Thoracic Nerve Glide Rehabilitation Protocol

This protocol outlines a comprehensive physical therapy rehabilitation program for individuals experiencing thoracic nerve impingement or entrapment. It is crucial that this protocol is individualized based on a thorough assessment of the patient's specific presentation, pain levels, irritability, and functional limitations. Progression through phases should be guided by the patient's tolerance and symptom response.

Pathophysiology

Thoracic nerve entrapment or impingement can occur at various locations along the course of the thoracic spinal nerves (T1-T12). Common sites include:

• Intervertebral Foramen: Nerve root compression due to disc herniation, facet joint arthritis, or osteophytes.
• Costovertebral/Costotransverse Joints: Inflammation or malalignment of these joints can irritate or compress the nerve.
• Intercostal Space: Muscle spasm (e.g., intercostals, serratus posterior superior/inferior), rib fractures, or scar tissue formation following surgery or trauma.
• Myofascial Trigger Points: Tightness and trigger points in the surrounding musculature (e.g., paraspinals, rhomboids, latissimus dorsi) can contribute to nerve compression.

Symptoms can vary depending on the nerve involved and the location of the impingement. Common symptoms include:

• Sharp, shooting, or burning pain along the rib cage.
• Numbness or tingling in the chest wall, abdomen, or back.
• Muscle weakness or spasms in the intercostal muscles.
• Pain exacerbated by breathing, coughing, sneezing, or certain movements.
• Postural abnormalities.

Common Special Tests

• Thoracic Rotation Test: Assess range of motion and pain provocation with thoracic rotation.
• Rib Springing: Palpation and mobilization of ribs to assess for joint restriction and pain reproduction.
• Slump Test: Neurodynamic test to assess the mechanosensitivity of the nervous system. Modification of head and neck position can help isolate thoracic nerve roots.
• Upper Limb Tension Test (ULTT) with Median, Radial, and Ulnar Nerve Bias: While primarily for upper extremity nerves, can be used to indirectly assess the influence of cervical and upper thoracic nerve roots.
• Palpation: Assessing for muscle spasm, tenderness, and trigger points in the paraspinals, intercostals, and other surrounding musculature.

Phase I: Protection (Acute Phase)

Goals: Pain reduction, inflammation control, promote healing, prevent further injury.

• Activity Modification: Avoid activities that exacerbate symptoms.
• Modalities:
  • Ice or heat as needed for pain and inflammation.
  • Electrical stimulation (TENS) for pain management.
  • Ultrasound for soft tissue healing.
• Gentle Range of Motion (ROM):
  • Scapular retraction/protraction.
  • Shoulder pendulums.
  • Cervical ROM exercises.
  • Gentle thoracic rotation in pain-free range.
• Breathing Exercises:
  • Diaphragmatic breathing to promote relaxation and improve ventilation.
  • Segmental breathing to improve rib cage mobility.
• Postural Correction: Education on proper posture and ergonomics.
• Isometric Exercises: Gentle isometric exercises for scapular stabilizers and core muscles.
• Nerve Glides (Low Amplitude, Pain-Free):
  • Thoracic Nerve Glide 1: Seated, arms at sides, gently laterally flex head towards the affected side, then simultaneously depress the shoulder on the affected side. Hold briefly, then return to neutral. Repeat 10-15 times, focusing on a gentle gliding sensation.
  • Thoracic Nerve Glide 2: Supine, arms at sides, gently tuck chin and flex the thoracic spine (small crunch motion). Hold briefly, then return to neutral. Repeat 10-15 times, focusing on a gentle gliding sensation.

Phase II: Loading (Subacute Phase)

Goals: Restore ROM, improve strength and endurance, normalize nerve mobility.

• Progressive ROM Exercises: Gradually increase the range of motion in all planes.
  • Thoracic extension exercises (e.g., prone press-ups, cat-cow).
  • Thoracic rotation exercises (e.g., seated twists, standing trunk rotations).
  • Lateral flexion exercises (e.g., side bends).
• Strengthening Exercises: Progress from isometric to isotonic exercises.
  • Scapular retraction/protraction with resistance band.
  • Rows with resistance band or light dumbbells.
  • Lat pulldowns (light weight).
  • Chest press (light weight).
  • Core strengthening exercises (e.g., planks, bird dogs, dead bugs).
• Manual Therapy:
  • Joint mobilization to address restrictions in the thoracic spine, ribs, and costovertebral/costotransverse joints.
  • Soft tissue mobilization to release muscle spasm and trigger points.
• Progressive Nerve Glides (Increased Amplitude): Increase the amplitude and duration of the nerve glides as tolerated.
  • Thoracic Nerve Glide 1 (Progressed): Seated, arms at sides, gently laterally flex head towards the affected side, then simultaneously depress the shoulder on the affected side and laterally flex the trunk away from the affected side. Hold briefly, then return to neutral. Repeat 10-15 times, focusing on a gentle gliding sensation.
  • Thoracic Nerve Glide 2 (Progressed): Supine, arms overhead, gently tuck chin and flex the thoracic spine (small crunch motion). Hold briefly, then return to neutral. Repeat 10-15 times, focusing on a gentle gliding sensation.
  • Consider adding other nerve glides targeting specific dermatomes based on presentation.
• Proprioceptive Exercises: Balance and coordination exercises to improve postural control.

Phase III: Return to Function (Chronic Phase)

Goals: Restore full function, prevent recurrence.

• Functional Exercises: Simulate activities required for work, sport, or daily living.
  • Lifting and carrying exercises.
  • Reaching and overhead activities.
  • Sport-specific drills.
• Advanced Strengthening Exercises: Progress to higher-level strengthening exercises.
  • Weight training with heavier weights.
  • Plyometric exercises.
• Endurance Training: Cardiovascular exercises to improve overall fitness.
• Maintenance Program: Continue with ROM, strengthening, and nerve glide exercises to maintain gains and prevent recurrence.
• Education: Educate the patient on proper body mechanics, ergonomics, and self-management strategies.
• Nerve Glide Progression (Dynamic): Incorporate movement with the nerve glides to simulate functional activities. For example, perform a thoracic nerve glide while reaching overhead.

Progression Criteria: Progression to the next phase is dependent on the patient meeting specific criteria, including:

• Pain levels consistently below a specified threshold.
• Full or near-full range of motion.
• Adequate strength and endurance.
• Ability to perform functional activities without pain or limitations.

Important Considerations:

• Monitor patient response to treatment and adjust the program accordingly.
• Educate the patient on the importance of adherence to the home exercise program.
• Address any psychosocial factors that may be contributing to the patient's pain and disability.
• Consider referral to other healthcare professionals (e.g., physician, pain specialist) if necessary.