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MSK II FINAL > Movement System Dysfunction and the Role of the Thoracic Spine > Flashcards

Movement System Dysfunction and the Role of the Thoracic Spine Flashcards

1
Q

What is the anatomy of the thoracic spine?

A

Unique architecture
Rib attachments
Designed for stiffness

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2
Q

Describe T spine vertebral bodies:

A

Long, wedge shaped

Responsible for the kyphotic angle (up to 45 degrees)

Multiple rib attachments

Short, thick pedicle

Small, round foramen

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3
Q

What is special about the T spine spinous processes and foramen?

A

Oblique spinous processes, roughly equal length

Asymmetric orientation in the coronal plane d/t multiple muscle attachments

Foramen high, above the level of the disc

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4
Q

What is special about the transverse processes?

A

Transverse processes widest at T1

Progressively more narrow

Dorsal to the articular pillars

Allows for rotation

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5
Q

Describe the Zygapophyseal Joints(Facets) in the transverse plane

A

Inclined 20 degrees in the transverse plane

Coursing ventrolateral to dorsomedial

Do little to limit motion in the transverse plane (rotation) or frontal plane (SB)

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6
Q

Describe the Zygapophyseal Joints(Facets) in the sagittal plane

A

Inclined 50-60 degrees in the sagittal plane

Coursing cranioventral to caudodorsal

Limit motion in the sagittal plane (flexion/extension)

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7
Q

T1-4 behave like ___ segments

A

cervical

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8
Q

T11-12 behave like ___ segments

A

lumbar

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9
Q

T4-10 often referred to as the ____

A

“True Thoracic Spine”

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10
Q

Cervical spine coupling:

A

ipsilateral side bending and rotation in both a flexed and extended position

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11
Q

Lumbar spine coupling:

A

ipsilateral side bending and rotation in a flexed position, contralateral side bending and rotation in an extended position (some debate)

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12
Q

“True Thoracic spine” coupling:

A

Synkinetic movement is reduced, little agreement on coupling pattern

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13
Q

Describe the ribs

A

Attach to vertebral bodies at the costovertebral and the costotransverse joints (CVJ & CTJ)

Primary constraint to movement in the frontal plane

Clinically: limits side bending

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14
Q

Ribs: primary purpose

A

Protect vital organs

Contribute to stiffness

Provides support for bipedal gait

Facilitate respiration

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15
Q

Rib cage: posterior

A

Thoracic spine and rib mobility are interdependent

Ribs 2-9 articulate with two vertebral bodies

Ribs 1 and 10-12 articulate with one vertebral body

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16
Q

Rib cage: anterior

A

Ribs 1-7 have direct sternal connections, true ribs

Ribs 8-10 have indirect sternal connections, false ribs

Ribs 11 & 12 have no sternal connections, floating ribs

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17
Q

Ribs: biomechanics

A

Stiff first two ribs allowing for little movement

Ribs 3-6 move in an ant-post direction, like a pump handle

Ribs 7-10 move more laterally, like a bucket handle

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18
Q

Intervertebral Disc function

A

Designed to contribute to overall stiffness

Less nuclear material than in the Csp or Lsp

Greater amount of dorsal annular material

Increases segmental stability

Limits flexion and axial rotation

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19
Q

Intervertebral Disc

A

Disc height increases moving caudally

Attachments to the anterior and posterior longitudinal ligaments (ALL & PLL)

Attachments to ribs via intra-articular ligaments

Ribs act as a natural abutment to protrusion

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20
Q

T spine Innervation

A

Sympathetic trunk anterior to vertebral bodies near the CVJ

Convergence of autonomic and somatic sensory information

Somatovisceral and viscerosomatic complaints

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21
Q

Convergence: Lamina I

A

Nociceptive specific
Low convergence

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22
Q

Convergence: Lamina V

A

Wide dynamic range neurons
High convergence

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23
Q

Thoracic spine…….high levels of convergence

A

Visceral Afference

Somatic Afference

C8-L2

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24
Q

T1-4 Axons: Innervation

A

Brachial plexus
Posterior cutaneous n
Medial cutaneous n

Clinical Implications:
Thoracic outlet syndrome (TOS)

T4 syndrome

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25
Q

Unique to the thoracic spine =

A

High incidence of neoplasms and metastatic disease

T4-9 = Critical zone

Narrow spinal canal

Relatively lower blood supply

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26
Q

Spinal cord signs:

A

L’hermitte sign
> Cold feet
> Electrical currents running down the back with neck flexion

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27
Q

Does pain change with….

