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Thorax - 1

Intro to UQ, UQ scan, thoracic anatomy, biomechanics review

Upper Quadrant (order of examination) Subjective, UQ Scan (C&T spine), Functional testing, Ortho exam, Motor control & Functional patterning
Nonperipheral causes of pain Peripheral processes: infl, tissue injury Central processes: plasticity, receptor changes
Peripheral sensitization altered transduction sensitivity of high threshold nociceptors
Central sensitization Incr excitability of pain-related CNS neurons, Initiated by activity in peripheral nociceptors, but can be sustained in the absence of peripheral nociceptive input
Pain processing: Peripheral nociceptive - mechanism & presentation Mechanism: - mechanical-excitatory stimulation - inflammatory-acute, re-irritation - peripheral neurogenic (neurointerface Presentation: - localized to an anatomical structure - mechanical factors incr & decr pain - pain behavior matches mvt behavi
Pain processing: Neurogenic up-regulation, peripheral sensitization - mechanism & presentation Mechanism: - altered transduction - sensitivity of high threshold nociceptors Presentation: - Hyperreflexia, possible clonus - Hyperresthesia, pinwheel sensitive - Allodynia
Pain processing: Neurogenic up-regulation, central sensitization - mechanism & presentation Mechanism: - incr excitability of pain-related CNS neurons Presentation: - same as peripheral but more vague and widespread
Pain processing: Neuropathic (loss of function) - mechanism & presentation Mechanism: compressive Presentation: - testable numbness - loss of reflexes - fatiguing weakness
Goals of the subjective (7) - Establish a rapport with the pt - Identify red flags - Establish working hypothesis - Identify cognitive beliefs and/or barriers (Assess psychosocial contribution) - Establish the meaningful task/pt goal - Description of pain - History of injury
Subjective- patient centered approach (7) - Pathoanatomical - Psychosocial aspects - Nervous system - Pathomechanical - Genetic/familial - Lifestyle - Endocrine
Adaptive vs Maladaptive - ankle sprain -> LBP - thoracic pull -> shoulder impingement
Psychosocial aspects - pt's belief strategy - pt's coping strategy - fear avoidance
5 Goals to achieve from the subjective - make pt feel comfortable (empathy, concern) - validate connections that pt is drawing - establish main complaint (meaningful task) & goal - pt has clear focus & goal for tx to stay on task - decr pt's fear about condition
Systems review for Thoracic - region specific concerns - Cardiac history - GI history - Respiratory history - Osteoporosis or osteopenia
Why does a PT do a UQ screen? - PT already has completed history - If a pt has complaints of UQ (above T6)
General guidelines of performing a screen - Beginning of IEV - Experienced do 1 jt above/below (newbies do whole screen) - Post op: concentrate on 1 jt above/below - Acute: specific jt has priority (r/o fx or lig instability)
Categories tested in a screen (7) - Vitals - Observation - AROM - PROM w/OP - Palpation - Neuro screen - Other considerations
4 components of neuro screen Dermatomes Myotomes DTR UMN signs
UMN testing (4) - clonus of wrist - clonus of ankle - Hoffmans - B LE slump test (T spine compression)
Purpose of cervical compression/distraction compare WB vs NWB sensitivities
Positive for cervical compression indicates foraminal compression
Positive for cervical distraction indicates ligamentous or muscle injury
4 tests done if PT suspects pathology - balance training - CN assessment - abdominal palpation (visceral dysfunction) - hearing screen
6-7 Thoracic red flags Chest pain w/: - pallor, sweating, dyspnea, nausea, palpitation - or pressure w/exertion - with insp (severe, sharp, knife-like) - may refer to lat neck/shoulder - Pain referred to mid back b/w scaps w/dyspnea & exertion - Sudden severe back pain
10 Functional tests - related to meaningful tasks or direction of pain - Cervical Rot - Thoracic Rot - Forward/Backward bend - B arm raise - Single Arm Raise - Squat or sitting posture - 1-legged stance focus on thoracic weight shift - Stepping forward and focus on thoracic rot - Push-up
Functional testing leads you to T spine - Functional motion improves with thoracic “Stacking” - Pain decr with thoracic “stacking”
2 purposes of ortho exam - Which tissues is damaged (comparable sign, determine irritability) - cause of tissue damaged (cause of the cause)
Pathoanatomical • Possible source of pain • Hypothesis on tissue. Inflamed or level of healing
Pathomechanical - Look for cause or cause of the cause - Mvt faults &/or patterns - Type and direction of mechanical stress - Physiological impairments that correlate to mechanical stress - Prognosis - Affects PT plan
T spine anatomy - 1st is like C: transverse>A/P diameter, long SP - 12th T sup facet face post/lat (T), inf facet face ant/lat (L) - T1,11,12 have costofacets, not demi - Typical T: A/P=transverse diameter. Inf facet face ant/med Demi-facet for rib - Narrow SC canal
