Grasslin Uni 45 Manual Muscle

TENS units, or transcutaneous electrical nerve stimulation units, are devices using low-voltage electric current to interrupt pain signals, helping to alleviate both acute and chronic back pain.

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The Top 5 Best TENS Units Summary

Best Overall Choice:

1) Digital TENS 7000 Unit with 5 Modes

View Price

The Top 5:

5) Impulse TENS D5 Pain Therapy Device	View Price
4) PM-720 Digital TENS/EMS Combo	View Price
3) Drive Medical Economy Dual Channel TENS Unit	View Price
2) Dolphin Neurostim Acupuncture Simulation TENS Unit Kit	View Price
1) Digital TENS 7000 Unit with 5 Modes	View Price

Benefits and uses of a TENS unit

Pain is your body’s way of telling you there is something going on in your body that needs your immediate attention. In this way, pain serves a definite purpose in helping us stay healthy and functional.

The downside of pain is that it can affect our quality of life, especially when the pain is chronic.

TENS units are a great alternative to pain-masking medication, which many people try to avoid - especially when faced with the possibility of taking pain medication for months, or even years.

Unremitting, chronic pain can lead to physical and emotional stress that in turn results in other ailments. It's for this reason TENS units block your body’s pain signals, all without the use of drugs.

How do TENS units work to relieve pain?

Through electrode pads taped to the skin over affected areas, the TENS device stimulates nerves with painless electrical signals. These electrical currents block the transmission of pain signals to the affected nerves.

While the device is in use, these electrical impulses encourage the body to produce higher levels of endorphins - the body’s own natural painkillers.

What are some common uses for TENS units?

TENS units are used for both chronic and acute pain. Some units can be purchased over-the-counter, while others require a prescription. Most units are portable, too!

TENS therapy can relieve pain associated with illnesses and conditions including:

• Post-operative incisions and post-surgical pain

• Chronic pain from tendonitis and bursitis

• Muscle, joint, or bone problems associated with osteoarthritis or fibromyalgia

• Lower back and neck pain

• Sudden acute pain from labor and delivery or from sports injuries

Who should NOT use TENS units?

TENS units should not be used by people who have:

• Poor sensation

• Cancer

• A pacemaker

Caution should be exercised by those who are pregnant or have epilepsy. In addition, TENS units should never be used around the heart, on the head, or over breast tissue.

And, as always, follow your doctor’s advice when selecting and using a TENS device!

5. Impulse TENS D5

Kicking off our Top 5 list is theImpulse TENS D5. This TENS unit has several notable features which make it convenient, as well as incredibly effective.

The Impulse TENS D5 incorporates a unique “clam shape” design that opens and closes smoothly. When closed, the cover protects the LCD screen and control buttons.

When open, the inside flip-top cover displays an instruction diagram which guides the user through the five modes of operation: constant, width modulation, rate modulation, and two different types of burst.

The first burst mode provides one second ON, and one second OFF, with adjustable pulse rate and pulse width. The second burst mode provides seven pulses per burst, two bursts per second, with adjustable pulse width.

As a safety measure, if the device is not attached to the patient correctly, the amplitude will not increase. The unit also features a timer and low battery light, indicating when the two AA batteries need to be changed, helping users to

Finally, the Impulse TENS D5 is a dual channel device. Each channel requires two electrode pads. This device has four, making it possible to treat two areas of the body simultaneously!

Features and Benefits

• Unique “clam shape” design with lid

• Lid protects controls, and provides a user guide

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• Easy-to-read LCD screen

• Five modes of operation, including two Burst modes

• Dual channel – can treat two areas at once

• Timer for convenience

• Low battery indicator

• Includes: 2 AA batteries, lead wires, 4 electrodes, instruction booklet, carrying case

• Small and convenient (weighs 3.35 ounces, measures 4.2 inches x 29 inches x 14 inches)

Customer Feedback

Customers have nothing but praise for the convenience and effectiveness of the Impulse TENS D5! They state it is lightweight, sturdy, and easy to use. Its compact size makes it easy to store as well.

Users who reviewed this device reported that it was extremely effective for them. One user with back and neck pain from degenerative disc disease reports that her pain was reduced simply by using the unit for about 30 minutes while eating breakfast. (What a great way to start the day!)

Another user was delighted with how compact the TENS D5 is! She says, “Great product. So lightweight and small, you can wear it and no one knows.”

Based on reviews, the Impulse TENS D5 has been successful in reducing chronic back pain, neck and shoulder pain; and, in particular, has found success with elderly users.

