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OCS prep > T-spine APTA (2) > Flashcards

T-spine APTA (2) Flashcards

1
Q

What are some visceral pathologies that can cause thoracic pain? (6)

A
  • myocardial ischemia
  • dissecting thoracic aortic aneurysm
  • peptic ulcer
  • acute cholecystitis
  • renal colic
  • acute polynephritis
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2
Q

What is the typical presentation of pain for a dissecting thoracic aneurysm?

A
  • usually felt in the chest with radiation to the back if the descending aorta is involved
  • typically sudden onset, unrelenting, and unrelieved with positional changes
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3
Q

What is the typical presentation of pain for a myocardial ischemia?

A
  • anterior chest pain or heaviness, occasional nausea, sometimes with pain radiating to the back
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4
Q

What is the difference in presentation between stable and unstable angina?

A
  • stable angina is provoked with exertion and relieved by rest
  • unstable angina is unpredictable and not necessarily relieved by rest; often a progression from stable angina
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5
Q

What is the CPR to rule out CAD in primary care? (4)

A
  • age/sex (female >/= 65 or male >/= 55)
  • pain worse during exercise
  • pain not reproducible with palpation
  • pt assumes pain is of cardiac origin
  • sensitivity if 2 variables are present is 0.98 (good cutoff to rule out)
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6
Q

What is the typical presentation of pain for a peptic ulcer?

A
  • boring pain from the epigastric area to the middle thoracic spine
  • key in hx would be pain triggered or relieved with eating, and/or long-term NSAID use
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7
Q

What is the typical presentation for pain from an inflamed gall bladder (cholecystitis)?

What is the Murphy sign?

A
  • right upper quadrant and/or infrascapular region
  • often accompanied by moderate fever, nausea, and vomiting.
  • often symptoms will follow a heavy meal by 1-2 hours
  • can have positive Murphy sign; palpate the R subcostal region and having the pt take a deep breath. If pain is provoked with inhalation, it’s positive
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8
Q

What is the typical presentation of pain from pancreatitis?

A
  • pain around the thoracolumbar region

- no other detail provided

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9
Q

What is the typical presentation of kidney or renal pain from pyelonephritis?

A
  • costovertebral angle or flank area
  • often accompanied by fever, nausea, vomiting, and renal colic
  • hx may include previous or current UTIs
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10
Q

What is renal colic?

A
  • flank pain accompanied by lower abdominal pain

- spreads to the labia in women and testicles in men

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11
Q

What are the primary cancers that metastasize to the T-spine?

A
  • breast, lung, and colon CA
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12
Q

T or F;

Primary T-spine CA is more common than secondary mets to the T-spine.

A
  • F; it’s less common to have a primary T-spine CA
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13
Q

What are the most common factors associated with predicting CA with T-spine pain?

A
  • age > 50 (positive likelihood ratio: 2.7)
  • hx of CA (PLR: 15.5)
  • unexplained weight loss (PLR: 2.5)
  • failure of conservative therapy (PLR: 2.6)
  • takeaway is that hx of CA raises concerns significantly.
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14
Q

What is the estimated prevalence of ankylosing spondylitis? What is it?

What are demographic factors?

A
  • 0.18%
  • inflammatory disease that can affect the ribs and T-spine
  • affects men more; 3:1 ratio
  • age of onset typically 15-40 yo
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15
Q

What are two CPRs for ankylosing spondylitis?

A

Berlin criteria

  • stiffness of > 30 mins in duration
  • improvement of back pain with exercise but not rest
  • awakening in the night because of back pain in the second half of the night only
  • alternating buttock pain
  • if 3 of 4 present, specificity is 0.94

Expert opinion criteria

  • age <40 at onset
  • insidious onset
  • alleviated with exercise
  • no alleviation with rest
  • pain at night with improvement on getting up

CPRs considered appropriate for dx inflammatory back pain, not necessarily ankylosing spondylitis

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16
Q

What is the key clinical finding associated with ankylosing spondylitis?

A
  • limited rib cage expansion.

- 5.0 cm is normal, >2.5 cm is considered pathological

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17
Q

What are some other general signs associated with ankylosing spondylitis?

A
  • sacroilitis
  • morning pain and stiffness
  • peripheral joint involvement
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18
Q

What are risk factors for osteoporosis?

A
  • caucasian
  • hx of smoking
  • early menopause
  • thin body build
  • sedentary lifestyle
  • steroid treatment
  • excessive consumption of caffeine or alcohol
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19
Q

T or F;

T-spine compression fracture is often occurs spontaneously.

