Ultrasound-guided procedures for the management of chronic thoracic back pain: a technical review

Pain arising from the thoracic region has been reported to be potentially as debilitating as cervical or lumbar back pain, and may stem from a vast number of spinal sources, including zygapophysial, costovertebral and costotransverse joints, intervertebral discs, ligaments, fascia, muscles, and nerve roots. Over the last two decades, the use of ultrasound in interventional spinal procedures has been rapidly evolving, due to the ultrasound capabilities of visualizing soft tissues, including muscle layers, pleura, nerves, and blood vessels, allowing for real-time needle tracking, while also reducing radiation exposure to both patient and physician, when compared to traditional fluoroscopy guidance. However, its limitations still preclude it from being the imaging modality of choice for some thoracic spinal procedures, notably epidural (interlaminar and transforaminal approaches) and intradiscal injections. In this technical review, we provide an overview of five thoracic spinal injections that are amenable to ultrasound guidance. We start by discussing their clinical utility, followed by the relevant topographic anatomy, and then provide an illustrated technical description of each of the procedures discussed: (1) erector spinae plane block; (2) intra-articular thoracic zygapophyseal (facet) joint injection; (3) thoracic medial branch block; (4) costotransverse joint injection; and (5) costovertebral joint injection.

Ultrasound-guided costovertebral joint injection-technique description and fluoroscopy and computerized tomography combined controlled cadaveric feasibility study

OBJECTIVES

To describe and assess the feasibility of an ultrasound-guided technique for intra-articular injection of the costovertebral joints, in an unembalmed cadaveric specimen, utilizing fluoroscopy and cone beam computerized tomography for confirmation of contrast spread and needle tip position, respectively.

METHODOLOGY

A single unembalmed cadaveric specimen was obtained. A single interventionist performed the placement of the needles under ultrasound guidance. Contrast dye was then injected through each of the needles under real-time fluoroscopy. Finally, the specimen was submitted to a cone beam computerized tomography with 3-dimensional acquisition and multiplanar reformatting to assess final needle tip position relative to the costovertebral joints.

RESULTS

In total, 18 spinal needles were placed under ultrasound guidance. Fluoroscopy showed 4 distinct patterns of contrast spread: intra-articular in the costovertebral joint (13 levels in total), epidural (1 level), intra-articular in the facet joint of the target level (3 levels), and undetermined (1 level). Cone-beam computerized tomography confirmed 13 out of 18 needles to be adequately placed in the costovertebral joints (72% of the total) and 5 out of the 18 needles to be misplaced: 3 needles were placed in the facet joint of the target level, and 2 needles were placed in the epidural space.

CONCLUSIONS

This study suggests that, when performed by experienced interventionists, this technique has an accuracy rate of 72%. Further studies are warranted before these results can be extrapolated to daily clinical practice.

Intra and inter observer agreement in the mobility assessment of the upper thoracic costovertebral joints

BACKGROUND

Determining the mobility of the costovertebral joints might be important in patients with neck-upper thoracic pain. Little research has been performed on observer agreement when assessing the mobility of these joints.

PURPOSE

The purpose of this study was to determine intra- and inter-observer agreements when assessing costovertebral joint mobility of the upper three ribs in those with and without neck pain and to compare the difference between the Kappa and AC statistic.

METHODS

Forty-four participants, with and without current neck/upper-thoracic pain, were assessed by two raters. Raters applied a posterior to anterior pressure to the anatomical neck of the first three ribs bilaterally. Mobility was graded: normal, increased, or decreased. An AC1, for nominal data, AC2 for ordinal data, and the Kappa statistics were used to analyze the results. The AC statistics determines chance agreement different than Kappa.

RESULTS

AC1 showed "moderate to very good" (0.74-1.0) intra-rater reliability, while inter-rater reliability showed "fair to good" agreement (0.51-0.79). Using the AC2 Intra-rater reliability was "very good" and "almost perfect" (AC2: 0.93-1.0), while using the AC2 was "good to very good" and "good to almost perfect" (0.76-0.94). Kappa values for intra-rater reliability ranged from "fair to moderate" (0.38-0.54), while inter-rater reliability ranged from "poor to fair" (-0.10-0.26).

CONCLUSION

Posterior/anterior pressure is a reliable method to assess the mobility of the upper costovertebral joints. Assessing costovertebral mobility is important when establishing a movement diagnosis in patients with neck/upper thoracic pain.

