2b - Tspine Path and Interventions Flashcards
facet joint dysfunction: pain presentation & aggravating factors
fairly localized
- facet joint pain pattern
- achy
TTP - on supraspinous ligs
- see some ms spasm/pain
pain w deep breaths
facet joint dysfunction: MOI
prolonged sustained position
- poor posture
- slow, gradual onset
awkward movement
mild to mod trauma
facet joint dysfunction: clinical exam findings
limited tspine AROM/PROM
limited/provocative PPIVMS/PAIVMS
(+) palpatory findings - TTP
facet joint dysfunction: 6 interventions
joint mob/manip to hypo
ROM exercise
scap/paraspin & ab strength
stretch shortened ms
posture ed
STM
what are the 2 most commonly restricted motions in facet joint dysfunction
thoracic ext
thoracic rotation
why would a footstool be important for a seated thoracic ext stretch
stabilize lumbar spine
- get tspine ext w/o hyperext lumbar spine
what is a consideration for the cervical spine when doing a thoracic ext stretch
keep cspine in neutral bc will be easier to tolerate
common duration/freq for PT in facet joint dysfunction
2x/wk for 4-6wks
when is STM appropriate in facet joint dysfunction
if condition for long period of time, can get soft tissue changes
- areas of inc density and tenderness
prognosis for facet joint dysfunction w treatment and what treatment is especially helpful
usually responds well to treatment
joint manips very helpful
what are 3 causes of rib dysfunction
hypomobility
- costovertebral or costotransverse joints
ant subluxation
- blow to post chest wall
- prominence of rib ant and concavity post
post subluxation
- blunt trauma to ant chest wall
- prominence of rib post
what is a common co-morbidity w rib dysfunction
facet joint dysfunction
rib dysfunction: palpatory findings
might feel a “speed bump” on a rib instead of it being flat
costotransverse joint pain referral pattern
rib dysfunction: MOI
prolonged sustained position
awkward mvmt
trauma
intense coughing/sneezing
repetitive mvmts
rib dysfunction: pain presentation and aggravating factors
sharp pain
- localized over costotransverse area
aggravated by:
- breathing
- coughing
- sneezing
- laughing
- trunk mvmt
what are 2 main clinical exam findings in rib dysfunction
altered breathing mechanics
- palpate for bucket handle motion
(+) rib springing
rib dysfunction: 7 interventions
mobilization
- rib and adjacent hypo
ms energy
breathing patterns
strengthening
posture ed
STM
taping
what is a contraindication to a rib springing test
fx
rib fx: MOI
trauma (often younger pts)
minor trauma/cough w OP
- older pts, post menopause
what is the main sx of a rib fx
severe pain
what are 3 exam findings for a rib fx
TTP
altered breathing mechanics
(+) palpatory findings
what is the emphasis of management of a rib fx and what are 3 other interventions
rest
incentive spirometer
breathing exercises
may need rib protection
consideration of imaging use in suspected rib fx and what is the implicaiton for us
radiographs:
- often not seen unless rib is displaced (which is uncommon)
US - higher sensitivity for rib fx (even if non-displaced)
implication for us to treat pts as if have fx as imaging won’t show it
what pt population are rib stress injuries common in, why and which ribs
rowers, swimmers, baseball players
repeated high energy ms contractions
anterolateral ribs 5-9
what the most common clinical exam finding for rib stress injuries
point tenderness
what are aggravating factors for rib stress injuries
rowing, breathing, rolling in bed
prognosis/recovery course for rib stress injuries
rest followed by gradual return to activity over 3-6wks
what intervention in rib stress injuries are especially important in stress injuries
biomechanical assessment
imaging in rib stress injuries
radiography limited in early detection
MRI and US more dx useful
what are 4 interventions for rib stress injury management
taping
soft tissue treatment
spine mob
biomechanical assess
what are examples of intrinsic and extrinsic risk factors to consider with rib stress injuries
reduced bone density