A
  • T

- often spontaneous or following trivial strain

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20
Q

In what demographic will there be a concern for T-spine compression fx?

A
  • any adult over the age of 60 presenting with acute thoracic pain
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21
Q

Is vertebroplasty an appropriate intervention to manage T-spine compression fxs?

A
  • probably not. Previously thought to at least have short term effects, but was found to perform no better than sham in the short or long term for pain, function, QOL, disability, or perceived improvement
  • not recommended after a Cochrane review
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22
Q

What is the efficacy of PT for management of T-spine compression fx?

A
  • hasn’t really been studied when compared to surgery

- generally limited evidence for specific conservative care guidelines

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23
Q

One study looked at PT management for stable T-spine fx. What interventions did they use? Were they successful?

A
  • education
  • postural taping
  • manual therapy (STM and Grade II mobs)
  • ROM therex
  • back extensor therex
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24
Q

What type of imaging is most appropriate to rule out cancer or infection?

A
  • MRI or bone scan
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25
Q

What is a potential indicator of primary rib cage involvement during pt subjective eval?

A
  • reporting symptom aggravation with respiration or deep inhalation or exhalation
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26
Q

Are psychosocial screening measures appropriate for T-spine pain?

A
  • probably (e.g., the Start Back Tool), but they haven’t been validated for thoracic back pain
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27
Q

What did one study find (Griegel-Morris et al) regarding the relationship between postural abnormalities (forward head, kyphosis, and rounded shoulders) and pathology?

A
  • found no association between what would be considered “abnormal” and incidence of pain/dysfunction.
  • What they did find was a significant increase in pain for those who were on the more severe range of abnormality
  • prevalence of forward head (66%), kyphosis (38%), R rounded shoulder (73%), L rounded shoulder (66%)
  • based on visual assessment
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28
Q

What is a way to objectively measure kyphosis?

A
  • use two inclinometers; one at T1-2, and one at T11-12. Have pt stand in a relaxed posture. Sum of the two angles is a gross measure of kyphosis. Can be more accurate by taking it 3 times and using the average.
  • Use C7 as a landmark for T1-2, and L3 (should be at the level of the iliac crests)
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29
Q

What is the standard measure of thoracic kyphosis? What is considered hyperkyphosis?

A
  • the Cobb angle as measured on lateral radiograph
  • hyperkyphosis is >50*
  • dual inclinometers have not been validated against the Cobb angle.
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30
Q

What is the general sequence for AROM testing for the T-spine?

A
  • pt seated w/ arms crossed. Test cardinal planes (flx/ext, side bend, rotation).
  • if nothing provoked, can do combined movements
  • can add overpressure as well
31
Q

What’s the general reliability of quantification of ROM with an inclinometer?

A
  • reported as moderate
32
Q

Describe how to find C7.

A
  • palpate the spinous pxs at the lower C-spine that are most prominent. Have the pt extend their neck. The spinous px that moves away from the finger is C6, the one that stays stationary is C7
33
Q

What points are recommended for inclinometer measurement?

A
  • T1-2 and T11-12
34
Q

What position is used to measure rotation for the pt?

A
  • pt in quadruped, sitting on heels
35
Q

What is the rationale for quantifying T-spine AROM?

A
  • can assess whether the pt has the requisite range for normal function. That said, normal values for thoracic ROM have not been established
  • Also, helpful to assess effectiveness of intervention; assess before and after.
  • For the C-spine, increases in ROM w/in a session are predictive of increases in ROM between sessions
36
Q

T or F;

The prognostic implications of centralization/peripheralization for the T-spine are the same as the L-spine.

A
  • T; would want to centralize symptoms with discogenic symptoms
37
Q

What are the most commonly prescribed treatment directions for the T-spine used by clinicians that use the McKenzie Mechanical Diagnosis and Therapy (MDT) approach?

A
  • extension. (85% per survey…but just a survey of clinicians, so can’t draw too much from it)
38
Q

What is the reliability of segmental motion palpation?

A
  • fair to poor reliability
39
Q

What is one of the greatest sources of variability with T-spine mobility assessment?

A
  • variation in accuracy for identifying the specific segment. It’s pretty easy to be off by one.
  • author recommends thinking of segmental mobility between upper, middle, and lower regions, then divided into their 4 segments
40
Q

T or F;

If there is pain to palpation in a specific segment, it is likely there is a positional fault of the spine at that location.