T spine biomechanics - smaller disc ratio + multiple jts at each level = incr stability - Coupling varies (ipsilat or contralat)
T spine functions - Transition b/w C&L - Most rigid - Protect viscera > mobility - Load transfer b/w upper & lower body - Up to 13 articulations at each level, smallest disc ratio (1:5) - direction of lamella, smaller nucleus (more similar to C than L)
Incidence of disc herniation in T spine - low incidence: .25-.75% of all herniations - nerve roots are situated inf and post to the upper vertebrae instead of near the disc - compression is less likely
Facets of T spine - Articular facets are ant/post - Flex/Ext limited - Costal facets articulate with the head of a rib - SPs are long and pointed
Rib articulations with vertebrae - each rib articulates with body and TP of same numbered vertebra - most ribs articulate with 2 vertebrae
Ligaments & IVD - Jt capsule & ligs: ◦Limit ROM b/w vert ◦Provide proprioceptive info ◦Store & release energy - Mobility is dictated by disc:height ratio (most in C) - IV disc makes up 20 to 33% of vert column - IVD is symphysis - Facets are diarthrodial
Motion segment (definition) - smallest functional unit - 2 vertebrae and the intervening soft tissue - Symphysis and synovial jts define quantity & quality of mvt of vertebral column
Facet alignment: Cervical ◦45 degrees from frontal & horizontal planes ◦Allows Flex/Ext ◦Coupling (SB & Rot) always ipsilat
Facet alignment: Thoracic - 20-30 degrees off frontal plane - Allows for Side Flex & Rot(less for Flex/Ext) - T10-12: aligns more in sagittal plane -> allows more Flex/Ext - Varied coupling
Facet alignment: Lumbar ◦L-shaped facets ◦Ideal for Flex/Ext ◦Resist Rot
Clinical division of T spine: Makofsky & Osteopathic - Upper T1-4 - Middle/ Lower T5-12
Clinical division of T spine: Diane Lee - Vertebromanubrial: T1,2 - Vertebral sternal: T3 to T7 - Vertebral chondral: T 8,9,10 - T-L region: T11,12
Varying length of SP: Rule of 3 T1-4 TP is 1 space above the SP T5-8 TP is 2 spaces above SP T9-11 TP is at base of the SP
Varying length of SP: Mitchell - T1-3 tip of SP is level with vertebral body of same level - T4-6 the SP is half way b/w its TP and TP of lower level with the IVD - T7-9 tips of the SP is level with TP of the lower vert - T10-12 in reverse arrangement
Costotransverse jt Vertebral sternal: upper segments convex on concave - rib sits in front of TP - Flex: ant roll, sup glide - Ext: post roll, inf glide Lower facets gliding - sits slightly above TP, plane gliding jt - Flex PMS (still sup) - Ext ALI (still inf)
What determines direction of mvt of upper and lower ribs? (2) - Shape of jt surfaces - Orientation of the common axis of mvt
Typical ribs - 2 facets on the head for articulation with the vertebrae - 1 facet on the tubercle for articulation with the same level TP - Radiate and costotransverse ligs stabilize these synovial jts
Sternum - Receives the costal cartilages via synovial jts - Except the 1st sternocostal jt which is a synchondrosis
Manubriosternal jt - Symphysis - Moves during ventilation
Xiphisternal jt synchondrosis
Massive L attachments of the diaphragm Anchor point for diaphragmatic contraction
Classification of mms for resp - Inspiratory or expiratory - Primary or accessory
Biomechanics of the closed chain - 2 vert, disc, R&L ribs connected b/w the vert, ligs, ant attachments of ribs to sternum Diane Lee - Functional unit (ring)= closed system that moves together with normal physiological motion - Multiple structures affect ring motion (ms, jt glide, disc
Motions of the ring - Flex/Ext - Rot - B Arm raise - Single Arm raise - Breathing
Major factor in determining plane of mvt Orientation of facet jts
Flex/Ext mvts b/w vert - Impact vertebral discs - Change the dimensions of intervertebral foramina
Coupling motion (definition) consistent assoc of 1 motion about an axis with another motion around a different axis
Functional unit: Flex - Avg 20-45 degrees - Range (4-15 degrees a segment) - 4-5 degrees in upper - 6-8 in middle - 9-15 in lower levels - facets help with stability with Flex - Sup ant glide of facet and ant roll of rib of upper
Functional unit: Ext -15-20 degrees -translation>rot bc of axis of motion -limited by ALL, ant disc, post elements, inf facet on lamina and SP -post sagittal Rot and post translation of sup vert -UE elevation: Ext & assoc glide -T stiffness may->T pivoting over the T-L r
Functional unit: SB - Segmental range (3-8 degrees) - Avg total range 25-45 degrees - upper segments 3-4 degrees - lower 7-8 degrees
Functional unit: Rot -3-7 degrees segmental (2-3 in L) -T1-4: 4-5 degrees (7 in upper) -T4-8: 6.5 degrees (5) -T8-12: 2-3 degrees -Total 35-55 degrees -Dutton: pure rot can occur in mid T bc axis of motion is in middle of vert -Pure rot only at TL and CT junction
Fryette Rule -Rule 1: in neutral coupling is opposite (type 1 neutral mechanics) -Rule 2: in Flex/Ext coupling is same side (C & T1-4 follow type II non-neutral mechanics) -Rule 3: when motion is introduced in 1 plane, available motion in remaining planes is reduced
Created by: neej



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