PT4 - Tspine Intro Flashcards
Why do we want to describe something as non-specific xyz?
- gives us freedom
What are the 4 signs to TTT?
- unilateral
- mechanically stimulated/eased
- no red flags
- no radiations (usually there are some radiations)
When can we treat non-mechanical conditions? (E.g. cancer)
- evidence must be clear
- must be transparent with PT about evidence around getting better from TTT (level of evidence concerning TTT may be unclear)
How long can we leave a PT with neurological symptoms?
- less than 12 weeks for recovery
- longer start to be concerned that nerve may not recover
What age should we be concerned if it’s a new onset of S+S that are not familiar?
- > 50 YO
- humans are good at recreating pain experiences if we’ve had it before
What does fascia provide us with?
- resilience
- joins things together
- blends with capsules, muscles, tendons, ligaments, connective tissues
- Tensegrity to hold shape as long as those tissues are holding well
- in standing not much work required (energy efficient)
- when starting to move we thing about joints and fascia required more
What do bones provide the skeleton with?
- provides shape
- transmission of forces during standing
What do joints provide us with?
- do not have good force transmission
- when we move we use joints + lumbar spine (flexion, extension, sidebending)
- limbs are attached to axial skeleton and lumbar spine
- L5 (most analomous) facets are frontal facing (different from the rest of the Lsp) to assist with force transferal (wedge shaped VB). Assists with translation of rotational force in Lsp.
- L5 have iliolumbar ligament from TPS onto innominate (L4/L5) => if L4 reduces risk of LBP. L5 does not resolve forces well (hence L4/L5 more prevelant to disc injury)
What happens at the hip + knee in locomotion?
- hip helps us get our feet underneath us
- forces like to travel in straight lines => knee already compromised
- menisci are deformable (rounded condyles change shape) => improve congruity for force transmission => should be used for shock absorption
- rotation of hip allows to move as biped
- hip rotates externally => more medial knee tension (meniscus + capsule + MCL) ==> increased tension medial + knee rotates medially => pes planus
Where is a commons site for knee pain + why?
- anterior knee pain
- capsule becomes inflammed when stretching, capsule holds fluid (proprioceptive, mechanical to maintain MM tone => results in altered feedback if altered movement)
- capsule influences VMO => VMO wastes => overuse laterally + underuse medially
- capsule tears off medially => more inflammation
- capsule works well in young people, not in older people
- in older people there is more debris + fewer lysosomes cleaning up the joint
- solution: educate PT on walking => heel first + lengthen gaze + PT stand slowly (wait for Baroreceptors to adjust; takes longer if they move)
Why can the shoulder girdle be maladapted?
- shape is shallow (glenoid) w/ very big humeral head
- lots of movement available => but cannot rely on bony congruity
- rely on rotator cuff + contractile forces
- ideal is for good posture => assists humeral head across deltoid, as soon as shoulder rounded capacity to deal with forces is reduced
Why is the neck a common presenting area?
- OA/subocciptials
- when head moves shouldn’t see too much shoulder movement
- happy neck depends on happy thorax
- thoracic health reduces as we age
- thorax becomes kyphotic, more osseous and less cartilageonous
- eyes + ears what to be presented with sensations => increase mechanical demand on tissues
- failure to adapt to force effectively => neck pain
How can you improve adaptability?
- movement assists by:
-> increasing CVS demand
-> respiratory capacity increased
-> hormone regulation => serotonin (calm/relax) => influence on parasympathetic/sympathetic nervous system, regulation of glucose (insulin + cortisol)
-> bones => increase calcium/bone density/regulation
-> ligaments => stronger, thickening, sacralspinous, sacrotuberous ligaments particularly important for posture
What happens to the Fiona Hendry balloon of adaptability as we age?
- boundary of balloon diminishes as we age, meaning we come closer to injury
What is peripheral resistance?
- micro vasculature working to keep blood pressure low
What happens when peripheral resistance increases?
- blood pressure increases
What do you need to consider with adaptation?
- is it cumulative towards failure?
- what is the PT clinical temporal profile?
- what has changed to result in maladaption?
- can you change forces or/and improve adaptability?
Why is 10k steps a bad metric for exercise?