A
  • F; current evidence shows that it is highly unlikely for positional faults to occur within the spine
41
Q

What should be recorded with T-spine mobility assessment?

A
  • presence of provocation

- normal, hypo-, or hypermobile

42
Q

Where is finger placement for palpation/assessment of the first rib?

A
  • just inferior to the sternoclavicular joint; have the pt inhale, then exhale completely. Assess for provocation and symmetry of movement
43
Q

What is a method of assessment for first rib dysfunction?

A
  • cervical rotation lateral flexion test; assesses for first rib elevation
  • pt seated. C-spine passively maximally rotated contralateral to symptoms, then side bend towards chest (relatively ipsilateral to symptoms)
  • test positive if side bend is limited or blocked
  • thought to be related to the transverse px of T1 being blocked/contacting the first rib during the side bend
44
Q

What is the relative prognosis between acute, subacute, and chronic T-spine pain?

A
  • usually better prognosis with acute/subacute pain

- with chronic pain, more likely to have to untangle psychosocial factors

45
Q

Is pt education an appropriate intervention for T-spine pain? What should it consist of?

A
  • Yes
  • for acute pts w/o psychosocial factors, just reassurance of a positive prognosis
  • for chronic pts, discussion of the specific factors that may be involved in the pt’s experience of pain or perpetuating the experience
  • can take place across multiple sessions
  • not explicitly investigated for the T-spine, but support for other regions of the spine
46
Q

Is manual therapy an appropriate intervention for T-spine/rib cage dysfunction? What are thought to be the nature of the benefits?

A
  • yes; no definitive evidence supporting one technique over another
  • benefits likely of short-term pain relief due to neurophysiological benefits
47
Q

What are the most common adverse symptoms that follow spinal manipulation?

A
  • muscle or joint soreness
  • in general, severe symptoms (e.g., cauda equina symptoms) are extremely rare; estimated as 1 in 100 million for L-spine manips
48
Q

What are the stats surrounding GI bleeds and hospitalizations/death associated with NSAID use?

A

~1-3% of NSAID users thought to get GI bleeds

  • ~7,600 deaths and 76,000 hospitalizations per year in the US due to NSAID use
49
Q

What is a contraindication for T-spine manipulation?

A
  • osteoporosis; may cause fx
50
Q

What are the DXA definitions for osteoporosis/osteopenia?

A
  • osteoporosis: 2.5 or more standard deviations below the mean
  • osteopenia: 1 - 2.5 standard deviations below the mean
51
Q

Are nonthrust T-spine mobilizations contraindicated with osteoporosis?

A
  • no

- would want to be careful though

52
Q

What is the state of evidence surrounding appropriate interventions for T-spine/rib pain?

A
  • lacking

- there is general support for T-spine mobs, general exercise, etc, but it’s not well established, high quality research

53
Q

What is manipulation-induced analgesia?

A
  • decrease in the pain-pressure threshold over application of a thrust or non-thrust mobilization, as well as sites distal to the mob
54
Q

What structures are though to to be involved in mediated pain-relief following mobilization/manipulation?

A
  • stimulation of endogenous nonopioid central pain-inhibiting systems in the periaqueductal gray matter
55
Q

Is it important to target a specific segment that is limited with mobs?

A
  • probably not, due to the nonspecific effect that is often regional
  • also, therapists are unlikely to actually be able to isolate specific segments
  • a study by Haas, et al, showed equal short-term reductions in pain when targeting the effected segment vs a random segment in C-spine pain
56
Q

If a pt has a limitation w/ pain with rotation to the R, what direction should the manip/mob be in?

A
  • commonly would want to go toward the restriction (R)
  • however, reductions in pain and improvements in motion (to the R) can often occur with mobs in the pain-free/unrestricted direction (L)
57
Q

Is pt expectation for positive effect of manipulation important for a good outcome?

A
  • it is. Discussion about the intervention should happen to ensure the pt understands and is able to think about it positively
58
Q

What are two appropriate positions for upper T-spine manips/mobilizations?

A
  • supine: hand underneath pt at targeted region, force transmitted through pt’s elbows (pt’s hands crossed on shoulders).
  • seated: pt’s hands on back of head. Therapist hands just below pt’s hands on neck, with elbows looped under pt’s shoulders. Force delivered from the legs, transferred through the pt’s upper T-spine relatively superiorly, with an intent of an AP thrust manip
59
Q

What is an appropriate position for a middle T-spine manip/mobilization?

