syndromes, accordwith the wrist held in extension. ing to McNair and Maitland.!'"
J Orthop Sports Phys Ther.Volume 30.Number 7.July 2000

Body Chart of Patient's Symptoms

P3 =
headache

TABLE 1. Mobility, strength, and limb circumference from initial evaluation and at discharge. Initial status
1. ROM:

f-{
Wrist: Flexion Extension Radial deviation Ulnar deviation MCP flexion MCP extension PIP flexion DIP flexion Shoulder flexion 2. Strength: Left Grip: Left Pinch:

At discharge
AROM ( W R O M (9

AROM (") PROM (")

0-6

P2 =

PI=

swelling cold distal fingem numbness itchiness sharp pain with movement purple discoloration

0-10 0-3 0 1 -10-30 -3 -10-45 -10-35 0-125

0 1 0 ' 0-40. 0 1' 5 0 1 0 ' 0-45' 0-5 0-90. 0-45' 0 1 35*

0-25 0-30 0-28 0-1 5 0-60 0 10 0-70 0-45 0 1 65 9.00kg 4.95 kg

0-38 0-60 0-30 0-30 0-60 0-25 0-1 05 0-90 0-1 75

4.05 kg (right at 24.75 kg) 1.80 kg (right at 4.95 kg)

Right 14.5 cm 15.5 cm 17.0 cm

FIGURE 2. Body chart of patient's symptoms at initial evaluation. P indicates pain.

3. Soft tissue swelling. Girth: Left 15 cm distal radius 17 cm carpal circumf. mid hand 18.5 cm

Left girth measures at: 14.5 cm distal radius carpal circumf. 15.0 cm 16.8 cm mid hand

Two and one-half months after injury, the patient was referred to physical therapy, where treatment included active and passive range of motion for the wrist and digits, joint and soft tissue mobilization, strengthening exercises, and a home program to manage the pain and swelling. The patient reported minimal changes in her status and one month into the treatment, she accidentally hit her left hand on a door and, consequently, discontinued therapy because of increased pain. Six weeks later (5 months after the initial injury), the patient was reevaluated in our clinic by one author (J.Y.M.). She received physical therapy 3 times a week for 12 weeks and was discharged with a significantly improved functional status. Following is a description of the patient's treatment in those 12 weeks.

ROM indicates range of motion; AROM, active range of motion; PROM, passive range of motion; MCP, metacarpophalangeal; PIP, proximal interphalangeal; and DIP, distal interphalangeal. Subject was discharged 8 weeks after initial evaluation. Endfeels were painful.

Patient Interview
Initially, the patient complained of 3 types of pain (Figure 2). The primary pain (Pl) was described as sharp, was located at the dorsal aspect of her left wrist and hand, and increased with any movement. The patient verbally rated this pain as a 6 on a scale from 0 to 10, where 0 represented no pain and 10 represented the worse pain imaginable. The secondary pain (P2) was along the posterior aspect of the entire left forearm, arm, and shoulder. This pain was described as dull and fatiguing. The third pain (P3) was a headache that affected the posterior and left side of the occiput and temporal regions. In addition, the patient reported that her left hand was cold, with numbness and tingling, and she complained of increased swelling. She had also experienced an itching of the hand in the previous 3
J Orthop Sports Phys Ther.Volurne SOeNurnber 7.Julv 2000

weeks. Initially, the patient was taking the oral analgesics Daypro and Vicodin. The patient's primary complaint was with her inability to perform selfcare activities of daily living (ADL) such as housework, driving, and writing. She was also unable to participate in sports and other recreational activities such as volleyball, softball, and dancing because of pain, numbness, and immobility (Table 1). In addition, she reported sleep disturbances and emotional distress since the accident; she was seeing a psychologist once a week. Before the initial injury, the patient worked ICLhour days 5 days a week, was independent in all ADL, and exercised regularly in a gym or by playing team sports. She denied any history of depression, trauma to the spine or u p per extremities, diabetes, drinking alcohol, or smoking. She lived with a supportive husband and 3 teenage daughters; the oldest daughter had assumed responsibility for the patient's normal household chores.

