Question | Answer |
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 |