Assessment of the physical and emotional health concerning the students' physical activity during the COVID-19 pandemic

Introduction. SARS CoV-2 caused the third global pandemic and by applying quarantine / isolation / lockdown, the movement was restricted, the physical contact between people was reduced, the physical activity was low, but the activities using electronic devices at home were frequent. The aim of the study was to assess the physical and emotional health in relation to the physical activities done during quarantine/ isolation during the pandemic. Material and method. The study was cross-sectional and consisted of completing an online questionnaire. It was conducted in a period of 6 months and it included 334 students. In order to point out the symptoms caused by quarantine / isolation/ lockdown, we considered it useful for students to participate by completing an online questionnaire about physical activities, physical health and emotional state, related to the implications of participating in online courses. Results. The questions in this questionnaire were grouped on the following aspects: physical activity, physical health, emotional state, all in the context of the pandemic period, including the period in which the academic activity was online. Thus, in the first year, there is a positive correlation between physical condition, physical activity, emotional signs and cognitive ones. In the second year, the positive correlation is present between the physical and the affective signs, whereas the negative correlation is between the affective signs, the cognitive ones and the physical activity. In the third year, the positive correlation is obvious between the affective signs, the cognitive ones and the physical activity, whereas the negative one between the physical and cognitive signs, as well as between the physical activity and the cognitive and physical signs. Discussions. There is a link between emotional and cognitive symptoms and physical health. Fear, anxiety, behavioral disorders, and limited physical activity among students during this period can be a public health issue. Conclusions. The COVID-19 pandemic affected the physical and mental state, with a greater resonance for youth, especially pupils and students. Many of them had emotional, behavioral, physical and cognitive symptoms. These symptoms are found to a greater extent in students in the final years, due to the social impact, social and professional integration. Keywords: physical health, mental state, students,

Treatment of thoracic spine pain and pseudovisceral symptoms with dry needling and manual therapy in a 78-year-old female: A case report

DESIGN

Case Report.

BACKGROUND AND PURPOSE

Thoracic spine pain and movement dysfunction is a relatively common problem in the general population but has received little attention in research. Dry needling is frequently utilized by physical therapists and has been shown to reduce pain and improve function in areas, such as the cervical and lumbar spine, shoulder, hip, and knee. However, little research has been performed on the use of dry needling in the thoracic area with only two prior case studies being published. This case report documents the use of dry needling and manual therapy to treat a patient with symptoms of thoracic spine pain with concurrent pseudovisceral symptoms of chest pain and difficulty breathing.

CASE DESCRIPTION

The patient was a 78-year-old female who was referred to physical therapy with complaints of pain focused in her mid-thoracic spine radiating anteriorly into her chest. The patient underwent medical diagnostic tests prior to her referral to physical therapy to rule out cardiac pathology, pulmonary pathology, and fracture. She was treated with dry needling and manual therapy for a total of four sessions over a two-week period.

OUTCOMES

Fifteen days after her initial evaluation, the patient reported she was pain-free with a pain score of 0/10 on the VAS. She reported she was no longer taking pain medication or NSAIDS. She was able to return to normal daily activities without restriction and normal sleep pattern. Her score on the Oswestry disability index at intake was 42% impairment and 2% impairment after 4 treatments. At follow-up 6 weeks and 12 weeks after her discharge from physical therapy, the patient reported she continued to be pain-free.

Inflammatory disease of the costotransverse joints: US evaluation in 15 symptomatic patients

The costotransverse joints (CTJs) are small arthrodial joints which articulate with the costal tuberosity on the transverse process of the thoracic vertebrae. CTJs are composed of oval-shaped facets with a major axis, vertical at the upper vertebrae and almost horizontal at the lower vertebrae. This position explains the different movements of the ribs: the cranial ribs move on the sagittal plane and the caudal ribs on the transverse plane. Movements in directions other than these usual CTJ spatial planes can cause inflammation resulting in a stinging pain in the space between the scapula and thoracic spine. We studied 15 subjects with paravertebral pain compatible with CTJ pathology. Mean age was 29 years, 11 females/4 males. In 12 patients, the non-dominant limb was affected. US imaging was carried out using linear 12 MHz and 9 MHz probes. Scanning was performed following the long axis of the rib (transverse plane) and the short axis (sagittal plane). Sagittal scanning is the method of choice for detection of possible joint effusion and comparison with undamaged joints above and below. US identified joint effusion correlating with the site of pain in all patients. Thickening of the posterior costotransverse capsular ligament was detected in six patients mainly affecting the first thoracic vertebrae. Power Doppler showed intraarticular hypervascularization in four patients. US imaging should be performed as a first-line examination in the evaluation of patients with stinging pain in the paravertebral region. US evidence of effusion within the joints is a sure sign of involvement of these structures.