Physical Exam
On initial evaluation, the patient held her left arm in a very rigid, protective posture. This posture included shoulder elevation, adduction, internal rotation, elbow flexion, and wrist and finger flexion. The patient wore a glove because of her intolerance to cold and she supported the arm by holding her left hand in her coat pocket. Compared with the right hand, the dorsal and ventral skin along the left distal

TABLE 2. Signs, symptoms, and functional status at initial evaluation and at discharge.
Initial status at week 0 Status at week 10

Diagnosis

At the initial examination, our diagnosis of CRPSI was based on the IASP Committee on Taxonomy, Normalization of skin temperaAbnormal skin temperature which states that "to satisfy a diagnosis of CRF'SI, the ture as well as skin color. Dorsal with left radial bursa warm to clinical findings include regional pain, allodynia, abskin at wrist flexible, taut at post touch and left distal fingers cold surgical scar. to touch compared with right normalities of temperature, edema, abnormal sudomhand. Dorsal skin shiny and otor activity that occurs after a noxious event and taut, palmar discoloration. does not involve a peripheral nerve."J5 Very recent No longer allodynic at left hand work regarding internal validity of these criteria Allodynia along left radial bursa or spine. to light touch and to pinwheel found the sensitivity to be quite high (0.98). howevwith (t) jump signs. Allodynic er, specificity was poor (0.36). This suggests the posto palpation of left lower cervisibility of false positives in diagnosing CRPS versus cal and upper thoracic paraspinal skin, muscles, joints. neuropathic pain with established nonCRPS etiology."n addition, Sandroni et a142found that using Decreased guarding of left upGuarded posturing of entire left per extremity with use of arm in the above composite autonomic clinical features of upper extremity in shoulder elgait. Initiates activity such as CRPS is both a sensitive and reliable tool with which evation and internal rotation, elreaching and writing with left bow and finger flexion. Deto formulate a correct diagnosis of CRF'SI. We furhand. creased left arm swing in gait ther classified the patient's symptoms as moderate with tendency to sling left arm and in the second (dystrophic) stage of the course of in coat pocket. No initiation of movement with left arm. this pain syndrome. Although there have been no reUse of left upper extremity to liability or validity studies on this staging, Bonica4 deUnable to use left hand to write, write and type 1 h/d. Resumed scribed "moderate" as characterized by throbbing, type, perform ADLs and housesweeping, combing her own aching diffuse pain and moderate or mild vasomotor hold chores, play volleyball or hair, cooking, dancing 2x1 softball, dance, or drive. and sudomotor disturbances. He classified the dysmonth, and driving. Limited entrophic stage as characterized by cold skin and trodurance wlabove. phic changes that develop from 3-6 months after on, Pain rating 3/10. Pain rating 6/10 (0 was no pain set.4 Our patient had a classic cold, purple, and paleand 10 worst pain). colored edematous wrist and hand, characteristic of CRF'SI, which appeared to have been progressing since the initial traumatic injury to the hand 5 months earlier. Allodynia, defined by Gracely et a1 as phalanges were significantly colder to the touch, "pain due to a stimulus, which does not normally while the radial bursa was warm to the touch. Addiprovoke pain,"4 suggested sympathetic dysfunction. tional examination of passive physiologic and accesHowever, the pain was not limited to the left upper sory mobility revealed hypomobility of the T3 and T4 quadrant. The patient also had signs of thoracic vertebrae and greater prominence of the left T3 and spine dysfunction, including abnormal posturing and T4 transverse processes in neutral and flexed spine. palpable joint stiffness at the T3 and T4 segments. Passive segmental upper thoracic flexion and extenThoracic spine dysfunction has not previously been sion were painful, with extension being more restrictassociated with CRPS. ed and painful. The patient also demonstrated an allodynic response to light touch of her left lower cerINTERVENTION AND OUTCOME vical and upper thoracic vertebral column. The patient was hesitant to initiate any movement The initial treatment objective was pain managewith her left arm even when requested to d o so. Iniment and edema control. The long-term goal was to tial physical examination findings are summarized in achieve the functional range of motion and strength Table 1 and Table 2. Measures of treatment outnecessary to resume using the left arm, shoulder gircomes for impairments included the following: pain dle, and trunk in work, and to permit the patient to assessment using a numerical scale (&lo), left arm engage in ADL. active and passive motion measured with a goniomeTreatment 1 consisted of gentle active and passive ter,2"40s4' grip and pinch-strength measured with dywrist and finger range of motion and tubagrip for n a m o m e t e r ~ middle ,~~~~ and lower trapezius edema management. A home program of desensitizas well as girth measured circumferening techniques was implemented because of the pacially with a tape measurem and segmental thoracic tient's allodynic response (Table 3). The patient's acmobility. A questionnaire was used to assess the pative participation in therapy was limited because the tient's functional status, including ability to resume pain was highly irratable and because she was unwillwork, perform some ADL, drive, and engage in ing to move her left arm. Treatment 2 included evaluation and manipulation sports and other recreational activities.
J Orthop Sports Phys Ther-Volume 30.Number 7.Jnlv 2000

