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Thoracic Spine PT
| Question | Answer |
|---|---|
| Sustained positions may be necessary to... | expose a derangement reduce a derangement or dysfunction |
| Interventions | Extension Flexion Rotation Combined movements Mobilization with Movement Manipulation |
| Purpose of extension interventions | Reduce Posterior Derangement Expose Anterior Derangement Remodel Extension Dysfunction Restore Inferior glide of Facet Restore function and remodel tissue after anterior derangement |
| Purpose of flexion interventions | Reduce anterior derangement Expose posterior derangement Remodel flexion dysfunctioin restore superior glide of facet Restore function and remodel tissue after reducing posterior derangement |
| Purpose of rotation intervention | Reduce posterolateral derangement Remodel rotation dysfunction Restore superior glide of contralateral facet or inferior glide of ipsilateral facet |
| Exposing and differentiating derangement/dysfunction/postural syndromes with flexion in standing | Repeated movement may expose derangement Overpressure may expose dysfunction Sustained may expose postural |
| Hypotheses for lesions that respond to manual therapy | Release of entrapped synovial folds or plica Relaxation of hypertonic muscles by sudden stretching Disruption of articular or periarticular adhesions Unbuckling of motion segments that have undergone disproportionate displacements |
| Pop or Crack... | Cavitation occurs as dissolved gases in the synovial fluid are released when intracapsular pressure suddenly decreases |
| Differentiate mobilization from manipulation | Speed of technique: manipulations are quick short movements |
| Contraindications to mobilization/manipulation | lack of diagnosis lack of pt consent Bony issues: tumor, infection, metabolic, congenital, iatrogenic, inflammatory, traumatic Neurologic: cervical myelopathy, cord compression, cauda equina, nerve root compression with increasing neuro deficit Vascul |
| Precautions to mobilization/manipulation | adverse reaction to previous manual therapy Disc herniation/prolapse Pregnancy Spondylolisthesis Psychological dependence upon manipulative techniques Ligamentous laxity |
| Serious/nonreversible complications of manual therapy | death CVA cord compression cauda equina |
| Substantive reversible complications of manual therapy | disc herniation/prolapse nerve root compression fracture |
| Transient impairment complications of manual therapy | local pain headache tiredness radiating pain paresthesia dizziness fainting nausea hot skin |
| Causes of complications: incorrect pt selection | lack of diagnosis lack of awareness of possible complications inadequate palpation assessments inappropriate or inadequate progression of forces lack of pt consent |
| causes of complications of manual therapy: poor techniques | excessive force excessive amplitude excessive leverage inappropriate combination of leverage incorrect plane of thrust poor pt positioning poor therapist positioning lack of pt feedback |
| CPR for thoracic manipulation for mechanical neck pain | symptoms less than 30 days no symptoms distal to shoulder looking up does not aggravate symptoms FABQ physical activity subscale less than 12 diminished upper t-spine kyphosis cervical extension ROM greater than 30 |
| Cervicothoracic manipulation for shoulder pain | pain free active shoulder flexion greater than 127 shoulder internal rotation greater than 53 negative neer impingement test not taking medication for shoulder pain duration of symptoms less than 90 days |
| Characteristics of thoracic vertebrae | 12 thoracic vertebrae primary kyphotic curve rotation limitation because of facet orientation and ribs ribs protect internal organs and provide stability while aiding in breathing |
| What are the transitional vertebrae | T1, T11, T12 located at regional junctions usually possess characteristics common to two regions |
| Facet orientation | superior facet faces posterior inferior facet faces anterior |
| Upper T-spine regional motion | limited by rigidity of ribs frontal plane facet orientation |
| lower t-spine regional motion | more flex/ext due to more sagittal facet orientation motion coupling |
| Spinous processes | project inferiorly to level of body of segment below |