- 10k steps is arbitrary, breads complacency => where is the CVS activity in that? Need to increase HR
What is a good metric and what happens when you’re unwell?
- Resting HR is a good metric
- Goes up by 4-5 bpm when unwell
How can we help the patient with exercise?
- rotation for thoracic compliance
- relieve on locomotion
- PT wants to be as fluid as they can be
- applicator is never resting on ligamentus tissue (esp. w/ hypermobile people), come to max and return to neutral
Why do we have a NSP diagnosis?
- non-pathological
- no red flags (safety)
- unilateral
- mechanically aggravated/eased
- may have mild radiations => evidence that OTM can help these individuals
- designed by GPs + physios as a diagnosis of exclusion
- for osteo’s it’s a diagnosis of inclusion
- NSP is not a diagnosis
What are the most sensitive tissues in the body?
- MM due to neuroreception
What happens when a PT stops going to the gym?
- reduced adaptability of tissues
When should you treat a patient?
- don’t treat 2-3 days post injury => let the body do what it’s best at, PT may need to seek pain relief, gentle mobilisation
- then triage 7 days post trauma
If you have a 35 YO PT w/ 4-5 week injury, it is recovering, unilateral, aggravated by movement, no red flags, known onset, with healthy habits and lifestyle, what is their prognosis?
- good prognosis of recovery
PT is standing for long periods of time, presents with chronic inflammation throughout their body, which is symmetrical, what might you need to consider
- ligaments around joints might be chronically inflammed
- suggested to tone up core and change footware (trainers vs hard soled shoe)
What do we look for in a healthy spine?
- no Fasciculation
- lumbar rounds on flexion
- extension largely eradicates kyphosis
- SB translates through hips and lower back
- CSP shoulders don’t move if on shoulder comes up then ribs may not be moving so well. CSP should move through thorax
- look for signs of measureable change
Where is a common site for OA?
- thorax
- big VB => big exits, means we don’t feel dysfunction in thorax
What is nonspecific thoracic spine pain?
- pain in tsp mechanically aggravated + not clearly caused by pathology/trauma/discal disease
- associated with altered movement/range of thoracic/rib movement active +/or passively
- no objective neurological deficit
- may be accompanied by referred pain
- may also involve shoulder, csp, UEX or LBP
- > = 70% population with suffer from NSTSP
- higher in children + adolescents + women
- associated with sitting duration
What other findings are there associated with Tspine pain?
- thorax most common site for degenerative change
- asymptomatic thoracic disc herniations are common
- symptomatic are rare (5:1000 herniations)
- tsp relatively commons site for inflammatory degeneration, metabolic, infective and neoplastic conditions
What DDX are associated with tsp pain and dysfunction?
- primary + secondary osteoporosis (primary => aging, secondary => trauma)
- AS
- OA
- Scheuermanns disease
What are the risk factors for NSTSP?
- 5% male: 15% female
- age
- being tall
- frequent sustained trunk bending
- lack of variety in tasks/lack of recovery
- posture/use of back pack
- extended sedentary work
What are the red flags for TSP pain?
- violent trauma
- minor trauma
- first ones <20 or >50
- illness - fever/chills/weight loss
- severe, constant, progressive pain
- non-mechanical
-severe morning stiffness
- severed/progressive neurological deficit in LEX
- pain not managed with drugs
What are the functional impacts of NSTSP?
- loss of healthy function at an area can affect the other integrated areas
- e.g. upper rib dysfunction may affect scapular position => humeral orientation + rotation cuff action
- functional change/loss of agency can involve/affect ANY of the functions of the thorax e.g. reduced scapula function after bad cough/cold
- TTT to thorax before rotator cuff => think architecture (predisposing/maintaining factors)
What are the functions of the thorax?
- ventilation - involves tsp vertebrae + ribs
- locomotion - axial rotation (determined by facet direction) + use of upper limb
- shoulder function - integrated movement + force transmission
- force dissipation => compression/torque via ribs
- protection - viscera/CNS
- adaptability + compensation
What is the specialised structure of the ribs?