TABLE 3. Summary of therapeutic management at initial (week 11, middle (week 4) and final (week 10) stages of treatment. Type of intervention Movement re-education Aerobic conditioning Dynamic strength and Coordination Exercises

Week 1
Generalized posture education. Facilitation of left upper extremity during transitional movements. Treadmill, 5 minld.

Week 4

Week 10
Use left upper extremity for all activities of daily living. Writing 30 midd. Bike, 15 midd. Walk at home 45 midd. PNF D I D 2 with green theraband. Throw and catch softball. Bicep curls 6 Ib. Scapular retraction with 40 Ib. Wrist flexion/extension/ulnar radial deviation with 2 Ib. Resisted mid4ow trap with red theraband.

Passive ROM

Desensitization

Edema management

Facilitation of left upper extremity during gait. Writing 5 midd. Bike or treadmill, 10 minld with left hand on the handrail. Walk at home 15 midd. ProprioceptiveNeuromuscular Facili- PNF D I D 2 patterns with red theratation (PNF)'.47including D I D 2 band. patterns with active assistance. Throw and catch tennis ball. Wall reach with towel. Biceps curls 4 Ib medicine ball. Scap ula retraction 20 Ib. Isometric wrist flexionlextension and ulnar and radial deviation. Active strengthening for mid and lower trapezius without resistance. Splint wear for finger flexion stretch, Splint for finger flexion. 10 min. PROM for wrist and fingers Mobilization of the wrist to gain flexbeyond per tolerance. ion and extension: Grade Ill and IV. Mobilization of scaphoid on trapeziurn to gain wrist extension. Manipulation: T3 and T4 to gain extension and rotation. Gentle towel rub 5 timedd, gentle Soft tissue mobilization at the dorsum self light touch massage 5 timedd of the hand. Resisted grasp with of the left hand. Warmkold conthera-putty. trast baths 3 timedd. AROMPROM per above. Tubagrip. Tubagrip as needed.

Upper limb tension test mobilization in radial nerve bias (ULTT#2).7 Stretch upper quadrant with weightbearing on gym ball (see Figure 5). Manipulation: T31415 to gain shoulder flexion and elbow extension. Thera-putty with increased resistance.

of the upper thoracic spine, as described by Kaltenb0rn,2~ Maitland,27McGuckin,3' and 0'Malley.38The objective was to place traction on the left T3 and T4 facet joints to gain thoracic extension and right rotation. The clinician used her manipulating hand as a fulcrum by placing it under the supine patient at the level of thoracic joint dysfunction (Figure 3). A thrust was delivered through the patient's folded arms as she exhaled and there was an audible click. There was immediate normalization of skin temperature and color, as well as a significantly decreased al-

FIGURE 3. Thoracic manipulation with the therapist's hand as a fulcrum at T3-T4.