A

Head movement? = C spine

UE movement? = Upper thoracic

Trunk movement? = Mid thoracic

Cough, sneeze, strain (CSS)

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28
Q

When breathing increases motion and increases pain =

A

disc

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29
Q

ALARM: Constant or night pain

A

Metastasis
Infection

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30
Q

ALARM: Unexplained capsular pattern – Red Flag!

A

Large limit

Capsular pattern = Extension -> equal limitations of SB and rot (painful) -> small or no flexion limit

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31
Q

Local pain:

A

Acute IDD, disc protrusion

ZAJ arthropathy

CVJ/CTJ arthropathy

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32
Q

Thoracic dermatomes =

A

do not follow a single intercostal space, occupy 2-3 intercostal spaces

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33
Q

Unilateral organ =

A

can produce bilateral pain in the thoracic region

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34
Q

Sternal pain with inspiration =

A

can be thoracic vs. cardiac

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35
Q

Pain in the UE’s and headache =

A

T4 syndrome

36
Q

Macrotrauma =

A

MVA

Axial load: disc lesion vs compression fx

High velocity rotation: disc lesion vs rib fx

37
Q

Microtrauma =

A

E.g. Golfing, repetitive work in manufacturing

38
Q

Consider the patient’s general health:

A

Long term asthma or COPD

RA: use of corticosteroids, increased risk of osteoporosis

Osteoporosis: 50% of all vertebral fractures in the Thoracic spine

39
Q

Surgical history:

A

Thoracotomy or CABG -> rib dysfunction d/t rib spreading

40
Q

Red flags

A

Fever, chills, nausea > 1 week

Unexplained weight loss, anorexia, malaise

Changes in bowel or bladder function

Rectal or vaginal bleeding

History of cancer

Consider visceral pathology

41
Q

Flexion

A

Flexion limited primarily by the disc and the ribs/sternum

Expiration induces thoracic flexion

If pain provocation is worst with 1D flexion……think disc dysfunction

42
Q

Extension

A

Extension limited by the spinous processes and facets

If pain provocation is worst with 1D extension……think facet jt dysfunction

Inspiration induces thoracic extension

43
Q

Side bending

A

Limited primarily by the ribs

If pain provocation is worst 1D side bending……..think rib dysfunction

44
Q

Axial rotation

A

Limited primarily by the disc

If pain provocation is worst with 1D axial rotation……think disc dysfunction

Facets do little to limit motion in the transverse plane

45
Q

Mechanics of breathing: inspiration

A

Ribs 1 and 2 – very little movement

Upper ribs move up and fwd = Pump handle

Lower ribs move up and lateral = Bucket handle

Thoracic spine extends

46
Q

Mechanics of breathing: expiration

A

Ribs 1 and 2 – very little movement

Upper ribs move down and back

Lower ribs move down and in

Thoracic spine flexes

47
Q

Biomechanical links

A

Regional Interdependence = Regional dysfunction contributes to local pain and dysfunction

Multiple shared muscle attachments for the spine and UE’s

Synchronous motion

Compensatory motion

48
Q

Biomechanical link

A

Synchronous motion

Unilateral arm elevation = ipsilateral axial rotation and side bending in the upper thoracic spine and scapular ER

Bilateral arm elevation = lower thoracic spine extension

49
Q

Pathological examples of link between the thoracic spine and UQ dysfunction =

A

T4 syndrome
TOS
Postural dysfunction

50
Q

Thoracic Outlet Syndrome =

A

Neurogenic thoracic outlet syndrome (NTOS)

Diagnosis of exclusion

Cluster of symptoms

Compression or tension event

51
Q

True Neurogenic TOS =

A

confirmed electrodiagnostically

Cervical rib

EMG – axon loss

More difficult to treat conservatively

52
Q

Disputed Neurogenic TOS =

A

NCS/EMG (-)…..not sensitive enough?

