PT4 - Thorax - Abnormalities Of The Spinal Curvature Flashcards
What are the functions of the thorax?
- ventilation
- protection of thoracic organs, SC + SNS (sympathetic nervous system)
- aid efficient locomotion => rotation (primary) + flexion/extension + SB
- support csp, shoulder girdle + lsp function and structure
What changes might occur in spinal curves?
- AP + lateral changes
How are AP + lateral changes in spinal curves caused?
- compensation, posture, congential/developmental defect or disease
How are lateral changes caused in the spine?
- scoliosis from compensation/developmental/congenital defect
How are AP changes caused in the spine?
- kyphosis from O/C (ossification?), osteoperosis, disease, hyperlordosis may be a cause or effect (lsp)
What are the major categories of spinal curves?
- functional (compensatory - short term) e.g. muscle spasm in lsp, altered weight balance in spine
- structural (permanent - long term) e.g. PSLE (Paediactric Systemic Lumpur Erythematosus?), idiopathic scoliosis, congenital anomalies - hemi-vertebrae
How does the csp link to the tlf (thoraco lumbar fascia?)?
- longus colii + scalenii from csp => rib 1+2
- ribs 2-6 = pump handle action
- ribs 7-10 = bucket handle action
- diaphragm = Xiphoid process + Lumbar vertebrae + Coastal cartilages of ribs 7 - 10 + ribs 11 - 12
- arcuate ligament from lumbar + right crura (L1-L3 + IVD = surround oesophagus) + left crura (L1-L2 + IVD) => crura attach onto psoas and quadratus lomborum
Where can inspiration lesions occur?
- Rib 1 => posterior angle of rib held down => pain on forced inspiration
- Rib 2-10 => angle close to rib above => pain on expiration
- Rib 2-10 => rib moves up and out => pain on forced expiration
- Rib 11-12 => exspiration lesion
What is the pathway of the embryonic Myofascial chain linking CSP with TLF?
- QL + longus colli/scalenes + extraocular muscles
- Influences of 2 of transverse diaphragm => central tendon + sibson’s fascia
What is the hueter -volkmann effect?
- decreased load => increased growth
- increased load => decreased growth
What occurs during functional scoliosis?
- adduction contracture of a hip
- scoliosis
- pelvic tilt
- flexion of opposite hip
- flexion of opposite knee
- plantar flexion of ankle
- short leg (apparent)
- antalgic posture (shift to one side to avoid pain)
Risk factors of idiopathic scoliosis
- female
- degree of angle
- age/developmental change to come (teenage years better outcome prognosis compared to early adolescence)
Which populations are affected by structural scoliosis
- idiopathic - 75-85% (Insidious IdS or Adolescent Idiopathic AIS)
- often arise in children (hence name)
- more prevalent in females (9:1)
- progressive curvature for early onset (8 years), often rate of 5-10%
- can ‘pause’ in teens and worsen again in later life
- classified by age group: infantile (0-3), Juvenile (4-13), Adolescent (13-20)
How is development of scoliosis measured?
- The Cobb method uses AP x-ray view: superior border of vertebrae with greatest angulation - inferior border of vertebra with greatest angulation => cobb angle between
- The Rib Angulation: PT flexed @ 90 degrees observed from behind: measurement taken from SP
What happens when PTs use breathing exercises with scoliosis?
- improve functional patterns + relaxation
- does not change tidal volume
What theories are there behind scoliosis?
- Burrell et al. 2016, Scoliosis & Spinal Disorders
- Late Childhood: Low fat mass => low leptin => starts asynchronous neuro-osseous growth
- Adolescence: backward vertebral tilt + axial vertebral rotation + torsion => contralateral cerebral hemisphere dysfunction + rib length asymmetry + shallow chest (cardio thoracic disproportion) + speech exhalation concept + Hueter-Volkmann effect
- Relative anterior spinal overgrowth => 3D scoliosis deformity
How is Scoliosis classified?
- Extrinsic => asymmetry, scoliosis capitis, other
- Intrinsic => Bony => congenital, acquired
- Intrinsic => Myogenic => Disease, Adaptation, Injury
- Intrinsic => Neurogenic => Developmental, Pain reflex, Degeneration
What is the Aetiology and Pathophysiology of Scheuermann’s Disease?
- unknown - possibly ischemic effects during hyper-vascular phase of rapid growth with deformation
- type of PID (prolapsed intervertebral disc) into the vertebral body + asymmetrical/scoliotic
- criteria = 3 or more consecutive wedged thoracic vertebrae
What are the radiological signs of Scheuermann’s Disease?
- in general population, lumbar MRIs would meet diagnostic criteria of SD
- in LBP, associated with:
—> increased rates of work absence
—> seeking medical care due to LBP episode
—> greater intensity of most severe LBP episode
- having SD like spine => associated with severity and progressive nature of LBP in general population
- tend not to see this while it’s happening
- tends to occur in teenage boys e.g. rugby players
- T11-T12-L1-L2 affected
What happens to the bones/discs Scheuermann’s disease?
- disc stronger than vertebrae
- bone loses resilience due to loss of blood supply
- damage to vertebral end plates occurs => higher risk of LBP => more angiogenesis (increased blood vessels)
What advice can you give a PT with Scheuermann’s Disease?