| ALL | ant/lat surface of vertebral bodies superficial fibers cross several segments deep fibers cross 2 segments, blend with annulus limits extension 2x as strong as PLL |
| PLL | in vertebral canal posterior aspect of body from C2-sacrum narrow in L-spine so less support limits flexion |
| Supraspinous lig | tips of spinous processes from C7-sacrum first to fail with hyperflexion injuries becomes ligamentum nuchea in c-spine |
| Ligamentum flavum | runs in post spinal canal from lamina to lamina C2-sacrum resists flexion, under some tension in neutral |
| costovertebral joint | synovial joint formed by head of rib, two adjacent vertebral bodies, intervertebral disc demifacets convex rib facets are convex, vertebrae are concave ribs 1, 10, 11, 12 are more mobile because they articulate with only 1 vertebrae |
| costotransverse joint | synovial articulation of costal tubercle of rib with costal facet on transverse process costotransverse lig--3 portions |
| costochondral joint | synchondrosis no ligamentous support |
| chondrosternal joint | synchondrosis/synovial radiate ligaments |
| 3 types of ribs | True False Floating |
| rib motions | pump bucket handle |
| disc height to body height in thoracic vertebrae | 1:5 due to limited mobility |
| Fryette's law 1 | segment in neutral--rotation occurs opposite of sidebending |
| Fryette's law 2 | segment in full flex or ext--rotation occurs same as sidebending |
| Fryette's law 3 | Motion introduced in any plane reduces motion in all other planes |
| Clinical considerations of T-spine | 1-2% of spinal problems lower c-spine can refer to upper t-spine upper t-spine tends to relate to hypomobility |
| systemic sx (red flags) | wt. loss (unexplained), night pain, fever |
| systemic causes | pleuropulmonary: pneumonia, emphysema, pleurisy, spontaneous pneumothorax, lung CA GI: peptic ulcers, pancreatic carcinoma, cholecystitis, esophagitis pyelonephritis MI |
| Scheuermann's disease presentation | in young condition of slow growth of ant aspect of vertebrae leads to kyphosis no history of pain due to disease but growing kyphosis findings: incr. kyphosis, if correctable=postural, no pain, incr risk of disc derangement or degeneration stressed ti |
| Scheuermann's disease intervention | bracing can reduce curve if still growing surgery for those skeletally mature, posture, stabilization exercise, modalities as applicable, bracing to reduce pain |
| Thoracic compression fx presentation | osteoporosis elderly long term corticosteroid use trauma if no OP benign activity if OP sharp, local pain constant or intermittant pain incr with flex protective mm spasm better sitting up or standing best reclined or supine kyphotic x-ray=ant |
| thoracic compression fx intervention | posture modalities for pain meds per physician: pain and anti-inflammatories activity modification bracing kyphoplasty if bracing fails |
| Dowager's hump | multiple ant. compression fx post menopausal osteoporosis, long term corticosteroid use |
| Hump back (Gibbus) | localized sharp angulation due to 1-2 level ant. wedging due to fx, infection, congenital anomaly |
| Flat back | decreased pelvic inclination, increased kyphosis, mobile t-spine with nonmobile lumbar and hypermobile thoracic, work on mobility with lumbar and stability with thoracic |
| Scoliosis | lateral curvature of t-spine combined with rotation=rotoscoliosis points to right=right 75-85% ideopathic structural=fixed nonstructural=correctable (rib hump decr in FF) Adaptive=poor posture, ANR, leg-length, hip contracture |
| Cobb Angle | line drawn parallel to superior cortical plate at prox end vert and to inf cortical plate at distal end vert perpendicular line drawn to each of these angle at intersection is angle of curvature |
| Scoliosis intervention | posture--stretch into curve education exercise muscle balance manual therapyy bracing: boston, milwaukee curves >40 require intervention curves higher in spine progress more females more likely to progress |
| 2 types of breathing | diaphragmatic=deeper---what we want chest/accessory=shallow if accessory muscle are overused or overactive they become painful |
| Barrel lung | hyperinflation chest deformity smokers COPD: emphysema, chronic bronchitis |
