Common Thoracic Conditions Flashcards
What is thoracic osteoporosis?
An age related change to the vertebrae where the vertebral bodies lose bone trabeculae which leads to collapse of vertebral end plates, increased kyphosis and loss of stature
What x-ray findings are indicative of osteoporosis?
collapse of endplates with marked increase in endplate concavity
What age range is common for osteoporosis to show up in adults?
Post menopause for women and about a decade later for men
What may cause the uncommon phenomena of anteriorly fused mid-thoracic vertebra?
diffuse idiopathic spondylitic hyperostosis (DISH) or from ankylosing spondylitis
How does pain from thoracic aging usually present?
localized posteriorly and slightly off to one side which radiates a few inches
chest wall pain is common and low back pain as a referral from T/L junction also common
Thoracic trauma when spine is flexed leads to what structure damage? How does this change when spine is in an extended position?
in flexion or axial compression vertebrae are injured more often than discs
in extension, thoracic facet injuries are just as common as cervical facet injuries
What are the four common injuries from a loading trauma to a flexed T spine from least to most severe?
- endplate fracture (least severe)
- bone bruise
- wedge compression
- burst fracture (most severe)
True or False: After a MVC it is more common in the T spine for a disc to be injured rather than the vertebral body
False, after a MVC the T spine will most likely have a vertebral body injury rather than a disc injury, this is not true, however, in the C spine where disc injuries are more common
Facet injuries are common in both spine segments after a MVC
What are the most commonly injured segments of the T spine after a MVC?
T12-L1
Which gender is more at risk for osteoporosis?
Females (40%) more than males (13%)
True or False: vertebral body fractures are twice as common as hip fractures
True
Which vertebrae are at the highest risk for compression fractures? Why?
T11-L1 (due to the increase percentage of body weight that they carry)
What is kyphoplasty?
What patients are most likely candidates for kyphoplasty?
A procedure to alleviate pain from vertebral fractures resulting from osteoporosis and try to restore natural kyphosis of the spine
patients who recently suffered from a fracture from osteoporosis and have painful symptoms due to fractures (usually within 8 weeks of fracture)
What symptoms can sprout from the resulting change in height and spinal alignment after vertebral stress fractures?
- chronic or severe pain
- limited function and reduced mobility
- loss of independence in daily activities
- decreased lung capacity
- difficulty sleeping
True or False: Kypho/vertebroplasty has no signifcant difference in outcomes compared to conservative care or placebo
True
What will be the cause of the greatest percentage of pts presenting with thoracic pain?
involved in a trivial accident such as a small fall or someone bumping into their rib cage
Roughly how many patients that present with acute chest pain in the ER are found to be due to MSK system?
1 in 4
True or False: Disc lesions in the T spine are probably very common and commonly asymptomatic.
True
what are some reasons for why disc lesions are so common?
- the attachment of ribs to annulus fibers (blow to ribs may disrupt the disc)
- higher viscosity of IVD in T spine
- asymmetrical loading with segmental motion
Where are disc lesion most common?
Lower T spine or at thoracolumbar junction
disc lesion common on convex side of scoliosis or kyphosis (asymmetrical loading)
What are some common clinical presentations of pain from disc lesions?
- pain is in blobs or patches (referred from vertebrae)
- somewhat segmental pain
- unilateral pain
- deep ache
- pain aggravated by coughing, sneezing or deep breathing
If nerve root pain is from a mechanical origin how might the pain present?
How does this change if the origin is chemical irritation?
mechanical: local discomfort w/ numbness and paresthesia
Chemical: severe pain with distal being more painful than proximal
True or False: In true nerve root pain proximal pain (back pain) will be greater than distal pain (anterior wall next to the sternum)
False, distal pain will be greater than proximal pain in true nerve root pain
What condition may closely simulate thoracic nerve root pain due to pain being located anteriorly at the sternum?
costochondritis
Where might the upper T spine refer pain to?
Upper extremity or axillary region
How does pain present in facet joint dysfunction?
What would provoke the pain?
usually sharp localized pain unilaterally which may become dull or aching pain in the chronic stages
pain would be provoked by closing down on facet joints via extension or by coughing and sneezing
If you have referred pain that is more intense proximally than distally what may be the cause of your pain?
Facet joint dysfunction
How does pain usually present from ligamentous injuries?
vague and ill defined that spread around the area but does not produce distal symptoms are neurological symptoms
What nerve innervates the ALL and PLL?
sinuvertebral nerve, which can cause pain that spreads up and down spinal canal
True or False: Muscle injuries to the thoracic spine are very common which is why most PT interventions focus on the muscles of the T spine
False, true muscle injuries to the spine are very uncommon but the MSK system does get affected through joint injuries and postural changes
What is T4 syndrome?
What causes this syndrome?
dull aching symptoms covering the whole hand (non dermatome) and with or without pins and needles which are usually unilateral
precise etiology is unknown but current evidence suggests autonomic involvement
What are common symtpoms with cervical uncovertebral joint issues?
- very little pain, more of a vague discomfort
- stiff more than painful
- no referred or neurological symptoms
- morning stiffness
What are common red flags for thoracic pain?
