OCS Chap 4 Thoracic/Rib Flashcards
who is most likely to have t spine pain
males over age of 50, tall, performed frequent or sustained trunk bending (>2 hrs per day), unable to change position or task during work or had an occupation requiring driving >4 hours per day
rule of 3’s
spinous process of T1-3 are at the same level as the transverse process of the same vertebra
spinous process of T4-6 are one half vertebral level below their respective transverse process
spinous process of T7-9 1 full vertebral level below their transverse process
spinous process of T10-12 are at the same level as the transverse process of the same vertebra
during inspiration ribs
upper rib cage rises (flexes) in the sagittal plane
lower ribs widen (abduct) in the frontal plane
what is the critical zone
T4 - T9
small diameter of the spinal canal and reduced blood supply in comparison to other regions of the spine
T4 syndrome
mobility impairments associated with upper or lower quarter neurogenic and sympathetic signs or symptoms, such as bilateral extremity paresthesias and sweating
during inspiration the ribs move
anterior and superior motion (pump handle)
laterally and superiorly (bucket handle motion)
11th and 12th ribs move during breathing
caliper type motion
inspiration - posterior and lateral
expiration - anterior and medial
due to not having an anterior attachment
visceral conditions that can refer pain to the thoracic spine
myocardial ischemia, dissecting thoracic aortic aneurysm, peptic ulcer, acute cholecystitis, renal colic, and acute pyelonephritis
dissecting thoracic aneurysm
felt in the chest and can radiate to the back (if descending aorta is involved) pain is usually of sudden onset, often is unrelenting, and is not relieved by position changes
myocardial ischemia
anterior chest pain or heaviness, occasional nausea, and sometimes pain radiating to the back
stable angina
pain is related to exertion and relieved with rest
unstable angina
occurs in random or unpredictable fashion and is not related to activity
clinical prediction rule: rule out coronary artery disease in primary care
sex and age (F >65, M >55)
known clinical vascular disease
pain worse with exercise
pain not reproducible w/ palpation
patient assumes pain is cardiac origin
(need 3 factors)
peptic ulcer of posterior wall of the stomach or duodenum
cause boring type pain from the epigastric area to the middle thoracic spine
thoracic pain triggered or relieved w/ eating
prolong use of NSAIDs
cholecystitis (inflamed gall bladder)
right upper quadrant and right infrascapular pain
moderate fever, nausea, vomiting
symptoms 1 to 2 hours after heavy meal
murphy sign (palpating the right subcostal region and asking the patient to take a deep breath) +pain w/ inhal
pancreatitis (inflamed pancreas)
pain around the thoracolumbar junction
kidney or renal pain caused by pyelonephritis (kidney infection)
costovertebral angle or flank area pain
fever, nausea, vomiting, and renal colic
spinal metastases is usually
secondary to a primary breast, lung, or colon cancer (most common forms of cancer in the thoracic spine)
hx findings for predicting cancer
age over 50, hx of cancer, unexplained weight loss, failure of nonsurgical therapy
ankylosing spondylitis predictor variables
morning stiffness of more than 30 min
improvement in back pain w/ exercise but not with rest
awakening because of back pain during the second half of the night only
alternating buttock pain
Key physical finding? limited chest expansion
normal expansion of the rib cage (measure at nipple)
5 cm
less than 2.5 is considered pathologic
HLA-B27
90 percent of patients w/ ankylosing spondylitis are positive
but only 10-20% of individuals that are positive have HLA-B27 = false positive rate is high for this test
risk factors for osteoporosis
caucasian race, hx of smoking, early menopause, thin body build, sedentary lifestyle, steroid treatment, excessive consumption of caffeine or alcohol
men or women age 60 or older presenting w/ acute thoracic spine pain
osteoporotic fx must be considered
red flag screening for infection
fever, chills, night sweats, known recent infection (pneumonia), current intravenous therapy or drug use, recent surgery
red flag screening for visceral/GI disorders
bowel or bladder dysfunction, abdominal pain, reflux, excessive use of NSAIDs, and alcohol abuse
red flag screening for cardiopulmonary
chest pain or SOB w/ physical exertion, personal or family hx of cardiovascular disease, and thoracic or chest wall pain described as throbbing or associated with pulsatile sensations
STarT Back Screening Tool (SBT)
9-item
includes biomedical and psychosocial targeting prognostic factors for the development of chronic pain and disability for patients w/ LBP
what is cobb angle
thoracic kyphosis measurement on lateral thoracic spine radiographs
hyperkyphosis cobb angle greater than 50deg
cervical rotation lateral flexion test
assess first rib dysfunction
elevated first rib in patients w/ brachialgia
rotate away from first rib and SB towards chest
low to medium risk of prolong pain and disability patients =
mechanically-patterned acute to subacute pain and without significant psychosocial factors or signs of central sensitization
patients w/ high risk category
greater extent of psychosocial factors and may have signs of central sensitization
Tietze syndrome
pain is unilateral and involves a specific upper rib (typically 2 or 3) there is visible swelling at the costosternal region
costochondritis
bilateral or involving multiple ribs without swelling
rib bone stress injury
chest wall pain from repeated loading, especially if they report a rapid increase in activity level over a short period of time
elit rowers
specific rib bony tenderness w/ palpation and compression
affects 6th rib commonly in the mid-axillary region
slipping rib syndrome
pain in the lower chest wall, usually 9/10 rib
most common in children and young adults
typical presentations: young female involved in athletics who reports lower, anterior chest wall pain that is sharp and may involve clicking sensation
rib conditions are painful so manual therapy
should be directed at thoracic spine
DXA osteoporosis score
T score of 2.5 or more
DXA osteopenia score
T score between 1 and 2.5
low to medium risk patients interventions
multimodal approach including edu, exercise and manual therapy
high risk patients interventions
more intense edu, graded exposure approach to rehab, and referral for multidisciplinary management
what exercise has been shown to decrease risk of vertebral compression fx?
spinal extensor strengthening