- advice: avoid contact sports (trampolining due to rebound/compression), fine to run on grass rather than track, football, swimming (make lifestyles manageable)
How does the PT present with Scheuermann’s Disease?
- paraspinal pain
- MM causing most symptoms
- Stretching should help
- Txx won’t change anything
What are the X-ray findings for diagnosis of Scheuermann’s Disease?
- increased AP diameter of VB
- 3 VB wedge shaped anteriorly + angled @ 5 degrees
- irregular + narrow disc spaces
- loss of lordosis + frank kyphosis
- schmorl’s nodes (dips in V end plates) => think swiss cheese
- flattened areas of superior surface of VB near epiphyseal ring
- detached epiphyseal ring
What is the active phase + management approach for Scheuermann’s Disease?
- often discrete episodes of back pain
- AGG during prolonged sitting/excessive activity
- pain at site of condition e.g. T11-L2
- explain + control pain + local TT of hypertonicity + BLT
What is the post-active phase management approach for Scheuermann’s Disease?
- emphasis on secondary compensating dysfunction above/below
- emphasis on local changes to spinal curves => lateral plane
What are the pathologies of respiration?
- COPD
- Bronchitis
- TB
- Flu
- COVID
- Breast Cancer
- Asthma
Where does the thoracic spine refer?
- locally
- neurology is local (intercostals)
- rare to get a disc injury
- can look like costalcondrosis (AGG by coughing)
- stenosis unlikely in tsp due to size of VB
What are the symptoms of annular tear?
- back pain
- neck pain
- radiating pain
- sciatic pain
- burning sensation along spine or sciatic nerve
- MM weakness in neck, back, arms, legs
- limited flexibility
- tingling + numbness in arms/legs
What is an annular tear?
- tear in the annulus fibrosus (ligament) connecting Vertebral end plate to disc
- tears occur if the disc ruptures + ligament tears
- nucleus pulposus (jelly) pushes through annular tear => herniated disc
- when no disc material ruptured => annular tear
- annular tear heals itself over time (suspectable to future weakness + tears)
- common at TL + L4
What are the cause of an annular tear?
- trauma e.g. car accident/sports injury
- improper lifting/movement
- repetitive motions such as lifting/twisting
- sitting for extended periods of time e.g. working at a desk
- carrying excess body weight
What other spine conditions are associated with an annular tear?
- degenerative disc disease
- herniated disc
- spinal stenosis
- Spondylosis
What types of annular tears are there?
- radial = begins @ centre + extends through other layers surrounding disc (caused by aging) => can cause disc herniation
- peripheral tear (transverse tear) = begin on tough outside layers of ligament => caused by traumatic injury
- concentric tear = develops in a ring that encircles nucleus of disc => caused by torsional injuries e.g. golf club
What can cause an intercostal strain?
- coughing
What is a common presentation of Osteoperosis?
- 75 yo, early onset menopause (<40 YO), experienced eating disorders (vegetarian/vegan/lactose intolerant), drinks alcohol (look for pitted fingers + acid damage on teeth + breath smell)
- had bronchitis recently
- acute spine pain
- on examination TTP SPs + paraspinal tenderness
- pain worse on coughing
- no bruising or swelling
- fasciculation
- PT has experienced loss of fitness
- suspect a spinal fracture => DO NOT TTT!!! => most settle on their own in 6 weeks, if they do not settle => orthopaedic surgeon may inject cement to assist stabilisation
If PT does not drink milk, what do you need to check?
- iron
- folate
- calcium
- tough to get these substances from non-animal products, milk is a good source for us
How to carcinomas/seconaries present in PTs?
- localised pain
- worse at night
- won’t respond to over the counter meds
- progressive
- increased heat around tumour due to increased blood supply (tumours create their own blood supply)
Where does CVS refer to?
- jaw
- neck
- chest
- abdominal cavity/stomach
What organs may refer to right shoulder?
- liver
- gall bladder
Which profession might see a reduced drainage in lymph under their armpits?
- dancers, due to continually being lifted
What happens in functional curvatures?
- leg length difference
- tends to be in older population
- if you sit down the curve goes straight
- adaptational
- can result in LBP
- can see in children 12-14 where their bodies are growing at different rates => proprioception doesn’t keep up
- parents see child on beach in summer => PT brought into clinic in Sept/Oct => can be the start of idiopathic scoliosis
- in these PTs usually by end of TTT PT is symmetrical again => review child regularly (every half term) to check => once growth spurt finished => should resolve
What happens in structural curvatures of the spine?
- idiopathic scoliosis => curves become more profound => more likely to see in 30s/40s due to decreased adaptability (ossification of tsp)
- may develop profound HAs first
- usually women => body develops high shoulder/low shoulder => drive by SB + rot
- older mothers + breached babies higher incidence
- neurogenically drive
- rotation + counter rotation of VBs
What is torticolis?
- shortening of SCM, can occur in babies @ birth or adults as a result of MM trauma
What other diagnosis may be a result of idiopathic scoliosis?
- spondylolythesis => hip OA => bigger lordosis in sp => facets become weight bearing => spondylolysis => spondylolythesis (slippage)