Pros:

• Small and lightweight

• Can be worn discreetly

• Easy to use and store

• Can give relief with brief use

Cons:

• None noted

4. Pro-Med ProM-710 TENS/EMS Combo

The Pro-Med ProM-710 supplies both types of neuromuscular treatment in one convenient unit: both chronic and acute pain, along with muscular pain or atrophy can be treated with this device!

The Pro-Med uses dual, isolated channels, which allows treatment to occur on two different parts of the body at the same time.

It features a built-in timer and a large easy-to-read LCD display, while the timer can be set for 15, 30, 45 or 60 minutes. A patient compliance counter shows the treatment time in minutes, making it a breeze to read and comprehend.

With this unit, you can choose among seven different TENS modes and three different EMS modes. This provides the helpful ability to fine-tune your treatment in terms of pulse (rate) and width (duration of stimulation).

An outstanding safety feature of the Pro-Med ProM-710 is its Software Ramp Up. When the user changes modes, the output re-sets to zero, then ramps up to the intensity that was originally set. This protects against sudden surges in output!

Features and Benefits

• Combination TENS/EMS treatment

• Seven TENS modes and three EMS modes

• Timer can be set in 15-minute intervals

• Patient compliance counter shows treatment time in minutes

• Large LCD display is easy to read

• Patient Lock System: Prevents the user from changing any fixed parameters set by the physician or licensed practitioner

• Comes with ProM- 010 1.5 inch x 1.5 inch electrodes (4 in a pack), ProM-040 36 inch lead wires (2 in a pack), 9-volt battery, instruction book and a hard plastic carrying case

• Dimensions: approximately 5 inches x 3 inches x 1 inch

• Weight: 0.39 pounds

Features and Benefits

Overall, users who reviewed the ProMed ProM-710 Combo Unit were satisfied with its operation; it was reported to be particularly effective on relieving back pain.

One feature praised by several users was the placement of the control knobs. The knobs are positioned in such a way that it is almost impossible to turn the power up unintentionally. In general, this unit was found to be very easy to control!

For a handful of users, the directions for use of this unit were a bit difficult to understand. (This is most likely due to the dual nature of the unit.)

Pros:

• Easy to control

• Can treat both nerves and muscles in one unit

• Varying options for setting pulse and strength of stimulation

• Small and easy to carry

• Safe placement of knobs prevents unwanted surge of power

Cons:

• Directions difficult to understand for some users

3. Economy Dual Channel TENS Unit

Drive Medical’s Economy Dual Channel TENS Unit is a lightweight, compact and portable unit that delivers customizable, effective treatment for acute and chronic pain.

This deluxe electrotherapy device is designed for rehabilitation and physical therapy. It features adjustable pulse frequency, intensity control and pulse width, enabling the user to have targeted pain treatment following an operation or while treating chronic pain conditions.

This unit comes with a carrying case and metal belt clip, weighs only 4.6 ounces and uses a 9-volt battery, while it’s convenient size makes it a great tool to pack when traveling (the unit measures just 3.75” L x 2.5” W x 1” D).

Dual isolated channels mean two body areas can be treated at once, each with its own appropriate intensity and pulse.

Features and Benefits

• Lightweight (4.6 oz)

• Compact (3.75” L x 2.5” W x 1” D)

• Portable (comes with carrying case, belt clip)

• Powered by 9V battery (included)

• Pulse amplitude 0 to 80mA

• Pulse frequency: 2-150 Hz

• Pulse width: 60-250 microseconds

Customer Feedback

Customers who have used the Economy Dual Channel TENS Unit have reported great satisfaction with the results they’ve been able to achieve.

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One user with tennis elbow stated how this unit greatly accelerated his healing process. Another was pleased with the ability it gave him to continue his physical therapy work at home and make progress more quickly. Finally, a patient with radial nerve palsy stated he felt a difference after just one use, and that he is now re-gaining muscle control!

Pros:

• Quick results

• Allows users to continue therapy at home

• Accelerates healing

Cons:

• None noted!

2. Dolphin Neurostim OTC TENS Unit Kit

The Dolphin Neurostim is classified as a “modified” TENS unit, which means it offers benefits not possible with conventional TENS devices!

The Dolphin offers targeted, temporary pain relief through a combination of modern neurology and ancient Chinese medicine. This hybrid therapeutic modality is known as Microcurrent Point Stimulation therapy, or MPS.

The unit itself is an elongated, hand-held device, and is held much like a pencil. When the tip is placed on a painful area, the device sends an electrical current to locate and stimulate nerve and acupuncture points related to the injury or condition causing the pain.