A
  • seated: Pt’s arms crossed w/ hands on shoulders, elbows forward. Therapist holds pt’s elbows and stabilizes T-spine on sternum. Force directed through elbows toward the therapist sternum. Noted to avoid directing the force through the pt’s diaphragm.
  • lifting the pt to create a distracting force is discouraged for the safety of the therapist (larger pts be larger)
60
Q

What are 2 appropriate positions for mid to lower T-spine manips/mobilizations?

A
  • prone: therapist places hypothenar eminances on targeted transverse processes, then twists hands towards each other to take up slack in skin, then perform HVLA. Can also do as non-thrust.
  • supine: pt’s arms crossed holding shoulders, w/ opposite arm on top. Therapist uses thenar eminence and palmar region of hand proximal to the 2nd MCP. Skin lock w/ ulnar deviation. common to have stabilization contact too far laterally Roll pt onto stabilizing hand into supine and produce pressure towards the stabilizing hand. Then, flex pt’s head and neck down to the targeted segment; easier to use pillows or to raise the HOB as able. Pt inhales, exhales, then at the right moment, the HVLA thrust is provided.
61
Q

What is an appropriate position for a thoracolumbar manip?

A
  • seated: Pt straddling the treatment table (assists stabilization of pelvis), or sitting on the side. Pt crosses arms. Therapist places shoulder w/ pillow under pt’s axilla (in direction of rotation). Therapist holds opposite posterior shoulder or rib cage w/ upper arm, brings the pt into slight side bend toward the rotation, and contacts the targeted transverse px with his other hand. HVLA in an anterior/superior direction.
  • a rotational manip.
62
Q

What is an appropriate position for a first or second rib mob? When should it be used?

A
  • seated: Therapist can support pt’s contralateral side w/ leg. Therapist hand web space on targeted first rib; contralateral hand supports pt head neck. Move T1 through arc of flx/ext to find midrange/neutral position. Ipsilateral hand produces translatory contralateral force through T1 transverse px (e.g., R to L, if R rib targeted) to create relative sidebend. Pt inhales, exhales; therapist creates slightly increased translation at T1 during exhale, then at the right moment, produce a HVLA thrust inferiorly and to the CL side (sort of anterior)
  • should be considered for use if there is difficulty restoring upper thorax mobility
63
Q

What are two appropriate positions for rib mobs?

A
  • supine: Similar to the T-spine manip, but the stabilizing hand is placed just medial to the rib angle, instead of the transverse px. Still an AP thrust, but less force used.
  • prone: cross-handed technique, w/ stabilizing force at the contralateral transverse px, and moving force along the shaft of the rib just lateral to the transverse px
64
Q

What is a consideration with rib mobs compared to T-spine mobs?

A
  • will likely use less force with a rib mob
65
Q

Within a session, when should exercise be used?

A
  • usually immediately following a mob/manip that improved mobility/ROM
66
Q

What exercise can be used to increase upper/middle thoracic flexion?

A
  • barrel hug stretch
  • imagine trying to get arms around 55 gallon drum while sitting. If targeted the L side, put more weight in the L hip and turn slightly to the R with a slight forward bend
67
Q

What exercise can be used to increase thoracic extension?

A
  • extension over foam roll or towel in supine hooklying
68
Q

What exercise is appropriate to re-educate lower trap activation? What can be done if there is difficulty with this exercise?

A
  • prone Y, essentially.
  • can facilitate activation with tapping of the musculature
  • can do a mid/lower t-spine manip to facilitate muscle firing
69
Q

What exercise is appropriate to improve T-spine rotation?

A
  • essentially open-books with deep breathing
70
Q

What is an appropriate exercise for older pt populations with thoracic impairments?

A
  • typically have increased kyphosis
  • prone trunk lift: place pillow under abdomen. Lift chest up and squeeze scapulae together, holding 5”, 10 reps, daily. Can be progressed w/ weighted backpack.
71
Q

Are T-spine manips appropriate for treatment of other regions?

A
  • yes

- C-spine and shoulder have most support, but most evidence is multimodal, not isolating T-spine mobs/manips.

72
Q

What are some of the features of presentation that would distinguish central from peripheral sensitization?

A
  • central sensitization is more likely to manifest a widespread, diffuse region, rather than a specific, mechanically patterned behavior. