Examination of the Thoracic Spine

Question 1

O que é a dor na coluna torácica? E quais as estruturas que podem reproduzir essa dor?

Answer 1

Pain experienced in the region of the thoracic spine, between the boundaries of T1–T12 and across the posterior aspect of the trunk (a maioria da dor permanece nesta região, pouca irradiação).
It may arise from a number of sources: thoracic and cervical spinal structures, the thorax, and the gastrointestinal, cardiopulmonary and renal systems.

Question 2

O que nos diz a prevalência desta condição? E em que tipo de população é mais prevalente?

Answer 2

Thoracic spine pain prevalence data ranged from 4.0 72.0% (point), 0.5–51.4% (7-day), 1.4–34.8% (1-month), 4.8–7.0% (3-month), 3.5–34.8% (1-year) and 15.6–19.5 (lifetime).
Generally, studies reported a higher prevalence for pain in child and adolescent populations, and particularly for females.

Question 3

Qual a incidência da Thoracic Spine Pain (TSP)?

Answer 3

The 1 month, 6 month, 1 year and 25 year incidences were 0–0.9%, 10.3%, 3.8–35.3% and 9.8%, respectively.

Question 4

Quais os fatores de risco para todas as idades?

Answer 4

Increased prevalence significantly associated with: concurrent musculoskeletal pain; growth and physical; lifestyle and social; backpack; postural; psychological; environmental factors.

Question 5

Quais os fatores de risco gerais na população adulta?

Answer 5

Concurrent musculoskeletal disorders; Exercising; Pre-menstrual tension and female gender; General work-related (high work load, high work intensity, perceiving ergonomic problems in the workplace); Working in some specialized areas; Performing boring/tedious work tasks; Employment duration; Driving specialized vehicles (and a high number of flying hours); Physical work-related (manual physiotherapy tasks, climbing stairs and high physical stress); Psychosocial work-related factors were reported (perceived risk of injury and high mental pressure).

Question 6

Quais são os achados chave subjetivos em TSP?

Answer 6

Was trauma involved?; Age; Puberty?; Use of corticosteroids?; Psychosocial Factors; Use of a back pack; Occupation; Asthma/COPD/Emphysema; Irritability Status; Duration of Symptoms; Behavior of Symptoms (How does movement affect pain?); Exercise regimen; Coughing (illness); Sleep patterns (recliner exacerbates thoracic problems).

Question 7

O que pode ser questionado para descartar non mechanical hystory?

Answer 7

• Night pain?
• Prior history of cancer?
• Psychosocial factors?
• Myelopathic symptoms?
• Bone density compromised?

Question 8

Quais os patient oriented outcome measures que podem ser utilizados nos casos de TSP?

Answer 8

Functional Rating Index (FRI);
Oswestry Low Back Pain Questionnaire (can be used);
Patient Specific Functional Scale.

Question 9

A nível postural, quais são os pontos de referencia para documentar uma possível escoliose?

Answer 9

Diferentes espaçamentos entre o braço e tronco.
Uma anca mais proeminente.
Cabeça descentrada do corpo.
Um ombro mais elevado.
Uma omoplata mais elevada e provavelmente mais proeminente.
Curvatura da coluna.

Question 10

Qual a relação entre a anteriorização da cabeça e cifose torácica?

Answer 10

Parece existir uma contribuição mútua, ou seja, excessive forward head posture (FHP) exacerba a cifose torácica e a cifose torácica exacerba a FHP. Portanto, devemos tratar ambas.

Question 11

Que desiquilíbrios podemos encontrar no pescoço e musculatura do membro superior?

Answer 11

Tightness of scalenes and upper trapezius;
Tightness of pectorals major and minor;
Upper thoracic stiffness and mobility compromise;
Shoulder restrictions of ROM (normalmente há restrições no ombro quando há restrições na coluna torácica);
Cervical Rib (costela extra).

Question 12

A que pistas importantes devemos estar atentos na avaliação postural?

Answer 12

Hypertrophic paraspinals; Scapular winging; Breast mass; Shoulder position.

Question 13

O que procurar através da observação da postura posteriormente?

Answer 13

Assess head position, shoulder heights, arm space variations, hip height, rib hump, leg length variations, and spinal curve.

Question 14

O que procurar através da observação da postura lateralmente?

Answer 14

Look for forward head posture, curve dynamics for the neck, thoracic and low back, and shoulder position.

Question 15

O que procurar através da observação da postura anteriormente?

Answer 15

Assess head position, shoulder heights, arm space variations, hip height, rib hump, and prominence of clavicles.

Question 16

Which conditions can be a primary cause thoracic kyphosis?

Answer 16

Dowagers Hump; Compression Fracture; Postural Oriented Pain Syndrome; Scheuermann’s kyphosis.

Question 17

Quais as red flags específicas para a TSP?

Answer 17

Breast Cancer; Osteoporosis; Compression fracture; Spondylodiscitis; Visceral Disorders; Pulmonary Embolism.

Question 18

Quais são as propriedades psicométricas do teste de palpação do peito para cancro?

Answer 18

SN 26.7; SP 98; LR+ 13.3; LR- 0.74.

Question 19

Como avaliar a necessidade de realizar um DEXA (Dual-energy X-ray absorptiometry) para determinar a densidade óssea?

Answer 19

(Weight in KG – age in years) X 0.2
Ex: (52kg - 67years) x 0,2 = -3

OST = inferior -1 _ DEXA is recommended.
O DEXA irá permitir-nos identificar as pessoas com susceptibilidade a fraturas.

Question 20

Quais são os fatores de risco e de detecção de uma fratura por compressão?

Answer 20

Female sex; Age superior 70 years; Significant trauma; Prolonged use of corticosteroids.
1 of 4 positive Sn = 88, Sp = 50, LR+ = 1.8
3 of 4 positive Sn = 38, Sp = 100, LR+ = 218

Age superior 52 years; no presence of leg pain; body mass index inferior to 22; does not exercise regularly and; female gender.
1 of 5 positive Sn = 0.97, Sp = 0.06, LR+ 1.04, LR- 0.39
3 of 5 positive Sn = 0.76, Sp = 0.68, LR+ 2.5, LR- 0.34
4 of 5 positive Sn = 0.37, Sp = 0.96, LR+ 29.6, LR- 0.65
5 o 5 positive Sn = 0.03, Sp = 0.99, LR+ 9,3, LR- 0.97

Question 21

Que testes podemos fazer para excluir problemas viscerais a causar TSP? E de outras componentes estruturais?

Answer 21

Murphy’s Sign for Cholecystitis (Sn 97, Sp 48, LR+ 1.9, LR- 0.06).
Palpation Liver.
Palpation Aorta.
Palpation Appendices (dor acentuada ao retirar as mãos subitamente após palpação).
Middleton’s Maneuver Spleen.
Nixon’s Percussion Spleen.
Kidney Palpation/Percussion.
Rule Out Pulmonary Embolism (PERC).

Cervical Over Pressure.
Lumbar Spine Overpressure

Question 22

Quais são os critérios para descartar Embolismo Pulmonar?

Answer 22

Age 50 years; Pulse 100 beats/min; Pulse ox 94%; No unilateral leg swelling; No hemoptysis (coughing up blood); No recent surgery; No prior DVT or PE; No oral hormone use.
The PERC score had a LR- of 0.17 (95% CI 0.11–0.25) for low risk groups.

Question 23

Como executar o Murphy’s Sign?

Answer 23

Palpate at the medial border of the lower rib angle on the patient’s right side. Have the patient breathe deeply in and as they exhale place pressure under the rib (at the gallbladder).

Question 24

Como palpar o fígado?

Answer 24

Palpate at the lateral border of the lower rib angle on the patient’s right side. Have the patient breathe deeply in and as they exhale place pressure under the rib (at the liver).

Question 25

Como palpar a aorta?

Answer 25

At each side of the umbilicus place a consistent inward and downward pressure until you feel a pulse. Measure the width of the fingers after finding the pulse on the left and right side.

Question 26

Como palpar o apêndice e verificar se têm o rebound sign?

Answer 26

Find the midpoint between the umbilicus and the Right ASIS. Push directly downward (patient in supine) and release the pressure quickly. Pain upon rebound is considered a positive finding.

Question 27

Como executar a Middleton’s Maneuver Spleen?

Answer 27

Have the patient place their arm behind their back to “push” the spleen anteriorly. Palpate for the enlarged spleen by “digging” below the stomach inferior to the rib angle. Pain during palpation or an enlarged spleen is considered a positive finding.

Question 28

Como aplicar o Nixon’s percussion of the spleen?

Answer 28

Perform percussion at the distal lateral rib region. Normally, the sound should be hollow (oco) since only the lungs are located below the ribs. If a spleen is enlarged the percussion will sound dull (massivo).

Question 29

Como executar o teste de percussão nos rins?

Answer 29

In sit, perform percussion at the distal posterior rib region. A positive finding is reproduction of pain during percussion over the kidneys.

Question 30

Como palpar os rins?

Answer 30

In supine, one hand pushes posterior to anterior to push the kidney to the surface. Palpate on each side for a painful kidney.

Question 31

Como podemos solicitar movimentos ativos fisiológicos de modo a incidir sobre coluna torácica?

Answer 31

Pedir ao utente para os realizar com as mãos a abraçar a parte posterior do pescoço.

Question 32

Que tipo de movimentos acessórios podemos aplicar na coluna torácica?

Answer 32

Central Posterior Anterior and Unilateral Posterior Anterior (facet; costotransverse joint).

Positive findings may be used as treatment. Os UPA tendem a ser mais efetivos no tratamento.

Question 33

Como é executado o movimento de flexão fisiológica ativa? E a overpressure?

Answer 33

The patient bends forward while in a sitting position and attempts to touch their elbows to their midsection.

While the patient maintains the flexed position the clinician provides an overpressure to the upper and lower thoracic region. The movement is analogous to stringing a bow.

Question 34

Como é executado o movimento de extensão fisiológica ativa e sua overpressure?

Answer 34

The patient bends backward while in a
sitting position and attempts to lift their
elbows toward the sky.

While the patient maintains the extended
position the clinician provides an
overpressure into further extension.

Question 35

Como é executado o movimento de inclinação lateral fisiológica ativa e sua overpressure?

Answer 35

While in sitting (com as mãos na nuca e os ombros em abdução e rotação externa) the subject side bends toward the left and the right side.

The clinician applies an overpressure by pulling the patient further into side flexion and blocking the side toward the movement.

Question 36

Descreve a execução do movimento de rotação fisiológica ativa e sua overpressure?

Answer 36

The patient is suggested to slump. They are then instructed to rotate to one side then the other.

The clinician applies an overpressure by pulling the patient further into rotation. Blocking the knee will keep the rotation focused to the thoracic region.

Question 37

Durante quanto tempo a média dos indivíduos conseguem executar o teste Anterior Neck Flexor Endurance? E as pessoas com fraca endurance?

Answer 37

Cerce de 45 segundos, em média.

Apenas o mantém entre 5 a 15 segundos, sugerindo que necessitam de algum trabalho de resistência na tentativa de balançar a relação do pescoço com a região torácica.

Question 38

Qual a relação entre a força torácica e a rotação externa do ombro?

Answer 38

As pessoas que têm um défice na força torácica tendem a ter um défice da força dos rotadores externos do ombro.

Question 39

Qual a relação entre a rotação externa do ombro e a escápula?

Answer 39

Se tivermos a estabilidade da escápula comprometida bilateralmente, iremos ter uma redução da força de rotação externa dos ombros, porque a base da alavanca não consegue suportar o movimento.

Question 40

Como se executa o Anterior Neck Flexor Endurance test?

Answer 40

The patient is instructed to perform a chin retraction while in a supine position. They are instructed to hold the position for a long as they can tolerate.

Question 41

Como se executa o chest raise test?

Answer 41

The patient is strapped down with a belt just below the thoracic region (at the upper lumbar region). Instruct the patient to lift their chest (with a chin retraction) and hold.

Question 42

Para que serve o Adam’s Forward Flexion test? E como se aplica?

Answer 42

Teste for scoliosis (SN 92; SP 69; LR+2,3; LR- 0,13).
The patient is instructed to bend forward. The clinician observes the sagittal symmetry of the spine during that position. A curved spine in the flexed position may be indicative of a positive scoliosis finding.

Question 43

Qual as diferentes implicações entre a cifose estrutural e flexível? Como se verifica qual o tipo?

Answer 43

Na cifose estrutural não conseguimos ter mais ganhos na extensão torácica, pelo que vamos focar-nos no fortalecimento. Na cifose flexível (ou seja, com mobilidade), vamos focar-nos tanto em alongamento como fortalecimento.

The patient is fixated to the table via a belt, just below the restricted area. The clinician lifts the patient into an extended position to determine if extension is present at the thoracic spine.

Question 44

O que é o Roos Test? Descreve-o.

Answer 44

It’s a diagnostic tool used in the identification of Thoracic Outlet Syndrome - SN 82, SP 100 (Quadas 5).

The patient is instructed to raise the arms at 90 degrees of abduction and to place the elbows at 90 degrees. They are instructed to pump their fist (~1 minute) in an attempt to reproduce like type symptoms.

Question 45

Para que se utiliza o Supraclavicular Pressure Test? E como se aplica?

Answer 45

É um teste utilizado para identificar se há problemas na zona superior à clavícula. SP 79-98; SN Not Tested.

The clinician places their thumb in the supraclavicle space in order to reproduce the symptoms of the patient.

Question 46

De que tipo é o Hyperabduction Test? Descreve-o.

Answer 46

É um teste vascular. Na mesma posição do roos test iremos palpar o pulso radial. SN NT; SP 38 vascular, SP 90 paresthesia, SP79 pain.

The patient assumes a similar position to the Roos test but turns the head away from the side in which the clinician is checking their pulse. A reduction of the pulse is considered with the rotation is considered a positive finding.

Question 47

Como se aplica o cervical rotation, lateral flexion test? E o que testa?

Answer 47

The test has two parts. To test the left 1 st rib position, the head is first rotated to the right then the head (while maintaining rotation) is side flexed toward the chest. A reduction of side flexion is considered a positive finding.