amenorrhea in female athlete
training errors
what will show up on an imaging which indicates a rib stress injury
bone marrow edema and a site of cortical disruption
what are 7 MOI/risk factors for 1st rib dysfunction
trauma (ie MVA, collision)
repetitive overuse UE
poor breathing pattern
- upper chest breather
tight scalenes
prone rotation sleeper
TOS
postural
- sloped shoulders
what is a consideration of a (+) palpatory test if you suspect first rib dysfunction
palpation pain is not always most reliable
- upper trap overlies it and often tender anyway
exam findings for first rib dysfunction
(+) palpation/mob tests
- limited mob/elevation
-> c/t/shoulder girdle pain
(+) cervical rotation/lat flex test
tight scalenes
(+) ULTT
what are the 3 compartments of the thoracic outlet
costoclavicular space (CC)
interscalene traingle (IT)
retropectoralis minor space (RP)
what compartment does the brachial plexus emerge from in the thoracic outlet and what is the implication of this location
interscalene triangle
- tight middle and posterior scalene ms can compress
what compartment in the thoracic outlet does the brachial plexus, subclavian a. and v. all sit in and what is the implication of this location
costoclavicular space
tight ant scalene can compress
4 interventions for first rib dysfunction
mobilization (tspine, rib)
stretch tight mm (pecs)
strengthen scap ms
correct breathing patterns
how do you correct breathing patterns to manage first rib dysfunction
dec apical breathing
instruct diaphragmatic breathing technique
how common in symptomatic thoracic disc herniation and where are disc herniations more likely
rare
- thoracic herniations are rare in general bc flatter discs, seen more in cervical and lumbar
tend to be in lower thoracic spine if anything bc of inc loads
pain presentation for a thoracic disc herniation
variable
- dull and local to spine
- can be referred to abdomen, ant chest, inguinal area
- radiculopathies
- dermatome distribution in bands
what is an important concern w a thoracic disc herniation
critical vascular zone in T4-9
- not a lot of extra space for forgiveness
- can compress blood supply to and from spine -> get lots of neuro signs w myelopathy
what are signs of spinal cord compression from a thoracic disc herniation
(B) lower limb weakness and sensory loss, loss of sphincter control and gait disturbance
thoracic disc herniation MOI
traumatic
insidious
thoracic disc herniation: common aggravating and relieving factors
aggravate - more pain w flex
relieve - better w ext
why are thoracic disc herniations less common than in other parts of the spine
discs are smaller and thinner
vertebral bodies don’t move as much bc of rib attachments
thoracic disc herniation: exam findings
poor posture
limited AROM
(+) repeated mvmt
(+) neuro exam
compress/distract test
6 interventions for thoracic disc herniation management
posture correction
scap/back ext strength
joint mob
ROM
stretching
HEP
what is the most common fx in pts w OP
vertebral compression fx (VCF)
where are VCFs most common
T8-L4
- lower T and upper lumbar
what is the prevalence and recurrence of VCFs
women:
26% at 50yo -> 50% at 80yo
people w 1 OP VCF are 5xs more likely to sustain a second VCF
what is the definition of a VCF
loss of height in ant, middle, or posterior dimension of vertebral body that exceeds 20%
what are the 2 main types of VCFs and which is more common
wedge compression **
- ant part of body is crushed, forming an ant wedge fx
burst
- entire vertebral body breaks
- usually from trauma (ie falls from a height w compression)
risk factors for VCF (11)
osteopenia, OP
women >50, men >70
hx of VCFs or falls
sedentary/inactive lifestyle
use of corticosteroids >3mo
thinner and lower BMI
female
F > 2 drinks/day, M > 3 drinks/day
smokers
vit D deficiency
depression
what are the 5 clinical features that were useful in predicting a VCF
- age >50yo
- female
- major trauma
- pain and tenderness
- distracting painful injury
- if more painful injury somewhere else in the body, can distract from vertebral compression fx