Osteoartrose costovertebral: Diagnóstico diferencial raro de dorsalgia no paciente jovem. Relato de caso

The differential diagnosis of dorsal thoracic pain can be a challange due to the proximity of the dorsal column to vital organs as well as to its unique anatomy, innervation, and rib joint. The patterns of referred visceral pain require, in most cases, extensive complementary diagnostic tests in order to exclude severe conditions. Referred pain patterns often result in numerous and expensive visceral workups in order to exclude serious conditions, and costovertebral joint osteoarthritis is usually only considered when the origin of the pain remains unexplained. The authors present the case of a 40-year-old man with disabling dorsal pain due to isolated costovertebral osteoarthrosis. The symptomatology was controlled after injection of methylprednisolone guided by computed tomography. This clinical case aims to describe the clinical presentation of a rare entity that should be considered in the differential diagnosis of back pain.

Dorsalgia rehabilitation in static disorders of the spine by therapeutic swimming in young adults

The purpose of this paper is to point out and propose the most effective means of therapeutic swimming in the use of work programs for patients with dorsalgia in spinal static disorders. The knowledge degree of therapeutic swimming is not sufficiently promoted and used, which is why we propose the following hypothesis: we start from the premise that therapeutic swimming can reduce the dorsalgia in the spine, improve lung capacity and physical condition in young adults. The objectives of this work are to identify subjects with spinal static dorsalgia and to establish the sample for the experiment; in the selection of therapeutic swimming means for the elaboration of the work program; in the registration and interpretation of the data in the form of tables and charts. The experiment took place at the Kinetic Therapy Practice of Mr. Constantinescu Mihai, as well as at the swimming pool in Cornisa, Botoşani county, with a sample consisting of 15 subjects aged between 18 and 22, all of whom suffered dorsalgia (in the spine). In this respect, we set out to implement a therapeutic swimming program for 6 months to achieve positive results. Keywords: dorsalgia, spinal static disorders, therapeutic swimming,

Applying a clinical decision-making model to a patient with severe shoulder pain ultimately diagnosed as neuralgic amyotrophy

OBJECTIVE AND PURPOSE

Shoulder symptoms are often encountered in physical therapy and a myriad of etiologies can cause these symptoms, either locally or remotely. The purpose of this case report is to describe the physical therapist's differential diagnostic process for a patient with acute and severe onset of shoulder pain. Case Description: The patient was a 37-year-old female with sudden onset of right shoulder pain that awakened her at night. Pain was associated with decreased range of motion and shoulder weakness. Faced with an uncertain diagnosis, the physical therapist followed a systematic approach to clinical decision-making. Outcomes: Neuralgic amyotrophy was the primary diagnostic hypothesis but other causes of shoulder pain could not be ruled out. Conclusion: The clinical decision-making process helped the physical therapist narrow down the differential diagnosis list and make a decision to send the patient for further testing. Magnetic resonance imaging and electromyogram confirmed the diagnosis of neuralgic amyotrophy.

Effect of fascia dry needling on non-specific thoracic pain - A proposed dry needling grading system

This case report describes a 42-year-old female who presented with complaints of diffuse pain in her thoracic paraspinal region from T2 to T7. Physical examination revealed tenderness, increased turgor and restriction of her superficial fascia. A potential first time description of successful management utilizing fascia dry needling is described in this report with improvements noted in pain, range of motion, and functional activities. The patient was discharged from physiotherapy after four treatment sessions, and a follow-up after 3 months revealed that she was pain free and fully functional. A grading system (Sudarshan and Murugavel Dry Needling Grading Scale^©) is proposed describing the various grades of dry needling to guide clinical reasoning and decision-making.