- 1st rib => sliding articular movement
- 2-5 ribs => rotation articular movement => pump handle
- 6-9 ribs => sliding articular movement => performing ‘bucket handle’ movements
- rotational effects on rib cage
What are the thoracic relationships with the sterno-pericardial ligament?
- diaphragm - pericardial ligaments
- vertebral - pericardial ligaments (inferior C3-4 + superior C4-5)
- descending group - sphenoid-pericardial from occiput & thyro-pericardium
How to classify thoracic spine presentation
- by symptom area/pain presentation
- functional loss
What are common thoracic pain presentations?
- unilateral posterior thorax pain => commonly spinal/paraspinal mechanical pain + evoked by stretching + associated with local tenderness + MM tension
- anterior radiation of pain => rib strain - intercostal MM involvement
- interscapular pain => usually unilateral - main include referred pain + postural MM strain/overuse/imbalance
- anterior thoracic pain
- Tietzes syndrome
- Trauma - WAD (whiplash associated disorder)
What are the compensatory effects of a hypo mobile area in the Tsp?
- primary hypermobile ridid zone = T2=>T4
- results in secondary hypermobile zone superiorly C6-T1
What are the Olsen classifications of function loss in Tsp?
- thoracic hypomobility
- thoracic hypomobility + UEX referred pain
- thoracic hypomobility + neck pain
- thoracic hypomobility + shoulder impairments
- thoracic hypomobility + LBP
- thoracic clinical instability
What are the effects of thoracic dysfunction?
- local pain - CV or CT
- GH or clavicular pain/dysfunction
- referred pain
- thoracic outlet syndrome
- Possible ANS disturbance - Horner’s syndrome
- Altered scalene mechanics
- Effect of Csp and Lsp mechanics
What is Tietzes syndrome?
- costochondrosis
- usually in adolescent population
- where rib meets cartilage or cartilage meets sternum + manubrium
What is Horner’s syndrome?
- problem with sympathetic nerve supply to one side of face
- symptoms: miosis (constricted pupil) + ptosis (droopy eyelid). Anhidrosis (inability to sweat) => happen ipsilateral as damaged nerve (SPAM = sympathetic, Ptosis, Anhydrosis, Miosis)
- damage along the occulosympathetic pathway e.g. spinal cord lesion above T1, compression to neuron (tumor), dissection of internal carotid artery
What happens if a PT has a C6 facilitation?
- skin pain in C6 dermatome (lateral part of forearm + thumb + index finger)
- MM pain + deltoid + brachioradialis spasm => effects shoulder/elbow mobility
- periosteal pain in radia head + lateral border of radius + radial stolid or thumb
- angiotomal burning sensations over lateral extensor compartment of arm
What structures are involved in rib cage dysfunction?
- intercostobracial nerve
- intercostal nerve => collateral branch + lateral cutaneous branch + terminates as anterior cutaneous nerve
- special features: intercostobrachial nerve of T2 (sometimes T3)
What are some DDx for thoracic pain?
- csp referral
- CVS presentations
- scoliosis
- shuermann’s disease
- osteochondritis
- thoracic discal disease
- chest infections
- polymalgia rheumatica (PMR)
- osteoporotic crush fracture
What happens when asymptomatic individuals have their thoracic spine MRI’d?
- 73% had significant findings
- 37% IVD herniation
- 53% IVD bulging
- 58% annular tear
- 29% spinal cord deformation
- 38% sheuermann end plate irregularities
What happens to the structure as the thorax ages?
- calcification of stool cartilages/chondrosternal joints
- asymptomatic discal degeneration (large spinal canal + foramena)
- reduced thoracic compliance from age 50 due to loss of collagen in ribs/reduced twisting capacity
- stiffness + increase in kyphosis
- reduced mid-thoracic ventilation - segmental degeneration
- increased protraction of scapulae
- reduced rib movement, reduced fluid movement at segmental level
- reduced diaphragm excursion
- increase in OA => reduced disc heigh, changes in facet joints, deformation of nerve roots + sympathetic chain
- Heart _ lung function highly tolerant of changes
What happens to the lungs as the thorax ages?
- reduction in elastic recoil of lung
- decrease chest wall compliance
- decrease respiratory MM strength
- increase in residual respiratory capacity (volume of air remaining in the lungs after expiration)