if asymptomatic what is clinical evidence to suggest VCF
significant hx height loss (>2’’)
prospective height loss
unable to flex (wedge)
- wall-to-occiput distance
- rib-pelvis distance
VCF: pain presentation, aggravating factors
acute fx: abrupt onset of pain w position changes, coughing, sneezing, or lifting
mid or low back pain
usually no leg pain
inc w walking, standing
- will inc w any mvmt as pain levels are high
VCF: exam findings
posture - may be kyphotic
thoracic ROM painful
- flex worse (compresses ant)
TTP affected vertebrae
neuro exam
dec function
dx a VCF
radiograph
MRI/CT
dual-energy XR
- should be performed soon after dx of VCF to eval for OP and determine dz severity
systemic treatment for OP in tspine
bracing
medical:
- vertebroplasty
- kyphoplasty
pharm therapy
- biphosphonates
- anti-resorptive
- parathyroid hormone
- combo therapy
- analgesic med for fx pain
what is the goal of rehab for someone w VCF / OP
“successful aging”
dec pain, able to return to activity quicker
what are 5 strategies to manage OP in VCF
prevent further bone density loss
posture, body mechanics
- back ext strength
caution flex and ext
- extremes of motion
dec fall risk (fx prevention)
balance program
what are 4 components of OP prevention
lifestyle
- vit D and calcium supplements
exercise
- multimodal, wt bearing
pharm
falls prevention - TUG
5 exercise interventions for OP management
strength progressive resistance / power training (prevents falls)
balance
posture
aerobic
- want it to be loading the bones
safe mvmt/ spine sparing
what are safe mvmt/ spine sparing strategies in OP treatment
ed - body mechanics, avoid flex
caution end ROM
attend to posture during mvmt
train back ext ms to inc endurance
stretch ms restricting optimal posture
what is a vertebroplasty
procedure in which bone cement injected into fx or weakened vertbra in order to repair and strengthen it
- augmenting the vertebral body
use of MRI sagittal views for surgical planning
what is a kyphoplasty
surgical filling of injured/collapsed vertebra to restore original shape and configuration, and relieves pain from spinal compression
restores vertebral body height and dec kyphotic angulation
better outcomes bc dec sx allowing for better participation as pain is main limiting factor
what patients are appropriate for surgical interventions after a VCF (3)
unable to amb after 24hrs treatment
pain intense enough to prevent participation in PT
adverse effects from analgesics
what is scoliosis
lateral curvature of spine >10deg which may be accompanied by vertebral rotation
what is adolescent idiopathic scoliosis
dx occurs at 10-18yo in absence of underlying congenital or neurological issue
how is scoliosis named
location and side of convexity
ex: R thoracic scoliosis
what is the most common type of scoliosis
idiopathic (85%)
how does the course of scoliosis vary in girls
more likely to have progressively larger scoliotic curve that will require treatment
how commonly will medical treatment/intervention be needed in scoliosis
10% of cases
what are the 3 types of idiopathic scoliosis
what are the 3 types of idiopathic scoliosis
infantile - <3yo
juvenile - 4-10yo
adolescent - 11-18
what are 4 non-idiopathic types of scoliosis
congenital
- present at birth, ribs or spine don’t form properly
NM
- nervous system dz like CP, MD, spina bifida, and polio
functional
- non-structural, can move out of it
older adults
- degenerative (de novo) scoliosis
- women w OP
what is the prevalence in girls vs body depending on concavity of curve in scoliosis
<10 deg
- girls and boys affected equally
> 30deg
- girls 10xs more commonly affected
what are 3 risk factors for scoliosis curve progression
large curve magnitude
- if bigger when first dx, then more likely for it to progress
skeletal immaturity
- still growing
female
how is scoliosis commonly detected
during recommended screenings in adolescence
AAOS: F 11-13yo, M 13-14yo
AAP: 10,12,14, and 16yo
what does the Cobb angle tell you and how do we measure it
