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Kines II > Exam 3: Thoracic > Flashcards

Exam 3: Thoracic Flashcards

1
Q

What plane of motion does most of the movement in the thoracic spine?

A

sagittal plane

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2
Q

The upper thoracic spine acts more like…

A

the cervical spine

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3
Q

The lower thoracic spine acts more like…

A

the lumbar spine

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4
Q

As you progress down the t-spine, you have more and more…

A

flexion/extension/sagittal plane motion

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5
Q

The reason the thoracic spine has fewer and fewer amounts of rotation is because the it’s becoming more and more _____.

A

vertical

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6
Q

The upper and mid thoracic have ______, but as you get down to like T10 or so it doesn’t.

A

rotation/horizontal plane motion

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7
Q

What is the natural amount of thoracic kyphosis?

A

40-45 degrees

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8
Q

What is the normal amount of lumbar lordosis?

A

45 degrees

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9
Q

What is the normal amount of cervical lordosis?

A

30-35 degrees

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10
Q

What is the normal amount of thoracic kyphosis?

A

40 degrees

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11
Q

See:

Slide 4

A
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12
Q

Thoracic kyphosis is basically saying that the thoracic spine is in a relatively ____ position.

A

flexed

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13
Q

Review:

Bony landmarks/facets from thoracic ppt. slide 8.

A
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14
Q

List:

The functions of the t-spine.

A
  • provide support - allows upright posture
  • provide protection - vital organs
  • acts as transitional zone between mobile cervical spine and mobile lumbar spine
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15
Q

T-spine is designed for?

A
  • rigidity to protect spinal cord
  • facilitates mechanical activity of the lungs
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16
Q

Primary motion at T1-T4 level?

A

mostly rotation

acts like neck

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17
Q

Primary motion at T5-T10 level?

A

combo

T6-T8 has most rotation potential overall

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18
Q

Primary motion at the T11-T12 level?

A

more flex/ext

more sagittal motion

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19
Q

Thoracic Facet Orientations?

A

avg is about 60 degrees

closer to 45 in upper, closer to vertical in lumbar

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20
Q

Hands behind head: elbows to lap

Norm Thoracic Flex?

A

30-40

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21
Q

Hands behind head: elbows to ceiling

Norm Thoracic Ext?

A

15-20

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22
Q

Total degrees of motion for thoracic spine?

A

45-60

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23
Q

Hands behind neck like a butterfly

Norm thoracic lateral flexion?

A

30-45

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24
Q

Hands crossed on shoulders, c-spine in neutral to avoid provocation

Norm thoracic rotation?

A

25-30

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25
Q

What is the AROM that you don’t utilize overpressure for in the t-spine?

A

flexion

more of a guide

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26
Q

degrees, coupling, limited motions

Upper and middle thoracic facets

A
  • 60 degrees from transverse
  • 20 degrees from frontal
  • Limits flex/ext
  • Coupled SB/rot ipsilateral in flexion
  • Coupled SB/rot contralateral in extension
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27
Q

motion, location, coupling?

Lower thoracic facets

A
  • sagittal facets from T9-T12
  • more flexion and extension
  • coupling evidence is unclear
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28
Q

Most people lack thoracic…

A

extension

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29
Q

Generally

Thoracic flexion…

A

opens up

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30
Q

Generally

Thoracic extension…

A

closes down

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31
Q

Review slide 15.

A
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32
Q

Thoracic ZAJ pain stays relatively …

A

local

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33
Q

Thoracic ZAJ Pain Study

A
  • study performed on asymptomatic patients
  • T3/4-T10/11 were injected with a noxious stimuli and subjects reported where they experienced pain
  • pain occurred one segment inferior and slightly lateral to joint injected
  • no joints referred pain more superior than one half of the vertical height of that vertebral segment
  • distal referral was up to 2.5 segments below injected level
  • 2 subjects had anterior chest wall and sternal pain when T3/4 and T4/5 segements were injected
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34
Q

See slide 17.

A
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35
Q

Overview

T1-T4?

A
  • acts like c-spine
  • canal is narrowing
  • inherent stability protects discs
  • also rotates like c-spine
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36
Q

Overview

T4-T10?

A
  • true t-spine
  • narrowed canal
  • critical vascular area or zone
  • inherent stability protects discs
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37
Q

Significance in T4-T10

Critical Vascular Area/Zone

A
  • poor blood supply
  • poor healing
  • disc pathology has hard time healing
  • pathology more rare in this area, but more difficult to treat
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38
Q

Overview

T6-T8?

A
  • greatest rotation
  • need mobility for interaction between upper and lower quarter
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39
Q

Overview

T11-T12?

A
  • acts like lumbar spine - more mobile
  • canal widens (cauda equina)
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40
Q

When is the ZAJ most stressed?

A

3D motion

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41
Q

If pain was with 3D motion at ZAJs, what might you do next?

A

local exam, checking for familiar symptoms that could indicate the ZAJs are the pain generator

ex. to the L, ext and SB and rot, closes L?

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42
Q

Critical Zone

What area is known as the critical zone and why?

A
  • T4-T10
  • small diameter of the vertebral canal
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43
Q

Critical Zone

Which spinal cord segment is reported to be a tension point?

A

T6

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44
Q

Critical Zone

Neural/dural tension test my be a result of what in this area? what test is positive?

A
  • result of poor mobility in area
  • positive slump test
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45
Q

Critical Zone

Mobilization and manipulation may be helpful in imporving joint … and allow for …..?

A
  • mobility
  • normalized neural tissue dynamics
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46
Q

Palpation

Simplified finger rule for finding TP.

A
  • 1 finger above SP at each level
  • about 1 inch lateral to SP

Others say T1-T2 and T11-T12: 1 finger above SP
T3-T4 and T9-T10: 2 fingers above SP
T5-T8: 3 fingers above SP

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47
Q

Palpation

What is level with T12?

A

head of 12th rib

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48
Q

Palpation

What is level with T7/T8?

A

inferior angle of scapula

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49
Q

Palpation

What is level with T4?

A

level with root of spine of scapula or apex of axillary fold

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50
Q

Palpation

What is level with L4?

A

superior border of iliac crest

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51
Q

Palpation

What is level with S2?

A

PSIS inferior portion

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52
Q

Palpation

What is level with sacral apex?

A

upper greater trochanter

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53
Q

Palpation

What is the first palpable SP below the occipital bone?

A

C2

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54
Q

Palpation

Thoracic TP Palpation Rule of 3s

A
  • T1-T3: at level of corresponding SP
  • T4-T6: 1/2 segment above SP
  • T7-T9: at level of SP of vertebrae above
  • T10-T12 have SPs that project from a position similar to T9 and rapidly regress until T12 is like T1
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55
Q

Palpation

Most prominent SP at base of neck?

A

C7 or T1

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56
Q

PPIVMs

PPIVMs - What does it stand for? What does it assess? How to assess?

A
  • Passive Physiological Intervertebral Movements
  • assessment of movement available at the spinal level identified by application of a passive physiological motion
  • PT palpates between or on posterior aspect of adjacent SP
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57
Q

PAIVMs

PAIVMs - What does it stand for? What does it assess? How to assess?

A
  • Passive Accessory Intervertebral Movement
  • Mobilization technique that produces movement of a mobile vertebral segment without the active participation of muscles related to the movement
  • PT applies posterior-anterior force on SP
  • Assess mobility and provocation
  • hyper/hypombile
  • painful/non-painful

Angle hand to appreciate kyphosis of t-spine, V position judy chop TP R

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58
Q

Ribs

Rib Joints?

A
  • costotransverse joint
  • costocorporeal/costovertebral joint
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59
Q

Overview/general function

Ribs?

A
  • 12 pairs of ribs enclose the thoracic cavity, forming protective cage for cardiopulmonary organs
  • head of the tubercle articulates with a thoracic vertebra, forming 2 costovertebral joints
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60
Q

Posterior and Anterior structures

Typical Ribs 3-9

A
  • posterior end of a typical rib has a head, neck, and articular tubercle
  • anterior end of rib consists of flattened hyaline cartilage

see slide 28 image

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61
Q

which ones, attachment

True ribs?

A
  • ribs 1-7
  • attach directly to lateral border of sternum via 7 sternocostal joints
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62
Q

Which ones, attachment

False ribs?

A
  • ribs 8-10
  • attach to sternum by fusing to the cartilage of the immediate superior rib
63
Q

which ones, attachment

Floating ribs?

A
  • ribs 11-12
  • free floating because they do not attach to the sternum
64
Q

Overview, orientation, attachment, stiffness, movement

Ribs 1-7

A
  • true ribs
  • transverse plane orientation
  • direct sternal attachment
  • more flex/ext stiffness
  • lots of rotation
65
Q

Overview, orientation, attachment, stiffness, movement

Ribs 8-10

A
  • false ribs
  • indirect sternal attachment
  • more rotation stiffness
  • lots of flex/ext
  • oblique orientation
66
Q

Overview, attachment, mobility

Ribs 11-12

A
  • no sternal
  • very mobile
67
Q

How many vertebrae are ribs 2-8 connected to?

68
Q

How many vertebrae does ribs 1, 9-12 connect to?

69
Q

Major restrictor of sidebending?

A

ribs –> pain

stress rib in SB –> pain likely from ribs

70
Q

Rib Ring Motions

Thoracic Flexion: ipsilateral and contralateral rib ring?

A
  • IR (anterior rotate), forward
  • IR (anterior rotate), forward
71
Q

Rib Ring Motions

Thoracic Extension: ipsilateral and contralateral rib ring?

A
  • ER (posterior rotation), backward
  • ER (posterior rotation), backward
72
Q

Rib Ring Motions

Thoracic Sidebend: ipsilateral and contralateral rib ring?

A
  • approximation, IR (anterior rotation), forward
  • separation, ER (posterior rotation), backward
73
Q

Rib Ring Motions

Thoracic Rotation: ipsilateral and contralateral rib ring?

A
  • ER (posterior rotation), backward
  • IR (anterior rotation), forward, contralateral translation
74
Q

See images on slides 34-36

75
Q

If you rotate L what are the ribs doing?

A
  • L rib ER and moves back
  • R rib IR moves forward
76
Q

Movement, see image slide 38

Ribs 2-6 (5 ribs)

A
  • pump handle movement
  • superior and anterior movement of sternum
  • middle costotransverse joint spins/rotates, little more rotation
77
Q

Movement, see image slides 39-40

Ribs 7-10 (4 ribs)

A
  • bucket handle movement
  • glides at lower costotransverse joints
78
Q

path, movement, combined movement, volume

Rib Motion on Inspiration

A
  • during inspiration, the shaft elevates in a path perpendicular to the axis of rotation that lies generally parallel with the associated transverse process
  • on inspiration, the rib rotates upward and outward, increasing intrathoracic volume
  • on inspiration, the movement of the ribs is combined with slight extension of the thoracic spine

see image on slide 41

79
Q

path, movement, combined movement, pressure

Rib Motion on Expiration

A
  • During expiration, the shaft depresses in a path perpendicular to the axis of rotation that lies generally parallel with the associated transverse process
  • On expiration, the rib rotates downward and inward, decreasing intrathoracic pressure
  • On expiration, the movement of the ribs is combined with slight flexion of the thoracic spine
80
Q

Movement, see image slide 43, what happens on inspiration and expiration

Ribs 11-12

A
  • caliper
  • inspiration - separation of ribs from midline
  • expiration - approximation of ribs toward the midline
  • keep in mind that motion will occur in 3D
81
Q

Rib ring motions during breathing

Expire

A
  • Ipsilateral ring IR (anterior rotation), forward
  • associated thoracic motion is flexion
82
Q

Rib ring motions during breathing

Inspire

A
  • ER (posterior rotation), backward
  • associated thoracic motion is extension
83
Q

what does it test, what is a positive test, how to test

Seated Rib Position Test

A
  • have pt SB and rotate towards you
  • test ribs from superior to inferior after breathing out to find rib stuck in inspiration
  • inspiration: positive test is a prominent superior border
  • test ribs from inferior to superior after breathing in to find a rib stuck in expiration
    *expiration: postive test is prominent inferior border
84
Q

when does it occur

Quiet Ventilation

A

occurs during sedentary activities with low metabolic demand

85
Q

when does it occur

Forced Ventilation

A

occurs during strenuous activities that require rapid and voluminous exchange of air = exercise

86
Q

Mechanics of Inspiration

A
  • intrathoracic voulme is increased by contraction of the muscles attached to the ribs and sternum
  • the expansion increases the negative pressure drawing air into the lungs
87
Q

Mechanics of Expiration

A
  • intrathoracic volume is decreased
  • pressure is increased and air is drawn out of the lungs
88
Q

Muscular Actions During Ventilation

Diaphragm

A

flattens to increase the vertical diameter of the thorax

89
Q

Muscular Actions During Ventilation

Scalenes

A

elevate the ribs and sternum to increase intrathoracic volume

90
Q

Muscular Actions During Ventilation

External Intercostals

A

elevate the ribs to increase intrathoracic volume

91
Q

Muscular Actions During Ventilation

Internal Intercostals

A

assists in forced expiration

92
Q

Forced Expiration

A

contraction of “abdominal” muscles, transversus thoracis, and intercostales interni (interosseous fibers) increases intrathoracic and intra-abdominal pressures

93
Q

orientation, thickness, endplate, disc:vertebral body ratio, restrictor

Thoracic Discs

A
  • very thin and oriented below nerve root
  • thin vertebral endplate = common to have schmorl’s nodes
  • 1:5 to 1:7 disc to vertebral body ratio
  • Major restrictor of rotation = pain due to torsion on disc
94
Q

Cervical has more … stress, while thoracic has more… stress.

A
  • sagittal movement
  • rotation

see slide 50

95
Q

Schmorl’s Node

A

common spinal disc herniation in which the soft tissue of the intervertebral disc bulges out into the adjacent vertebrae through and endplate defect

96
Q

Disc/Dura primary controls?

A
  • rotation
  • extension (as you move down)
97
Q

Disc/Dura minor controls?

A
  • flexion
  • SB
98
Q

What is unlikely in t-spine and why?

A
  • radicular/nerve root impingment
  • high foramen
  • rare radicular symptoms due to high foramen
99
Q

Dura involvement due to ….leading to … pain

A
  • narrow canal
  • posterior diffuse
100
Q

Disc are major restrictor of … can lead to pain.

101
Q

Rotation increased by … degrees after …. percent disc resection.

A
  • 12
  • 70
  • large increase in extension
102
Q

If I SB, I am mostly testing the …

103
Q

If I do 3D motion, I am mostly testing..

104
Q

If I rotate, I am mostly testing…

105
Q

incidence of asymptomatics, referral patterns

Thoracic Disc Pathology

A
  • incidence of asymptomatic thoracic disc protrusions is approximately 37%
  • referral patterns of thoracic discs are unclear as no studies have directly investigated them
106
Q

Disc Pain, location, how common

Posterior Disc Lesion

A
  • local thoracic pain
  • most common
107
Q

A majority of the thoracic disc herniations are …

A

asymptomatic

108
Q

Symptoms of disc herniation can present as …

A

chest wall pain, epigastric pain, upper extremity pain, and sometimes, a pain in the groin or the lower extremity causing the clinician to think of a more common problem than a disc herniation

109
Q

Capsuloligamentous, what ligaments, population

General predisposition to ossification

A
  • especially in Asian population
  • both of PLL and flaval ligament
110
Q

Capsuloligamentous, referral, how likely pain, why

ZAJ Capsule

A
  • thin, no meniscus, very voluminous
  • 3D movements are needed to stress it
  • Mechanoreceptors present
  • Low number of nociceptors = ZAJ is not likely the main t-spine pain generator
  • ZAJ does not refer pain in the midline
111
Q

Nerve, Ventral Rami, 12 pair

Intercostal nerves innervate:

A
  • pleura
  • CT and CV joints
  • intercostal muscles
  • skin on ventral trunk
  • abdominal muscles from T6 down = altered abdominal reflex
112
Q

See image on slide 57

113
Q

What do the dorsal rami innervate?

A
  • CV joints
  • lateral ZAJs
  • sacrospinal muscles
  • skin on dorsal trunk
114
Q

What do recurrent sinuvertebral nerves/Nerves of Von Luschka innervate?

A
  • PLL
  • Vetrebral body
  • disc
  • ventral and lateral dura
  • vascular supply
115
Q

Pathology and dysfunction has implication on … actions.

A

sympathetic

116
Q

Sympathetic influence

Eyes

117
Q

Sympathetic influence

heart

A

increases rate and force of contraction

118
Q

Sympathetic influence

lungs

A

dilates bronchioles via circulating adrenaline

119
Q

Sympathetic influence

blood vessels

A

dilation in skeletal muscle (in animals)

120
Q

Sympathetic influence

gastrointestinal

A

constricts in organs

121
Q

Sympathetic influence

sweat glands

A

activates sweat secretion

122
Q

Sympathetic influence

digestive tract

A

inhibits peristalsis

123
Q

Sympathetic influence

kidney

A

increases renin secretion

124
Q

The sympathetic nervous system is a division of the … nervous system.

125
Q

See image of sympathetic chain on slide 60.

126
Q

where does it lie, how might it present, relationship to scoliosis

Aorta

A
  • lies on L side of anterior thoracic vertebrae
  • may present with osteophytes on the R > L side
  • possible relationship with idiopathic scoliosis - most common is R sided convexity = L SB
127
Q

A weakening of the aortic wall can lead to…

A

an abdominal aortic aneurysm

128
Q

See image on slide 62.

129
Q

Muscles of the Anterior-Lateral Trunk (abdominal muscles)

A
  • rectus abdominus (RA)
  • external oblique (EO)
  • internal oblique (IO)
  • transverse abdominis (TA)
130
Q

Hyperkyphosis, see image slide 64

Osteoporosis may lead to…

A

anterior wedge compression fractures and anterior disc degeneration

131
Q

Medical Causes of Kyphosis

A
  • Scheuermann’s disease: excess anterior wedging in adolescents
  • Osteoporosis: chronic metabolic in primary postmenopausal (estrogen component) women (not just aging)
  • Trauma related spinal changes
  • Tumor
  • Infection
  • Vertebral fractures
  • Degenerative disc disease diagnostic procedures/examination
132
Q

See slides 66-67 and video

Define scoliosis curve off of …

133
Q

see slide 68 image

Excessive Kyphosis

A
  • leads to excessive anterior shear forces
  • increased thoracic flexion torque
  • resultant extensor muscle elongation
134
Q

Quotes about

Thoracic Outlet Syndrome

A
  • “A controversial cause of neck and shoulder pain due to complex mechanisms involving muscular dysfunction and nerve compression”
  • “A group of disorders that occur when there is compression, injury, or irritation of the nerves and/or blood vessels in the lower neck and upper chest”
  • “The most underrated, overlooked, misdiagnosed and probably the most important and difficult to manage peripheral nerve compression in the upper extremity’
135
Q

as relating to ribs

Scalenes

A
  • anterior and middle scalenes are relevant contributing factors to dysfunction of the first rib because they both can elevate the first rib when the c-spine is fixed
  • posterior scalene can potentially elevate the 2nd rib when c-spine is fixed
136
Q

How many dynamic compartments are there?

137
Q

Compartments

Anterior Triangle Borders

A
  • SCM
  • anterior scalene
  • first rib
138
Q

Compartments

Anterior triangle contents

A
  • subclavian vein
  • lymph vessels
  • phrenic nerve
139
Q

Compartments

Posterior Triangle Borders

see image on slide 71

A
  • anterior scalene
  • middle scalene
  • first rib
140
Q

Compartments

Posterior triangle contents

see image on slide 72

A
  • subclavian artery
  • brachial plexus
141
Q

Compartments

Costo-clavicular borders

A
  • dorsal: scapula, subscapularis
  • ventral: clavicle, subclavius muscle
  • caudal: first rib, upper serratus
  • cranial: clavicle
142
Q

Compartments

Costo-clavicular contents

see image on slide 73

A
  • brachial plexus
  • subclavian artery and vein
143
Q

Compartments

Thoraco-coraco-pectoral borders

A
  • ventral: pectoralis minor
  • medial: thoracic wall
  • cranial/lateral: coracoid process
144
Q

Compartments

Thoraco-coraco-pectoral contents

A
  • brachial plexus
  • subclavian artery and vein
145
Q

Anatomical Considerations of TOS

Cervical Rib

A
  • only symptomatic 10% of the time
  • vascular consequence
  • with or without fibrous bands
  • rudimentary 1st rib (off of C7) with postfixed plexus
146
Q

Anatomical Considerations of TOS

Tension or Compression?

A
  • tension is more common, travel longer distance
  • occurs with cervical rib, 1st rib elevation, scalene hypertonicity (MVA), decreased costoclavicular space, decreased thoraco-coraco-pectoral space
  • objectifiable findings are elusive
  • difficult differential diagnosis - multiple abnormalities, varying s/s, no root involvement (symptoms are non-radicular)
147
Q

Etiology of TOS

Congenital

A
  • cervical rib
  • fibrous bands
  • muscle anomalies
  • elongated transverse process
148
Q

Etiology of TOS

Acquired

A
  • whiplash
  • clavicle fracture
  • ligamentous laxity
  • overhead work
  • posture
149
Q

%, what vessel types, due to

What percentage of TOS is true vascular?

A
  • 1.5%
  • venous and arterial
  • more likely to be due to anatomical variation
150
Q

What percentage of TOS is likely to be neurogenic?

151
Q

What percentage of TOS is likely to be true neurogenic?

152
Q

Why might someone with true neurogenic TOS not do well with PT?

A

True compression on nerves

153
Q

What percentage of neurogenic TOS is disputed neurogenic?

Kines II (2 decks)

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