Clinical exam for symptom provocation

Responds to conservative treatment

53
Q

Disputed NTOS symptoms =

A

Numbness/paresthesia

Pain – non-radicular

Paresthesia – 4th & 5th digits only or whole hand

Subjective weakness – rarely a true, objectifiable weakness

Subjective reports of swelling

Vasomotor instability – discoloration of the hand

“Release phenomenon”

54
Q

“Release phenomenon” =

A

Return of sensory info

“Pins and needles” – like a foot waking up after it has fallen asleep

Often happens at night – reduced tension around the scapulae during sleep

3 relevant time periods
> Irritation period
> Delay
> Release period

Better prognosis

55
Q

hyperabduction syndrome =

A

pinches the nerves that run under the pec mnor muscle when you lift your arm overhead

56
Q

anterior scalene syndrome =

A

pinches nerves and vessels between the scalene muscles and other structures

57
Q

costoclavicular syndrome =

A

pinches nerves underneath the collarbone

58
Q

Cervicothoracic junction and shoulder joint mechanics

A

Thoracic stiffness/excessive kyphosis -> limited thoracic extension

Influences scapulae position -> posteriorly tilted or downwardly rotated

Clavicle should be able to elevate and spin posteriorly

SCJ, ACJ, GHJ

59
Q

Hypomobile SCJ/ACJ ->

A

excessive dorsal translation of clavicle

60
Q

Hypomobile GHJ ->

A

can stress brachial plexus at end-range elevation

61
Q

First rib position =

A

Elevated first rib

Compromises the thoracic outlet container

62
Q

Upper plexus =

A

C5, C6, C7

Scalene compression

63
Q

Lower plexus =

A

C8, T1

Includes sympathetic fibers

Temp and trophic changes often sympathetically mediated

64
Q

Brachial plexus:

A

More often ulnar nerve distribution

Sensory info from the brachial plexus relays back into the ANS via cervical ganglia

Sympathetic fibers to the head originate C7 to T3

Sensitization can occur through the trigeminal nerve and sympathetic wind up

65
Q

TOS Clinical Examination: posture

A

Long neck

“Droopy shoulders”

Protracted head and shoulders

“Swelling” – 1st rib elevation or fullness in the supraclavicular fossa

Hands
> Sweating, temperature
> Trophic changes

66
Q

TOS: Roos Inclusion Criteria

A

UE pain and sensory changes – brachial plexus distribution

Pain worse with UE use

Pain with palpation over the brachial plexus

Roos Test

67
Q

Cyriax Release Test

A

Patient shrugs and leans back against PT, then relaxes

Unloading the brachial plexus looking for release

Hold up to 3’

68
Q

Cyriax Release Test – alternative

A

Patient positioned with elbows at 90° with towels sufficient to elevate the shoulder girdles

Forearms and wrists neutral

Position held until symptoms are produced

Up to 30’, to patient tolerance

Looking for symptom intensity to decrease

69
Q

T4 syndrome =

A

Constellation of symptoms

Unilateral or bilateral upper thoracic spine pain

Ventral chest pain

Glove-like paresthesias of the hands

Headache

Occasionally: Weak grip, sense of hand fullness or tightness, difficulty breathing

70
Q

T4 syndrome history:

A

Whiplash, trauma

Can be insidious after vigorous upper body activity

Duration – 1-6 years

Difficulty sleeping supine

71
Q

T4 syndrome clinical examination
:

A

Full supraclavicular fossa or convex upper trap contour

Hypomobility of one or more segments T2-T7

Hypomobile ribs

(+) Roos

vasomotor changes in the UE’s

72
Q

T4 syndrome is representative of the ___ and ___ links between the thoracic spine and the upper extremities, head and neck