Those nerve and trigger points are actually tiny, tight bundles of nerve endings located throughout our muscles. When a muscle is injured, these points become tender. When stimulated, these points work to relax muscles and improve circulation.

As with other TENS treatments, the stimulation of these trigger points increases the production of endorphins, the body’s natural painkillers.

The Dolphin Neurostim TENS Unit comes with a manual that guides the user through finding the appropriate trigger points. An optional extension probe makes it possible to reach and treat areas such as the lower back and back of the neck.

Features and Benefits

• Combines benefits of TENS and acupuncture

• Treats specific muscle groups for pain from injury or other conditions

• Offers quick pain relief

• Pain relief can last from several hours to a few days

• Polarity switch reproduces both hot and cold sensations

• Has been tested for over 30 years for safety and effectiveness

• Has been used to treat conditions such as scar adhesion pain, sports injuries, menstrual cramps, and arthritis

Customer Feedback

People with a range of pain conditions are reporting outstanding results with the Dolphin Neurostim. For example:

A man with Bell’s palsy stated he’s seen results with the Dolphin that he never achieved with other TENS units. He also reports that the manual and instructions are easy to use!

Another user reports his lower back pain has been eliminated by using the Dolphin Neurostim.

One woman said the Dolphin got her through the first difficult days following back surgery with only minor pain.

And finally, one user called the Dolphin an “essential” for his gym bag. He’s used it to treat sciatica and muscle pulls!

Pros:

• Offers quick pain relief for muscle pulls, post-surgical pain and lower back pain

• Directions and manual are easy to follow

• Convenient and portable

Cons:

• None noted!

1. Digital TENS 7000 Unit with 5 Modes

While it requires a doctor’s prescription, the Digital TENS 7000 Unit offers an impressive range of options to help pinpoint the exact type and strength of treatment needed for each individual at any given time!

The five modes that can be programmed on this device are Burst, Normal, Modulation, SD (Strength/Duration) 1 and SD 2. Pulse width, intensity and frequency of stimulation can be finely tuned, making treatment just right for the level of pain being addressed.

Eight levels of intensity control are available. Pulse width, or how long each pulse lasts, can be modulated gradually within a range of fifty to 300 microseconds, in increments of ten microseconds per step.

A timer allows users to manually pre-program the length of each use. A treatment session can be programmed for just five minutes, or for as long as sixty minutes. Time is conveniently adjustable in five minute increments. The other option available to users is to set the device to run on continuous mode.

Additionally, this is a dual channel unit, allowing treatment of two areas of the body at once.

All the control buttons on the TENS 7000 are covered with a plastic lid, preventing unexpected surges in intensity or other changes in programming during treatment. The inside front lid has a printed guide that shows how to use the four buttons that control Power, Modes and Setting.

This unit runs on a single 9V battery, and will run through about twelve hours of use before the battery needs to be replaced!

Weighing just over five ounces, and smaller than a typical cell phone or remote control (measures 3.98 inches x 2.4 inches x 0.96 inches), the TENS 7000 is around the size of a candy bar--very easy to carry around!

Features and Benefits

• Small and lightweight (weighs 5.29 ounces, measures 3.98 inches x 2.4 inches x 0.96 inches)

• One 9V battery gives about twelve hours of use

• Five modes

• Eight intensity levels

• Can use timer to pre-set sessions, or use continuously

• Safety lids prevent intensity surges and other changes during treatment

• Prescription required

Customer Feedback

It was difficult to find any complaints about the TENS 7000! Users suffering with a variety of pain problems talk about its ease of use, safety and effectiveness:

“ … This gizmo has decent power output and runs for a long time off of one 9v battery. You do not need to 'amp' up the output to painful settings to achieve effective results. The modulation setting is perfect for the wrists, hands, and forearms …”

“I have a surgically reconstructed spine which at times induces incredible pain at the slightest misstep or miscue.' (This user found quick and consistent relief with the TENS 7000.)

The only negative comments to be found about this unit involved the wish that it were rechargeable!

Pros:

• Covered knobs prevent accidental adjustments

• Works quickly on a variety of conditions

• Easy to carry around

• Instruction manual explains everything, including the components, setting it up, the modes and what they do, maintenance and storage of the device

• Powerful and effective

Cons:

• Not rechargeable

Summary

TENS units offer a safe, drug-free alternative for living better with both chronic and acute pain. While there are literally hundreds of TENS units on the market, the five we’ve highlighted here are some of the best and most highly rated by customers, and have some unique characteristics and advantages.