Clinical Effectiveness of Ultrasound-guided Costotransverse Joint Injection in Thoracic Back Pain Patients

Because of its anatomical location and function, the costotransverse (CTRV) joint can be a source of thoracic back pain. In this retrospective observational study, we evaluated the clinical effectiveness of the CTRV joint injection in thoracic back pain patients with suspected CTRV joint problems. We enrolled 20 thoracic back pain patients with localized tenderness that was provoked by the application of pressure on the affected CTRV joints. We injected it with 0.5 ml of a ropivacaine and triamcinolone mixture at each level. The mean pre-injection pain score decreased by 37.9% (7.2 ± 1.5 to 4.5 ± 1.7, P < 0.001) two weeks after CTRV joint injection. In addition, 70% of patients reported an excellent or good level of satisfaction. We demonstrated that an ultrasound-guided injection of the CTRV joint reduced patients' pain scores and led to a high level of satisfaction at short-term follow-ups in patients with suspected CTRV joint problems.

Presentation of Coronary Artery Disease in a Chiropractic Clinic: A Report of 2 Cases

OBJECTIVE

The purpose of this report is to describe 2 patients with coronary artery disease presenting with musculoskeletal symptoms to a chiropractic clinic.

CLINICAL FEATURES

A 48-year-old male new patient had thoracic spine pain aggravated by physical exertion. A 61-year-old man under routine care for low back pain experienced a secondary complaint of acute chest pain during a reevaluation.

INTERVENTION AND OUTCOME

In both cases, the patients were strongly encouraged to consult their medical physician and were subsequently diagnosed with coronary artery disease. Following their diagnoses, each patient underwent surgical angioplasty procedures with stenting.

CONCLUSION

Patients may present for chiropractic care with what appears to be musculoskeletal chest pain when the pain may be generating from coronary artery disease necessitating medical and possibly emergency care.

Incidence and risk factors for thoracic spine pain in the working population: the French Pays de la Loire study

OBJECTIVE

To examine the incidence and risk factors for incident thoracic spine pain (TSP) in workers representative of a French region's working population.

METHODS

In this prospective study, 3,710 workers were assessed in 2002-2005, and 2,332 (62.9%) of them were reassessed in 2007-2010. TSP was assessed by a self-administered Nordic questionnaire at baseline and at followup. At baseline, all participants completed a self-administered questionnaire on personal factors and work exposure. A total of 1,886 subjects (1,124 men and 762 women) without TSP at baseline were eligible for analysis. Associations between incident TSP and risk factors at baseline were analyzed by multivariate logistic regression.

RESULTS

The incidence rate of TSP was 5.2 (95% confidence interval [95% CI] 3.9-6.6) per 100 men and 10.0 (95% CI 7.8-12.1) per 100 women. TSP was often associated with low back pain and neck pain. TSP in men was associated with age (odds ratios [ORs] ranging from 2.6 [95% CI 0.95-7.1] at 30-39 years to 6.0 [95% CI 2.1-17.3] at ≥50 years), being tall (OR 2.2 [95% CI 1.2-3.9]), frequent/sustained trunk bending (OR 3.0 [95% CI 1.5-6.1]), lack of recovery period or change in the task (OR 2.0 [95% CI 1.2-3.6]), and driving vehicles (OR 2.8 [95% CI 1.4-5.5]). Being overweight or obese was associated with lower risk (OR 0.5 [95% CI 0.3-0.96]). TSP in women was associated with high perceived physical workload (OR 1.9 [95% CI 1.1-3.3]), after adjustment for confounding variables.

CONCLUSION

The risk model of TSP combined personal and work-related organizational and physical factors. Trunk bending appeared to be a strong independent predictor of TSP in this working population.

Canine thoracic costovertebral and costotransverse joints: three case reports of dysfunction and manual therapy guidelines for assessment and treatment of these structures

The costovertebral and costotransverse joints receive little attention in research. However, pain associated with rib articulation dysfunction is reported to occur in human patients. The anatomic structures of the canine rib joints and thoracic spine are similar to those of humans. As such, it is proposed that extrapolation from human physical therapy practice could be used for the assessment and treatment of the canine patient with presumed rib joint pain. This article presents 3 case studies that demonstrate signs of rib dysfunction and successful treatment using primarily physical therapy manual techniques. General assessment and select treatment techniques are described.