A

biomechanical

neurophysiological

73
Q

Biomechanical links =

A

Fwd head, accentuated kyphosis, increased angulation at CTJ

Upper Tspine mobility limits

74
Q

Neurophysiological links =

A

Paresthesias

Headache

Difficulty breathing

75
Q

Clinical examples:T4 syndrome

A

T4 most commonly affected segment

Suggested that noxious stimuli activate nociceptors in the dorsal horn of the spinal cord and spinal medulla

Autonomic involvement

oscillatory mobilization results in sympathoexcitatory effects of stimulating the dorsal periaqueductal gray (PAG) of the midbrain, as well as stimulating spinal reflex pathways

Activating the dorsal PAG triggers descending non-opioid analgesia resulting in increased pain pressure thresholds and improving functional movement.

In addition, sympathoexcitation via noradrenergic pathways increases skin conductance and decreases temperature

76
Q

Primary problems =

A

Thoracic disc

Postural dysfunction

TOS

Compression fracture

Scoliosis

Ribs: Costosternal, costotransverse or costovertebral joint

77
Q

Secondary problems =

A

Thoracic hypo or hypermobility contributing to a regional complaint (cervical, shoulder)

78
Q

Thoracic spine diagnosis =

A

Cervical spine – CPG

Lumbar spine – CPG

Thoracic spine – no CPG = Left with pathoanatomic diagnoses

79
Q

Development of a clinical prediction rule (CPR) example 1

A

Patients with shoulder pain most likely to respond positively to cervicothoracic manipulation

80 patients

Five prognostic indicators

If 3 of the 5 indicators were positive, the chance of treatment resulting in a successful outcome increased from 61% to 89%

80
Q

Five prognostic indicators

A
  1. Painfree shoulder flexion < 125°
  2. Shoulder IR < 50°
  3. (-) Neer test
  4. Patient not taking meds for pain
  5. Duration of symptoms < 3 months
81
Q

Development of a clinical prediction rule (CPR) example 2

A

Patients with mechanical neck pain most likely to respond positively to thoracic manipulation

78 patients

Six prognostic indicators

probability of success = 86% when 3/6 variables are present

probability of success = 93% when 4/6 variables are present

82
Q

Six prognostic indicators

A
  1. Duration of symptoms < 30 days
  2. No symptoms distal to the shoulder
  3. Looking up does not aggravate symptoms
  4. FABQPA score of < 12
  5. Diminished upper thoracic spine (T3-5) kyphosis
  6. Cervical extension ROM of < 30° (inclinometer)
83
Q

Clinical Bottom Line =

A

Patients with cervical spine pain and 3 or more of the above findings are likely to experience moderate perceived global improvement from

> thoracic spine manipulation and cervical ROM exercise
> within 2 treatment sessions (4-8 days)

2010 f/u study did not support the CPR but DID demonstrate significantly greater improvements in disability at short- and long-term f/u for patients who received manip+ther ex vs. ex alone

84
Q

Outcomes: Reducing neck pain

A

Single manipulation at C7-T1 increased pressure pain thresholds in facet joints of C5-C6 in asymptomatic subjects

RCT in 36 patient’s with primary c/o neck pain, thoracic manipulation reduced pain scores on VAS

Outcomes better among patients who receive OMPT in addition to other treatment modalities, such as ther ex

Long-term improvements (e.g. 1 month and 6 month f/u) have been reported in patients with acute and chronic neck pain

Pain reduction: immediate analgesic effect
Most studies – single manipulation

85
Q

Outcomes: Reducing shoulder pain

A

Manipulation Group
> Manipulation to the thoracic spine and ribs, cervical spine and GHJ

> 70% of patients reported feeling “cured” at 5 weeks post-randomization

Traditional PT Group
> Therapeutic ex, massage, physical agents
> 10% of patients reported feeling “cured” at 5 weeks post-randomization

MSK II FINAL (13 decks)

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