But among traditional TENS units, the Digital TENS 7000 stands out from the others! It’s small and convenient, easy to use, and includes built-in safety features, while offering a wide range of settings to personalize the treatment experience. And it's for these reasons that it easily scoops up our number-one spot!

Want to learn even more? Find dozens of videos featuring products and caregiver tips like these at Rehabmart’s YouTube channel!

Author:

Co-Founder of Rehabmart and an Occupational Therapist since 1993. Mike has spent his professional career working in multiple areas of Occupational Therapy, including pediatrics, geriatrics, hand therapy, ergonomics and inpatient / outpatient rehabilitation. Mike enjoys writing articles that help people solve complex therapeutic problems and make better product choices.

Original Editor - Cassidy Lake and Kristen Templin as part of the Temple University EBP Project

Top Contributors - Cassidy Lake, Kristen Templin, Adam Vallely Farrell, Kim Jackson and Rachael Lowe

• 2Subjective Assessment
  • 2.1Symptoms (Recorded on a Body Chart)
• 4Region-Specific Historical Examination
• 5Objective Examination
  • 5.1Observation (from in front, behind and from the side)
  • 5.3Movement Testing
  • 5.5Neurologic Assessment

Functional Anatomy

The function of the thoracic spine and ribcage is the protection of the heart, lungs and viscera, ventilation of the lungs and a stable base for the attachment of muscles of the upper limbs, head and neck, vertebral column and the pelvis.^[2][3]Stability is provided at the expense of mobility. Reduced thoracic mobility may be due to; rib cage, spinous processes, zygapophyseal joint capsules, ligamentum flavum, dimensions of the vertebral bodies.^[2]

The thoracic spine lies between the superior cervical spine and the inferior lumbar spine. It consists of 12 vertebrae that are distinct in shape and function from vertebrae found in other regions of the vertebral column. The bodies of the thoracic vertebrae are medium sized and heart shaped.^[4] They are all weight-bearing and generally increase in size from superiorly to inferiorly with an increase in the amount of weight that needs to be supported. They possess articular facets on their sides for articulation with the heads of the ribs.^[4][3]

For more detailed explanations of the anatomy of the thoracic vertebrae see here.

The rib cage consists of 12 pairs of ribs:

• 1 st – 7 th ribs: (true) attach directly to sternum
• 8 th – 10 th ribs: articulate with sternum via the costal cartilages above them
• 11 th and 12 th ribs: floating ribs as they do not attach to sternum^[2]

Subjective Assessment

Primary thoracic spine pain disorders comprise approximately 15% of all back/spine complaints.^[5] Compared to cervical and lumbar spine, the research is lacking for the thoracic spine. As a result there is less evidence available for the evaluation and management of thoracic spine disorders. What follows is an outline of a musculoskeletal examination for patients with primary thoracic spine disorders. Where evidence from the peer-reviewed literature is utilized, however more research is required for this region.

Symptoms (Recorded on a Body Chart)

Area

• Distribution
  • May follow course of rib or run horizontally across chest.
  • Thoracic spine, scapula or sternum
  • Upper limbs (upper cervical spine)
  • Lower limbs (lower cervical spine)
  • Clear all other relevant areas and mark with ticks^[6]

Type

• Quality

• Intensity
  • VAS
  • Pain diary may be useful for chronic pain patients

• Depth

• Abnormal sensatio
  • Paraesthesia
  • Numbness

• Constant/Intermittent
  • If, constant, check whether there is variation in the intensity of symptoms
  • Constant unremitting pain may be indicative of neoplastic disease

Behaviour^[6]

• Aggravating factors
  • Deep breathing, rotation of the thorax

• Easing factors
  • Thoracic extension

• Severity and irritability
  • Used to identify those who will not be able to tolerate a full objective examination
  • Severity - If patient is able to sustain a position that reproduces the symptoms then condition is considered non-severe. If patient cannot sustain the position, the condition is considered severe and no overpressures should be attempted

• Irritability- If symptoms ease immediately after provocation then the condition is considered to be non-irritable and all movements can be tested. If symptoms take a few minutes to ease, the symptoms are irritable and only a few movements should be attempted to avoid exacerbating the patients’ symptoms

• 24hr symptoms- Night, morning and evening symptoms (morning stiffness for a few minutes suggests spondylosis, stiffness and pain for a few hours suggests inflammatory processes such as A.S.) Position of sleep, no. of pillows, do symptoms affect sleep? Soft or firm mattress?