amt of SBing present
take vertebrae and top and bottom of curve that are most angled and measure the angle between the two
how does the SBing seen in scoliosis impact the positioning of pt’s ribs
common to see rotation with SBing
vertebrae rotates toward convex side of curve
-> get prominent ribs on that side and hollowing of ribs on concave side
what is the purpose of the Risser Stages and what are they correlated with
gives an estimate of how much skeletal growth remains by grading the progress of bony fusion of the iliac apophysis
correlated w curve progression
what are the Risser Stages
Grade 0 or 1 - still a lot of growth
1 - 25% ossification
2 - 50%
3 - 75%
4 - complete excursion of ossified apophysis
5 - complete fusion
Grade 5 - no longer growing
what is the common complaints from the pt when first dx w scoliosis
often no complaint of pain or functional limitation
what is the goal of PT in scoliosis
restore ms balance and promote good posutre
why are pts often seen in PT in later years of scoliosis
discomfort d/t ms imbalance and adaptive shortening associated w scoliosis
what is the main examination tool used in measuring/screening for scoliosis
adam’s test w scoliometer
- if fixed deformity, ribs will be more prominent on one side and can be measured
what are 8 components of the clinical exam for scoliosis
- posture
- adam’s test
- ROM
- strength
- hip, lumbar, abs, flexor ms - joint play
- flexibility
- leg length
- respiratory function
why is it important to have good hip flexor flexibility if dx w scoliosis
brace might put pelvis in post tilt
may have to compensate w leaning forward or flexing knees if not flexible
guidelines for interventions in idiopathic scoliosis where curve is growing
10-25deg - monitor
25-45deg - brace
>45deg - surgery
Pt might not be recommended in all stages
guidelines for interventions in idiopathic scoliosis if skeletally mature
<45deg - monitor
>45-50deg - surgery
how does an orthotic intervention for scoliosis work
3 points of fixation to create unbending moment in curve
- 1 above
- 1 below
- 1 at apex of curve
worn up to 23 hrs a day
what is a Milkwaukee Brace, who is appropriate
cervical-thoracic-lumbar-sacral- orthosis (CTLSO)
bending moment at vertex of curve
distraction force on spine by virtue of being anchored at chin/pelvis
more severe and higher level curves
- don’t see much anymore as often opt for lower profile braces
what is a Boston Brace
lower profile thermoplastic molded thoracic-lumbar-sacral orthoses (TLSO)
what is a Providence brace, who is appropriate
brace shaped to overcorrect the curve
only worn when pt is sleeping
good for pts w lower level, less severe curve
what is a spine cor, and what are the pros/cons
non rigid TLSO, “dynamic”
made up of series of elastic bands and pelvic girdle and is worn 20 hrs/day w 2 separate 2hr rest periods out of brace
pro - less restricting
con - more complicated than rigid TLSOs
what is a rigo chêneau brace
3D scan or handmade cast
de-torsional forces and 3-point pressure systems to improve spinal alignment in all 3 planes
what are 6 components to PT interventions for scoliosis
- posture
- education
- breathing exercises
- strengthening
- convex side ms (spine, hip ABD) - stretching
- concave side ms, lengthen - sports
- anything promoting good posture and lengthening
- swimming is great, dancing, running
what are scoliosis-specific exercises
individually adapted exercises taught to pt in center totally dedicated to scoliosis treatment
- more intense approach to exercise for scoliosis
what are 3 goals of scoliosis-specific exercises
- limit or stop scoliosis progression
- improve physical functioning
- dec scoliosis pts disability and avoiding more invasive methods of treatment such as bracing
what is the Schroth Method
intensive IP PT protocol 5-6hrs/day 6x/wk for 4-6wks, followed by HEP 30min/day
exercises work to correct scoliotic posture
- elongation, realignment of trunk
- use of specific breathing patterns w various forms of feedback (ie tactile, mirror, etc.)