J Orthop Sports P h p Ther .Volume SO Number 7 .July 2000

lodynic response to light touch along the left arm and left upper thoracic vertebral column (Figure 4). The segmental thoracic mobility improved and there was an immediate increase in shoulder flexion after this treatment. This reduction of signs and symptoms of CRPSI made it possible to proceed with functional rehabilitation. The improvements were maintained and functional retraining, progressive strengthening and use of the left arm in activities were possible in subsequent visits. A stress loading program of the arm as described by Dzwierzynski and Sangerlowas implemented. Mobilization was also used to address the pain localized at the left lateral epicondyle region. This pain was specifically reproduced by the Upper Limb Tension Test #2 (ULTT2) with a radial nerve bias described by B ~ t l e rButler .~ suggests using the ULTT2 when treating thoracic syndromes by combining the test with thoracic rotation and lateral flexion to place the thoracic spine on tension. Thoracic manipulation directed at the patient's T3T5 facet and cost-transverse joints resulted in gains of both left shoulder flexion and decreased sensitivity to the ULTI'2. For example, in treatment session 20, the patient demonstrated limited passive left shoulder flexion to 135' with a painful end-feel. In the ULTT2, left lateral elbow pain was reproduced with scapula depression and elbow extension to 90' with neutral shoulder rotation and wrist position. Following thoracic manipulation to
405

headache

d .

:r

headache (no change)

resolved

If' cold swelling painful purple

temperature and color

FIGURE 4. Signs and symptoms before (A) and after (El) manipulation. P indicates pain.

tient resumed use of the left arm in activities such as the left T3, T4, and T5 facet and costo-transverse cooking, cleaning, driving, and writing. Emotionally, joints with the patient prone and head rotated right, left shoulder flexion increased to 175" with no pain at she showed anxiety in initiating activity with the left hand and upon discharge, she was considering reend-range. Reexamination of the ULTT2 showed an joining a gym club and enrolling in a program to increase in left elbow extension range to 16". There train for return to work. was decreased pain at the end-range of elbow extension. Treatment included passive stretching of the arm in external rotation and active stretching mobiliDISCUSSION zation while in the sitting position, including weight Manipulation of the thoracic spine may have rebearing onto a gym ball (Figure 5). sulted in improvements in distal upper extremity The patient's progression of therapeutic exercises pain, skin color, and temperature in a patient with and desensitization therapy is summarized in Table 3. CRPSI. We hypothesize that there is a unique link Five weeks after the thoracic manipulation, Neuronbetween symptoms of upper quadrant CRF'S and the a s prescribed for left elbow pain; the patient retin w thoracic spine. One explanation is that disuse of the ported that she took it on an irregular basis to "help arm and abnormal posturing may contribute to thoher sleep." racic hypomobility. Furthermore, the anatomic proximity of the sympathetic chain to the dysfunctional R E S U L T S thoracic joints may predispose the ganglions to mechanical pressure. Therefore, we concluded that e d The patient's status at 10 weeks is summarized in uation and treatment of areas proximal to the paTables 1 and 2. She showed significant improvements tient's symptoms were necessary. in range of motion and pain levels, as well as a norOur patient was evaluated 5 months after initial inmalization of autonomic activity. Functionally, the pa406 J Orthop Sports Phys Therevolume 30-Number 70July 2000

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thoracic h, h o s i s . which then allowed an im~rovement in shoulder elevation. However, we did not expect an additional immediate change in the sympathetic symptoms. Possible explanations for those changes include: neurogenic stimulation to the sympathetic nervous system, relief of mechanical pressure to the sympathetic trunk, reduction of thoracic z y g a p physeal referred pain, reflexive inhibition of muscle guarding, and possibly a placebo effect.