• Improving, staying the same, getting worse^[6]

Special Questions

Special questions are used to identify precautions or absolute contraindications to examination or treatment)

• General health
• Weight loss
• RA
• Drug therapy
• X-rays and medical imaging
• Neurological symptoms

History of Present Condition (HPC)

• Known or unknown cause
• Sudden/slow onset
• How long ago did symptoms start
• Route to physiotherapy

Past Medical History (PMH)

• Relevant medical history
• Previous episodes
• Previous Rx

Social History

• Employment, dependants, leisure activities etc.

Performance‐Based Outcome Measures

There are no validated region specific outcome tools for the thoracic spine, the following are recommended but require validation for use with patients with primary thoracic disorders:

• Neck Disability Index (NDI) for upper thoracic complaints
• Oswestry Disability Index (ODI) for lower thoracic complaints
• Numeric Pain Rating Scale (NPRS) where patient is able to rate their pain on a scale of 0 (none) to 10 (severe).
• Patient Specific Functional Scale (PSFS) can be used to measure activity limitations and to compare progress from the baseline measurement.

Region-Specific Historical Examination

The thoracic area is a common place for the cervical spine to refer symptoms, a screening examination of the cervical spine including assessing for previous neck pain or neck trauma is necessary to rule-out cervical spine involvement.^[7][3]
Wainner and Fritz developed questions to help determine if the patient has a cervical radiculopathy;^[8]

• “Do neck movements improve your symptoms?” If yes there is a positive likelihood ratio (+LR) of 2.2, if no there is a negative likelihood ratio (-LR) of .50.
  
• “Where is the pain most bothersome?” With the answer “shoulder/scapula area” has a +LR 2.3.

Using a pain diagram and follow up questioning the examiner should begin to differentiate, as best as possible, if the disorder involves the upper or lower thoracic spine, as well as, vertebral or rib pain.
See the special questions below to rule out red flag disorders for the thoracic spine region.

Special Questions

The use of a medical screening form is recommended to gather important data on the patient’s past medical history and to begin screening for the presence of red flags.

Red Flags

• Thoracic spine pain and visceral pain can mimic the other due to the shared afferent innervation of the ANS sympathetics, which originate from T1-L2 afferents from the spinal cord.^[9]
• Segments T4-T7 have the potential to cause pseudoanginal pain as well as symptoms generated by a cough, sneeze, deep breath, movement of the trunk, palpation, and compression.^[10]
• Other potential red associated with thoracic spine pain are listed the following charts:
  

Cardiac Ischemia	Dissecting thoracic aneurysm	Peptic Ulcer	Cholecystitis	Renal Infection and Kidney Stones
- History of risk factors for CAD, MI - Angina - Nausea	- Sudden, severe and unrelenting chest pain that can radiate to the upper back. - Unrelieved with laying down.	- Boring pain from epigastric area to middle thoracic spine. Triggered or relived with meals. - History of NSAID use. - Perforated ulcer can refer pain to shoulder with irritation of the diaphragm.	- Right upper quadrant and scapular pain. Fever, nausea and vomiting. 1-2 hours after a fatty meal.	- Renal colic/flank pain. - Fever, nausea, and vomiting. - Increased risk for kidney infection with ongoing UTI.

Fracture	Neoplastic Conditions	Inflammatory Disorders	Inflammatory or Systemic Disease
- Traumatic: blunt trauma or injury. - Compression Fractures: Caucasian race, history of smoking, early menopause, thin body build, sedentary lifestyle, steroid treatment, and excessive consumption of caffeine or alcohol. - Acute thoracic pain from trivial strain or trauma in males or females > 60 years.	- Age over 50 years. - Previous history of cancer. - Unexplained weight loss. - Constant pain, no relief with bed rest. - Night pain.	- Ankylosing Spondylitis:limited chest expansion, less <2.5 cm measured at nipple line. - Sacroilitis. - Morning pain and stiffness. - Peripheral joint involvemnt. - HLA-B27	- Temperature > 100° - Blood Pressure >160/95mmHg - Resting Pulse > 100 bpm. - Resting Respiration > 25 bpm. - Fatigue. - Osteomyelitis, diskitis, epidural infection, pericarditis.

Yellow Flags

• Fear-Avoidance Beliefs Questionnaire (FABQ) can be used to screen for behaviors that may require a consult or an increase in treatment duration.
• Patients involved in on-going litigation have been found to have reduced changes in quality of life and higher rates of disability with the physical gains made in therapy.^[11]
• Research has found that patients with work-related low back pain and covered by workman’s compensation are at risk for psychosocial issues and negatively affecting treatment outcomes.^[12] This relationship has not been studied in the thoracic spine pain population, but should be taken into consideration.
  