- unaffected by spinal movement
- associated symptoms i.e heartburn
- past medical history
- insidious onset of symptoms
What factors cause a significant increase of risk for visceral thoracic problems?
age (under 20 or over 50)
family history
past personal history
sudden, unexpected weight loss/gain
How does cardiac pain usually refer or present clinically?
pain is from decreased blood flow build up of metabolites in ischemic segment of heart muscles and characterized as squeezing substernal sensation, tightness or pressure and pain in upper left arm and left side of jaw
What is angina pectoris?
Increased pain with exertion (except variant) that is relieved with rest, regardless of location of pain
If a patient has normal blood pressure but their distal pulses are decreased or absent and they have sudden unrelenting pain in their chest what disorder may they have?
aortic dissection
What can cause pericarditis? (inflammation of the pericardium)
infection, systemic diseases (rheumatoid arthritis, connective tissue disease), metastatic tumors, drugs, or can be idopathic
What usually aggravates pericarditis pain and what eases the pain?
Agg-respiration, coughing, or thoracic motion
Ease-sitting and forward bending
If pain from pericarditis is in left trapezius what does that suggest?
irritation of the diaphragm
What condition can present like an angina but can be heard with a stethoscope (mid-systolic non ejection clock and late holosystolic murmur) and the pain is non-exertional and momentary but can occasionally last for minutes to hours?
mitral valve prolapse
Pain typically more frequent during periods of emotional stress
What position often causes the worst pain with esophageal disorders?
Supine position which allows reflux of stomach acid into the esophagus
How common is scoliosis greater than 25 deg.?
1.5/1000 persons in the U.S
True or False: Generally curvature of less than 30 deg will not progress after a child is skeletally mature
True
What is the most common cause of scoliosis?
idiopathic genetics
most common type is adolescent idiopathic scoliosis
What are the age ranges for idiopathic scoliosis types?
infantile-2 months to 3 yrs (least common)
juvenile- 3 yr to 10 yr
Adolescent- over 10 years (90% 0f causes)
roughly how fast does the T1-S1 grow in children age groups?
0-5: 2.2 cm/yr
5-10: 1 cm/yr
Puberty: 1.8 cm/yr
what are the 3 classifications for idiopathic scoliosis?
Failure of formation (hemivertebra)
Failure of segmentation (unilateral bar or block vertebra)
Combination
What is the Cobb angle?
angle formed by the inclination of the upper end plate of the upper end vertebra and inclination of the lower end plate of the lower end vertebra
Which gender is more affected by scoliosis? How big is the gap?
females
gap depends on severity of curve
mild scoliosis (10-25 deg)-4:1
moderate (25-50 deg)-7:1
Severe (over 50 deg)-10:1
What mechanical process progresses the curve of scoliosis?
torsion with eccentric loading of the spine and vertebral growth modulation
As scoliosis progress how does the vertebral body change?
What changes are seen in the muscles?
spinous process deviates towards concave side
vertebral body distorted toward convex side
“gibbus deformity” (knot like deformity)
kypho scoliosis
muscle weakness
hypertrophy
muscle imbalances
trigger points
What are the common causes of neuromuscular idiopathic scoliosis?
poliomyelitis cerebral palsy syringomyelia muscular dystrophy amyotonia congenita friedrich's ataxia spina bifida spinal cord injury
What are the mesenchymal disorders that can cause idiopathic scoliosis?
Marfan's syndrome Morquio's Syndrome Rheumatoid Arthritis Osteogenesis imperfecta Dwarfism disorders
What trauma can cause idiopathic scoliosis?
fractures
irradiation
surgery
What two factors lead to a poor prognosis for scoliosis?
Young age and having a thoracic curve
What movement clinical signs suggest scoliosis?
- curve enlarges w/ flexion
- limited extension movement
- asymmetric side flexion
- gibbus deformity in flexion
If scoliosis curve is between 20 and 50 deg. what is the recommended treatment?
What if it is above 50 deg?
Brace
Surgery
What are the PT goals for scoliosis?
- slow progression of curve
- maintain or improve general fitness and lung capacity
- observe and monitor curve changes
- self correction and stretches for posture
- treat painful symptoms
- motor control
- education (reduce fear)
- brace use
- adapting ADL’s
True or False: Through several years of research and discussion we have a clear path for treatment of scoliosis patients
False, there is still a lot of debate about proper treatment plans
What are the pros and cons of bracing:
Pros-seems to stop curvature progression
Cons-not a lot of solid evidence and studies show no improvement in quality of life, a lot of questions about proper bracing habits
What is the consensus about exercise for scoliosis?
Very little quality evidence for scoliosis specific exercise, a lot of research needs to be done
What is the resurgery rate for adolescent idiopathic scoliosis?
40%
What is currently the best evidence for treating scoliosis?
- conduct a skilled physical exam
- identify red flags
- educate patient about the nature of the problem (reduces fear and makes the ‘unknown’ known)
- provide prognostication
- promote self-care (self help ideas, most do well with no surgery and no bracing, promote a home program)
- get patients active and moving as earlt as possible and appropriately after injury (motion is lotion)
- help patient experience success
- use any measures possible to reduce pain (modalities, stretches, soft tissue work, mobs and manips, breathing techniques, aqua therapy, etc.)