Neurogenic Stimulation to the Sympathetic Nervous System

Kornberg and McCarthy2"resented a study in which a slump stretch resulted in a significant shortterm temperature increase of the mobilized extremity compared with a control. They attributed the temperature change to an intraneural stretch stimulus that caused an afferent barrage to the system. In an in vitro study, Sato and S w e n ~ o n reported ~~ sympathetic nervous system responses to applied forces to the lateral aspect of two mobile vertebral segments in rats. They identified large changes in blood pressure and smaller decreases in heart rate. The thoracic manipulation in our patient may have also caused an immediate afferent stimulus ;hat altered sympathetic outflow; however, the exact nature of the mechanism is uncertain.

1
FIGURE 5. Functional retraining with patient sitting and weight bearing arm extremity on gym ball. The therapist is standing.

Relief of Mechanical Pressure to the Sympathetic Trunk

We believe that in addition to the neurogenic response, the thoracic manipulation in our patient may have also relieved a mechanical pressure on the adjacent paravertebral sympathetic chain ganglia in the sympathetic nervous system, causing the long-term changes we observed. In a comprehensive study of 1000 cadavers, Nathan3' found that 65% had osteophytes compressing the sympathetic chain. In an earlier study, Nathanw found that 100% of the 400 vertebral columns studied had evidence of osteophytes by the fourth decade. Furthermore, Gilesa2 pkrformed a histologic investigation of 3 cadavers, which showed evidence of the osteophytes deforming the paraspinal chain ganglia. Finally, Gonzalez-DarderI3reported that the surgical removal of osteophytes compressing the T4 nerve relieved a patient's chronic back pain in the distribution of T3T5 dorsal rami. The patient also had autonomic symptoms of pallor, sweating and syncope, which were relieved with the surgery. In addition, Weinbergwobserved degenerative arthritis in the upper costovertebraljoint in all 40 patients who were diagnosed with thoracic outlet syndrome. He attributed the radiating pain of these patients to the pathological joint changes, which affected the sympathetic trunk. Stellate ganglion blocks in the area of these ar407

jury and after having had one month of occupational therapy and one month of physical therapy that produced little change in symptoms. Therefore, the initial objective was to evaluate the possible sources of symptoms. Immobility of the trunk with restricted thoracic intervertebral motion was observed. We chose to manipulate the most restricted and symptomatic thoracic vertebral segment (T3T4). This resulted in improved joint mobility and sympathetic outflow. We were then able to proceed with a protocol suggested by Stanton- hick^,^" which focuses on the distal extremity symptoms and functional re-education. Concurrent with physical therapy, the patient was receiving psychological and drug therapies. We cannot discount the possibility that the overall improvement in status was due to the multidisciplinary intervention. Identifying the specific mechanism responsible for changing the distal symptoms after thoracic manipulation is difficult. We hypothesize that there may have been both mechanical and neurologically mediated mechanisms. The immediate increase in shoulder flexion after manipulation was likely due to a mechanical change in the tissue. We may have reduced the
J Orthop Sports Phys Ther-Volume 30-Number 7.July 2000

thritic joints completely relieved symptoms in 25 patients and gave partial relief in 14.

Reduction of Thoracic Zygapophyseal Referred Pain

While we have assumed that sympathetic distal symptoms in our patient were a result of the distal trauma, we cannot discount the possibility of referred peripheral pain from the thoracic zygapophyseal joint. In a study of pain patterns in normal s u b jects, Dreyfuss et a19 administered provocative intraarticular injections of the thoracic joints. They reported symptoms of unilateral glove paresthesias of the upper limbs and headaches after injection of the T3T4 or T5T6 joints, in addition to the expected intrascapular pain. Therefore, the manipulation in our patient, which was directed to the zygapophyseal joint, may have affected the joint mechanics and resulted in a reduction of the patient's distal symp toms. The immediate relief of the distal symptoms may indicate that there was a possible direct link between the apophyseal joints and the patient's pain pattern.