Investigations

• Diagnostic Imaging Considerations- Patients that present with acute thoracic spine pain with risk factors for osteoporotic compression fractures should have standard thoracic spine radiographs.
• Radiographs are sensitive to assess for acute compression fractures; however, if the patient’s initial radiographs were read as normal and they are still experiencing extreme pain or symptoms consider a referral for advanced imaging such as CT or MRI.
• Patients with red flags for cancer should be referred for imaging to rule out cancer.
• Patients with suspected Ankylosing Spondylitis are typically referred for radiographs of the sacroiliac joints and lab studies including assessing for the presence of HLA-B27.
  

Objective Examination

Observation (from in front, behind and from the side)

Posture (Sitting and and Standing)^[3][13]

• The examiners observe the patient’s thoracic spine region and assesses for the presence of deviation from normal including the thoracic spine curvatures in the frontal and sagittal planes.
• The overall impression of inter-rater reliability for postural observation of kyphosis and label either excessive, normal or decrease range from moderate to substantial according to a study performed by Cleland et al.^[14]
• Paying attention to some of the following; symmetry, Cx/Tx/Lx curvatures, deviations of the spine, shoulder levels, shoulder girdle, scapula position, GH joint position, level of the pelvis, limb position
• Muscle bulk and tone (compare sides, hand dominance)
• Soft tissues (Skin colour and quality, Swelling, scars)
• Gait (Trendelenburg gait, short leg gait)
• Attitudes and feelings^[6]
  

Movement Patterns

The examiner can ask the patient to perform the following movements to check for any change symptoms; looking up, transferring from sit to stand, lifting one or both arms overhead, and any other movements that aggravate or relieve symptoms. While the patient performs these movements watch for any deviations, compensations, or discrepancies between sides. If applicable, any of these movement patterns can be used as asterisk or comparable signs for reassessment after a trial intervention. ^[13]

Palpation

To begin, palpate superficial structures and then move to the deeper structures of the thorax. Feel for any changes in temperature, texture, and moisture, as well as lymph node and soft tissue swelling. Check for symmetry between bony landmarks including the rib angles and attachments, this can also be done through observation.^[15]

Assessment of skin temperature, soft tissues, muscle tone, tenderness, increased or decreased prominence of bones, position of vertebrae and ribs

• Supine- sternum, ribs, clavicle, sternocostal and costochondral joints
• Prone- spinous process, costotransverse and costovertebral *Note thoracic facet and costotransverse joints refer pain locally or 1 level above or below
• Seated- 1st rib anteriorly and posteriorly^[6][13]

Movement Testing

Thoracic Spine AROM, PROM, and Overpressure

• Flexion
• Extension
• Side-bending
• Rotation
• Combined Movements (rotation with extension)
  

• Assess for baseline symptoms including intensity and location prior to testing. Note changes in intensity and location of symptoms and where in the range they occur during test.
• Ensure the motion is purely thoracic by ensuring the patient is not compensating with lumbar and pelvis movement.
• Repeated motion may be performed to assess for centralization of symptoms or a directional preference.
• Repeated motion testing has been predominately studied for lumbar and cervical spine at this time.
• The normal end feel for all the motions listed is firm.
• Flexion, extension and side-bending may be measured with a double inclinometer method, but no normative values have been found, and reliability of these measurements has not been researched.
• Rotation and combined movements measured purely on observation.^[16][13]

Passive Intervertebral Motion

To access accessory intervertebral motion apply pressure in a posterior to anterior direction to the thoracic spine either centrally directly on the spinous process (central) or unilaterally located just lateral to the spinous process.

Rib motion may be accessed in two locations, posterior to anterior pressure applied to the rib angles and anterior to posterior pressure applied at the costosternal joints.