The use of functional and traditional mobilization interventions in a patient with chronic thoracic pain: a case report

There is little information in the literature regarding the efficacy of spinal manual therapy (SMT) interventions for patients with chronic thoracic spinal pain. In addition, information regarding the clinical decision-making associated with the application of SMT for this patient population is deficient. The purpose of this case report is to present the rationale for and results of applying specific SMT interventions on a patient with chronic spinal pain. A 51-year-old female with 9 months of significant thoracic, chest, sternal, and left shoulder pain was managed with both mobilization with movement and spinal manipulative procedures. The report offers insight into the decisions that guided the selection of these SMT techniques in this case. The outcome provides preliminary support for using these specific SMT procedures in patients with chronic thoracic spinal pain.

Sonographically guided costotransverse joint injections: a computed tomographically controlled cadaveric feasibility study

OBJECTIVES

The primary purpose of this study was to describe and validate a novel sonographically guided costotransverse (CTRV) joint injection technique.

METHODS

The bilateral T3-T10 CTRV joints of an unembalmed cadaveric specimen were localized using a 12-3-MHz linear array transducer. A 22-gauge, 2.5-in spinal needle was directed into the CTRV joint using an in-plane, lateral-to-medial approach under direct sonographic guidance. After needle placement, 3-dimensional computed tomographic (CT) images were obtained to assess the locations of the needle tips. This step was followed by injection of an iodinated contrast agent and repeated CT to assess the contrast flow pattern. An experienced musculoskeletal radiologist reviewed the CT images and assessed the accuracy of the injections (intra- or extra-articular). For intra-articular injections, a quantitative assessment of the percentage of injectate within the joint was performed.

RESULTS

A total of 16 sonographically guided CTRV joint injections were completed on a single torso-pelvis specimen. Using our technique, 11 of 16 sonographically guided CTRV joint injections (68.8%) placed the contrast agent into the target joint. Quantitative analysis of the arthrograms showed 6 of 11 intra-articular injections (54.5%) with greater than 50% injectate within the joint capsule.

CONCLUSIONS

To our knowledge, this study is the first to determine the feasibility of sonographically guided CTRV joint injections. Overall, 68.8% of injection attempts produced acceptable CTRV joint arthrograms, which compares favorably to a previously reported 76% accuracy rate for fluoroscopically guided CTRV joint injections. Although these injections are technically challenging, the use of sonographic guidance to perform CTRV joint injections is feasible and warrants further investigation to establish its role in the management of patients presenting with thoracic pain syndromes.

The influence of patient attitude toward massage on pressure pain sensitivity and immune system after application of myofascial release in breast cancer survivors: a randomized, controlled crossover study

OBJECTIVE

The purpose of this study was to evaluate the influence of patient's attitudes toward massage on pressure pain sensitivity and the immune effects of myofascial release in breast cancer survivors (BCS).

METHODS

Twenty BCS participated. They presented to the laboratory at the same time of the day on 2 occasions separated by 2 weeks. At each session, they received either a myofascial release technique or control (special attention) intervention. Salivary flow rate, cortisol and immunoglobulin A (IgA) concentrations, and α-amylase activity were obtained before and immediately after intervention from saliva samples. Pressure pain thresholds (PPT) over the cervical spine and temporalis muscle were assessed bilaterally. The attitude toward massage (ATOM) scale was collected before the first session in all BCS.

RESULTS

The analysis of covariance revealed a significant intervention × time interaction for salivary flow rate (P = .010), but not α-amylase (P = .111), IgA (P = .655), and cortisol (P = .363) in favor of the experimental group: BCS exhibited an increase of salivary flow rate after myofascial release intervention. When the ATOM scale was included in the analysis, significant influence on IgA (P = .001) was found: BCS with positive attitude had a significant increase in IgA (P > .05). The analysis of covariance did not find a significant intervention × time interaction for PPT over the cervical spine or temporalis muscle, with no effect of ATOM scales for PPT (P > .05).

CONCLUSION

The current study suggests that myofascial release may lead to an immediate increase in salivary flow rate in BCS with cancer-related fatigue. We also found that the effect of myofascial release on immune function was modulated by a positive patient's attitude toward massage.