| Pigeon chest | pectus carinatum result of childhood respiratory illness forward, downward projection of sternum incr a/p diameter |
| Pectus excavatum | funnel chest marfan's syndrome post. projecting sternum due to outgrowth of ribs |
| what to look for with t-spine assessment | quantity (asymmetrical movement) quality (compensatory movement) provocation (pain/symptom reproduction) end feel |
| Flexion | normal 20-45 seated so no pelvic motion or hamstrings |
| Extension | 15-20 normal |
| Measuring methods | inclinometer at T1 and T12 subtract T12 from T1 measure distance between T7 and T12 2.5 cm difference from neutral to ext normal |
| Rotation | 35-50 normal 20 functional |
| Sidebending | 25-40 normal |
| Passive neck flexion | seated, fully flex neck stretches dura of cerv and thor region may indicate dural irritation or dural meningitis |
| passive scapular approximation | T1-T2 dural stretch pt. seated protracts & retracts shoulders PT overpressure retraction pulls on thoracic extent of dura mater if positive suspect upper thoracic space occupying lesion (HNP, tumor) |
| Scalene mm length test | contralat neck lat flex and ipsilat rotation limited |
| pec major mm length test | limited horiz abd and lat rot lower portion=flex and abd limited |
| pec minor mm length test | depressed coracoid fwd and downward |
| lat mm length test | limits arm flex & abd, depresses shoulder girdle downward and forward |
| Functional testing includes... | deep inhilation, exhilation, cough posture correction--achieve & maintain active flex, ext, sb, rot of trunk shoulder flex, horiz add, abd, scap retrac/protrac gait observation |
| palpation includes... | spinous processes pinch test transverse processes accessory joint glides costo-vertebral palpation ribs, costal cartilages, intercostal spaces of ribs 2-10 mm/soft tissue--spasm, pain atrophy abdomen-tenderness, distention, rebound tenderness |
| Visceral pain presents as... | dull, vague, may be accompanied by nausea or sweating, can refer to different areas of thorax |
| Acute Facet Dysfunction | pain local or referred, unilateral acute onset, insidious, pain with lifting, reaching, bending limitation > in one direction than other limited ext/SB toward or flex/SB away, pain PA mobs, unilat mobs pain on one side, mm spasm dx: neg except facet |
| Acute Facet Dysfunction intervention | prognosis good if isolated lesion posture, body mechanics, exercise, mobilization/manipulation |
| Thoracic derangement | acute or chronic, constant or intermittent, know what makes better, occupation with repeated movement or sustained flex, flex or rot produces, incr, periph pain; ext or opp rot central, reduces, abolishes pain x-ray neg, MRI pos or neg |
| Thoracic derangement intervention | posture, exercise into direction of preference, body mechanics/ergonomics, mobilization/manipulation |
| Thoracic dysfunction | some hx of trauma/surgery, 6-8 wks min intermittant, localized pain unless ANR ERP ROM limitation? consistent will not change quickly diagnostics neg prognosis good if follow recommendations treatment stretch tissue |
| Postural syndrome | pain with sustained postures/positions local, intermittant pain negative exam findings except sustained positions diagnostics neg prognosis excellent tx: posture, ergonomics |
| differentiating rib and t-spine | rule out c-spine if flex is limited have pt take deep breath and hold then flex until pain is felt if able to flex further after exhaling, suggests rib involvement rib springing while blocking thoracic motion |
| costal sprains | local pain, usually history of trauma, will hurt with thoracic movement, breathing , rib springing treat inflammation, activity modification, brace/girdle, stretching as tolerated to prevent dysfunction |
| First rib syndrome | local or diffuse neck or shoulder pain tenderness over first rib, spasm and pain over local mm, rib feel elevated vs other loss of neck ROM or provocation of neuro/vascular sx may occur with certain positions of neck treat with rib and soft tissue mobs |
| Rib dysfunctions | pain 3-4 cm from midline in region of CV jt often secondary to trauma painful with inspiration or expiration hypermobility: posture, breathing, exercise, brace, avoid agg factors hypomobility: mobilize, stretch |
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