The examiner assesses for pain provocation and mobility of each joint and determines whether it is hypomobile, hypermobile or normal. Also note pain provocation.^[16]

Reliability of Thoracic Spine Passive Accessory

Thoracic Spine Central PA assessment

• Intra-rater and inter-rater reliability in the thoracic spine when determining mobility dysfunction was fair when using strict agreement of spinal levels. When the expanded agreement to include one segment above or below intra-rater and inter-rater reliability increased to good to moderate.^[17]
• Cleland found thoracic spine mobility testing ranged from fair agreement to substantial agreement between each separate segment of the thoracic spine.^[14]
• In the study by Potter, testing for thoracic joint dysfunction using postural observation, active and passive range of motion, palpation, and PAs was rated as poor to moderate for intra-rater reliability.^[18][16]

Rib Cage

• The intra-rater reliability was found to be fair with strict agreement and increased to good with expanded agreement.^[17]

Reliability of Pain Provocation

Central Thoracic PAs

• Intra-rater pain provocation with strict agreement ranged from fair to good and inter-rater reliability was fair. When the agreement was expanded intra-rater reliability was increased to very good and inter-rater reliability increased to good.^[17]
  
• Pain provocation had a similar variance across the thoracic spine with a range from no agreement to substantial agreement.^[14][16]

Rib Cage

• Strict agreement the intra-rater reliability ranged from no agreement to moderate and no agreement for the inter-rater reliability. When the agreement was expanded both intra-rater and inter-rater reliability increased to complete agreement and good respectively.^[17]
  

Muscle Testing

Testing both muscle length and strength is important to identify functional limitations and compensations of each muscle. The measurement serves as a baseline to aid in tracking progress and allows the therapist to properly target impairment with interventions.

Muscle Length Testing^[13][14]

• Latissimus Dorsi - moderate to substantial inter-rater reliability
• Pectoralis Major- fair to substantial inter-rater reliability
• Pectoralis Minor- moderate to substantial inter-rater reliability
  

Muscle Strength^[13][14]

• Middle Trapezius- no inter-rater reliability
• Lower Trapezius- no inter-rater reliability
• Seratus Anterior- fair to substantial inter-rater reliability
• Rhomboids- moderate inter-rater reliability^[6]
  

Neurologic Assessment

Questions to help determine the direction of the neurological screen.

• Do you get symptoms into the legs or low back with neck movements?

If yes, perform a detailed neurological examination

• Have you experienced any bilateral upper extremity symptoms or occasional loss of balance or lack of coordination in the lower extremities?

If yes, perform a detailed neurological examination

• Upper Motor Neuron Reflexes (Hoffman, Babinski, Clonus)
• Sensory Testing: T1 dermatome (medial forearm)
• T1 Nerve Root Level: first dorsal interossei
• Upper Quarter Neurologic Screen for upper thoracic
• Lower Quarter Neurologic Screen for lower thoracic

Neural Tissue Provocation Tests

• Passive neck flexion
• Neural tissue provocation tests for the upper limb
• Straight leg raise
• Passive knee bend
• Slump test^[13]

Special Tests

[19]

• Cervical Rotation Lateral Flexion (CRLF) Test- If first rib elevation or hypomobility is suspected.
• Slump Test- To determine neural tension.
• Adsons test - provocative test for Thoracic Outlet Syndrome accompanied by compression of the Subclavian artery by a cervical rib or tightened anterior and middle scalene muscles
• Kehr’s sign- With the patient in supine and legs elevated, a report of pain in the supraclavicular area can be secondary to irritants or blood in the peritoneal cavity rather than musculoskeletal involvement. It is a classic symptom for a ruptured spleen and can result from other splenic injuries, renal calculi, diaphragmatic lesions, peridiaphragmatic lesions, or an ectopic pregnancy.
• 'Cervicothoracic tests' - to provoke the patient’s symptoms of neck pain. These clinical tests are part of the examination proceeded in order to establish the differential diagnosis
• Murphy’s Percussion- Place hand over costovertebral angle of the back and thump hand with the other fist. If there is a reproduction of back or flank pain this is a positive test and indicative of kidney involvement.
• Palpate Abdomen:

-Right Upper Quadrant: Liver, gallbladder, duodenum, head of pancreas, right kidney and the hepatic flexure of the colon.

-Left Upper Quadrant: Stomach, spleen, left lobe of liver, body of pancreas, left kidney and adrenal gland, splenic flexure of colon, and parts of the transverse descending colon.

-Right Lower Quadrant: Cecum, appendix, ascending colon, right ovary and fallopian tube and right ureter.

-Left Lower Quadrant: Left ovary and fallopian tube, left ureter, descending colon and sigmoid colon.