Immunohistochemical study of human costotransverse joints: A preliminary investigation

The human costotransverse joint (CTJ) is the articulation between the posterior tubercle of the ribs with the first through tenth costal facet of the thoracic transverse processes. While the CTJ is well defined anatomically and considered a synovial joint, the human CTJ as a pain generating structure is controversial and not supported from a histological perspective. The objective of the present study was to investigate the histological pain producing properties of CTJ capsule tissue. Ten micron cross-sections at each level (1-10) were stained with H & E or immunostained with antisera against Substance P (SP), calcitonin-gene-related peptide (CGRP), and neuropeptide Y (NPY). Immunoreactivity was confirmed for SP, CGRP, and NPY within the CTJ tissue samples of two unembalmed male cadavers. The presence of previously mentioned neuropeptides suggests that human CTJ is capable of producing pain through somatic and autonomic nervous systems. Therefore, clinicians should consider the CTJ as a differential diagnostic possibility when examining and treating painful thoracic conditions.

Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review

BACKGROUND

Thoracic spine pain (TSP) is experienced across the lifespan by healthy individuals and is a common presentation in primary healthcare clinical practice. However, the epidemiological characteristics of TSP are not well documented compared to neck and low back pain. A rigorous evaluation of the prevalence, incidence, correlates and risk factors needs to be undertaken in order for epidemiologic data to be meaningfully used to develop evidence-based prevention and treatment recommendations for TSP.

METHODS

A systematic review method was followed to report the evidence describing prevalence, incidence, associated factors and risk factors for TSP among the general population. Nine electronic databases were systematically searched to identify studies that reported either prevalence, incidence, associated factors (cross-sectional study) or risk factors (prospective study) for TSP in healthy children, adolescents or adults. Studies were evaluated for level of evidence and method quality.

RESULTS

Of the 1389 studies identified in the literature, 33 met the inclusion criteria for this systematic review. The mean (SD) quality score (out of 15) for the included studies was 10.5 (2.0). TSP prevalence data ranged from 4.0-72.0% (point), 0.5-51.4% (7-day), 1.4-34.8% (1-month), 4.8-7.0% (3-month), 3.5-34.8% (1-year) and 15.6-19.5% (lifetime). TSP prevalence varied according to the operational definition of TSP. Prevalence for any TSP ranged from 0.5-23.0%, 15.8-34.8%, 15.0-27.5% and 12.0-31.2% for 7-day, 1-month, 1-year and lifetime periods, respectively. TSP associated with backpack use varied from 6.0-72.0% and 22.9-51.4% for point and 7-day periods, respectively. TSP interfering with school or leisure ranged from 3.5-9.7% for 1-year prevalence. Generally, studies reported a higher prevalence for TSP in child and adolescent populations, and particularly for females. The 1 month, 6 month, 1 year and 25 year incidences were 0-0.9%, 10.3%, 3.8-35.3% and 9.8% respectively. TSP was significantly associated with: concurrent musculoskeletal pain; growth and physical; lifestyle and social; backpack; postural; psychological; and environmental factors. Risk factors identified for TSP in adolescents included age (being older) and poorer mental health.

CONCLUSION

TSP is a common condition in the general population. While there is some evidence for biopsychosocial associations it is limited and further prospectively designed research is required to inform prevention and management strategies.

Thoracic costotransverse joint pain patterns: a study in normal volunteers

Background

Pain referral patterns of asymptomatic costotransverse joints have not been established. The objective of this study was to determine the pain referral patterns of asymptomatic costotransverse joints via provocative intra-articular injection.

Methods

Eight asymptomatic male volunteers received a combined total of 21 intra-articular costotransverse joint injections. Fluoroscopic imaging was used to identify and isolate each costotransverse joint and guide placement of a 25 gauge, 2.5 inch spinal needle into the costotransverse joint. Following contrast medium injection, the quality, intensity, and distribution of the resultant pain produced were recorded.

Results

Of the 21 costotransverse joint injections, 16 (76%) were classified as being intra-articular via arthrograms taken at the time of injection, and 14 of these injections produced a pain sensation distinctly different from that of needle placement. Average pain produced was 3.3/10 on a 0–10 verbal pain scale. Pain was described generally as a deep, dull ache, and pressure sensation. Pain patterns were located superficial to the injected joint, with only the right T2 injections showing referred pain 2 segments cranially and caudally. No chest wall, upper extremity or pseudovisceral pains were reported.

Conclusion

This study provides preliminary data of the pain referral patterns of costotransverse joints. Further research is needed to compare these findings with those elicited from symptomatic subjects.