ter a treatment in which there is an audible pop or snap, the placebo factor is undeniably high.39 However, studies have been done to determine whether the effects of manipulation are due to the treatment effects or the "laying on of hands." Hoehler and Tobis2' did a double-blind study of manipulation versus sham in which the manipulation group reported significantly greater relief compared with patients experiencing "laying on of hands." They concluded that something intrinsic to the manipulative thrust could reduce spinal pain. While we cannot dismiss the placebo effect of pain reduction, we did observe objective signs of change in skin temperature.

CONCLUSION
Chronic and heightened perception of pain after trauma or surgery is a common but poorly understood impairment. The Guide to Physical Therapist Practice2 (consensus of experts), suggests that for a diagnosis of reflex sympathetic dystrophy, the prognosis for return to highest level of function is up to 4 months, and 80% of all patients are expected to achieve the desired outcome in 3 to 21 visits. Our patient was treated for 3 months; however, her 36 treatments exceeded the expected number of visits. Factors that may have increased the number of treatments beyond the number specified in the guide included chronicity and severity of her symptoms, as well as continued emotional distress. In addition, the treatment we have described was delayed until 5 months after the initial injury. We believe that there may be a link between the thoracic spine and distal symptoms in patients with CRPSI. Thoracic joint manipulation appeared to improve spinal mobility, and also appeared to relieve distal and autonomic symptoms. These improvements allowed for functional rehabilitation of the affected arm. Therefore, it is our opinion that mobility of the thoracic spine should be evaluated for patients with autonomic dysfunction diagnosed with CRPSI. Further research is warranted to help define the relationship between neurogenic symptoms and musculoskeletal pathology. In addition, the physiologic responses of manual therapy in patients with CRPSI should continue to be documented and reported.

Inhibition of Muscle Guarding

Pain inhibition after spine manipulation has been s u g g e ~ t e d .Herzog ~ ~ . ~ ~et a120 reported a sharp decrease and cessation in the electromyographic signal of hyperactive muscles after manipulation and suggest that the motor neuron drive to the spastic muscles was eliminated because of the treatment. They concluded that the reflex response was associated with a multitude of mechanoreceptors and propri* ceptors in the muscles, tendons, skin and joint c a p sule underlying the treatment area. The specific mechanisms included an interruption of the transmission of pain, a reflex response in the target musculature, and reflex relaxation of spastic muscles. This muscle response is similar to the reflexive inhibition first described by Sherrington in 1906 where contraction of a muscle will be immediately followed by inhibition of that muscle.45Furthermore, the reduction in pain may be secondary to the increase in sensory input of the manipulation. MelzackMintroduced the gate theory, which states that any increase in sensory input, whether cutaneous, muscular, articular, visual or auditory, will block the afferent transmission of pain pathways. It is possible that the manipulation provided a sensory input, which either inhibited the muscle or blocked the pain.

REFERENCES
Adler S, Beckers D, Buck M. PNF in Practice: An Illustrated Guide. Berlin, Germany: Springer-Verlag; 1993. American Physical Therapy Association. Guide to Physical Therapist Practice. Phys Ther. 1997;77:1264-1275. Bennett G, Roberts W . Animal models and their contribution to our understanding o f complex regional pain , Stanton-Hicks M, eds. syndromes I and II. In: Janig W Reflex Sympathetic Dystrophy: A Reappraisal. Seattle, Wash: IASP Press; l996:lO7-12 1. Bonica J. The Management of &in. 2nd ed. Philadelphia, Pa: Lea & Febiger; 1990.
J Orthop Sports Phys Ther *Volume SO. Number 7.July 2000

The Placebo Effect

The psychological effect of the clinician's hands is well-accepted in the medical community and cannot be discounted as a factor influencing the patient's response to thoracic manipulation. It is known that af-

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