• Palpation of the Aortic Pulse in the Abdomen- Use this test on patients at risk for an abdominal aortic aneurysm. Place the patient in a supine hooklying position with the abdominal muscles on slack. Palpate to the left of the patient’s navel feeling for a pulse, once felt continue laterally until the pulse can no longer be detected. If the distance the pulse is detected is > 2.5 cm refer the patient for additional diagnostic studies.
• Rebound Tenderness- Place hand on abdomen in an area away from suspected inflammation, slowly and deeply palpate. Quickly remove hand. If the patient feels pain on release this is called rebound tenderness and can be indicative of an inflamed peritoneum.
• Thoracic Excursion- Thoracic excursion can be measured on a patient you suspect decreased chest expansion, including ankylosing spondylitis. Using a cloth measuring tape and standardized measuring locations (5th thoracic spinous process/3rd intercostal space and 10th thoracic spinous process/xyphoid process) have the patient exhale completely and take the measurement, then have them inhale to their full capacity and record the measurement. ^[6]

Presentations

Anterior and Posterior Chest Wall Pain Differential Diagnosis for the Physical Therapist This presentation, created by Stephanie Pascoe, Evidence in Motion OMPT Fellowship, 2012.

References

1. ↑Thoracic Vertebrae
2. ↑ ^2.02.12.2Oliver, J., Middleditch, A., (1991), Functional Anatomy of the Spine, Butterworth-Heinemann, Oxford
3. ↑ ^3.03.13.23.3Levangie P, Norkin C, (2001), Joint Structure and Function; A Comprehensive Analysis, 3 rd Edition, F.A. Davis Company, Philadelphia
4. ↑ ^4.04.1Thoracic Vertebrae. (2018, January 15). Physiopedia, . Retrieved 13:45, January 28, 2018 from https://www.physio-pedia.com/index.php?title=Thoracic_Vertebrae&oldid=182308.
5. ↑Linton SJ, Hellsing AL, Hallden K. A population-based study of spinal pain among 35-45-year-old individuals. Prevalence, sick leave, and health care use. Spine (Phila Pa 1976) 1998 Jul 1;23(13):1457-1463.
6. ↑ ^{6.06.16.26.36.46.56.6}Magee, D, (2002) Orthopedic Physical Assessment, 4 th Edition, Saunders, London
7. ↑Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine (Phila Pa 1976) 2003 Jan 1;28(1):52-62.
8. ↑Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine (Phila Pa 1976) 2003 Jan 1;28(1):52-62.
9. ↑Benhamou CL, Roux C, Tourliere D, Gervais T, Viala JF, Amor B. Pseudovisceral pain referred from costovertebral arthropathies. Twenty-eight cases. Spine (Phila Pa 1976) 1993 May;18(6):790-795.
10. ↑Hamberg J, Lindahl O. Angina pectoris symptoms caused by thoracic spine disorders. Clinical examination and treatment. Acta Med Scand Suppl 1981;644:84-86.
11. ↑Blake C, Garrett M. Impact of litigation on quality of life outcomes in patients with chronic low back pain. Ir J Med Sci 1997 Jul-Sep;166(3):124-126.
12. ↑Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychosocial yellow flags in acute low back pain: risk factors for long-term disability and work loss. New Zealand: Accident Rehabilitation; Compensation Insurance Corporation of New Zealand, and the National Health Committee, Ministry of Health 1997.
13. ↑ ^{13.013.113.213.313.413.513.6}Petty, N, Moore, A, (2002), Neuromuscular Examination and Assessment A Handbook For Therapists, 2 nd Edition, Churchill Livingstone, Edinburgh
14. ↑ ^{14.014.114.214.314.4}Cleland JA, Childs JD, Fritz JM, Whitman JM. Interrater Reliability of the History and Physical Examination in Patients With Mechanical Neck Pain. Arch Phys Med Rehabil 2006 10;87(10):1388-1395.
15. ↑Flynn TW, Cleland JA, Whitman JM, Users’ Guide to the Musculoskeletal Examination. Cervicothoracic spine examination. Evidence in Motion, 2008. p72-102.
16. ↑ ^{16.016.116.216.3}Maitland, G, (1991), Vertebral Manipulation, 3 rd Edition, Butterworth Heinemann, London
17. ↑ ^{17.017.117.217.3}Heiderscheit B, Boissonnault W. Reliability of Joint Mobility and Pain Assessment of the Thoracic Spine and Rib Cage in Asymptomatic Individuals. Journal of Manual and Manipulative Therapy 2008 12;16(4):210-216.
18. ↑Potter L, McCarthy C, Oldham J. Intraexaminer Reliability of Identifying a Dysfunctional Segment in the Thoracic and Lumbar Spine. J Manipulative Physiol Ther 2006 4;29(3):203-207.
19. ↑Physical Therapy Nation. Lindgren's Test for First Rib Dysfunction. Available from: http://www.youtube.com/watch?v=U7ZRo09Vn04 [last accessed 14/12/13]