- often clinics do a modified schroth method bc more feasible
what does literature say about the use of the Schroth method
more effective than less intense typical ther-ex
has to be done every day, if not done consistently then won’t have benefits
what is the gold standard of surgical interventions for scoliosis
fuse spine and individual vertebral segments w use of metal rods to stabilize
what is the point of a vertebral body tethering surgical intervention in scoliosis
designed to allow growth and some correction of curve as individual grows
- doesn’t require fusing
why is posture education w mirror feedback a necessary PT intervention in scoliosis
w scoliosis, shifted posture begins to feel like normal posture
- need to reorient
what is Scheuermann’s disease
scheuermann thoracic kyphosis (scheuermann dz) is a structural deformity of tspine, defined by ant wedging of at least 5deg of 3 or more adjacent thoracic vertebral bodies
spinal osteochrondritis - uneven growth results in signature “wedging” shape of vertebrae -» causing kyphosis
sheuermann’s dz: age of onset, etiology, most commonly impacted vertebrae
adolescents - 11-17yo
(juvenile kyphosis)
autosomal dominant
- gene unknown
T7 and T10
clinical presentation of scheuermann’s dz
presents w acute inc in kyphosis
- progressively worsening in months
pain in lower thoracic region associated w cord compression
- usually don’t have cord compression
how is scheuermann’s dz dx
with lateral radiographs
- see Schmorl nodes (intervertebral disc herniations thru vertebral body endplate and the adjacent vertebrae)
- vertebral endplate narrowing
what is the dx criteria for scheuermann’s dz
rigid hyperkyphosis, >40deg
- norm: 25-40deg
ant wedging, >/= 5deg in 3+ adjacent vertebral bodies
what are the guidelines for management of someone w scheuermann’s dz
based on severity of curve
<50deg = conservative
- stretching, postural changes
50-75deg = extension bracing
>75deg = surgery/operative treatment considered
what are 5 PT exam components for Scheuermann’s dz
posture
ROM
trunk and LE flexibility
trunk ext & ab mm strength/endurance
breathing pattern
what are 4 PT interventions for Scheuermann’s dz
pt ed to improve posture aware
back ext and ab strength
ROM and flexibility
breathing exercises
what is ankylosing spondylitis
rheumatological condition affecting spine, SIJ, costovertebral
-> leads to stiffening in pain in younger people (unusual finding at that age)
etiology of ankylosing spondylitis
HLA B27 is the antigen present in AS
- not everyone w AS will have this antigen
what is an important PT exam component in AS
chest expansion
what are 4 PT interventions for AS
inc mob
improve posture
inspiratory ms training
aerobic exercise
what is a consideration of when PT is appropriate for someone w AS
don’t treat during acute flare up
usually treat during recovery phase
what is costochondritis and how is it caused
pain and inflammation of costochondral junctions of ribs or sternocostal joints, usually at multiple levels
can be gradual onset
can be after a collision
what are exam findings in costochondritis
pain and tenderness localized to costochondral or costosternal joints on the ant chest wall
what are exam findings in costochondritis
pain and tenderness localized to costochondral or costosternal joints on the ant chest wall
s/sx of costochondritis and why
pain w deep breathing
pain w horizontal ABD/ADD
- ADD = compression
- ABD = stretching joints
people might think they have a heart attack or fx
PT management of costochondritis (4 interventions)
manual therapy
- rib mob
- joints above and below
- spinal mobility
breathing exercises
IASTIM
taping
what is a non-PT option for costochondritis management
injection
what is T4 syndrome
sympathetic reaction to a hypomobile segment
- doesn’t have to be T4, anything from T3-7
SNS may provide pathway for referral from tspine to head and arms
s/sx of t4 syndrome
pain, paresthesia, numbness
- in glove-like distribution
what are clinical findings for T4 syndrome
local tenderness
(+) neural tension tests
local segmental hypo (T2-7)
grip weakness
what are differential dx for T4 syndrome
TOS
CTS
cervical disc dz
neurologic dz
paget-schroetter syndrome
parsonage turner syndrome
what is paget schroetter syndrome
effort thrombosis
axillary-subclavian v thrombosis
associated w strenuous and repetitive activity of UEs
what is parsonage turner syndrome
brachial neuritis
neurological disorder characterized by sudden, excruciating pain in shoulder, followed by severe weakness
what is PT management of T4 syndrome
treat impairments (duh)
- mob/manip involved segment
- exercise progression
- breathing mechanics
- strengthen weak ms (scap)
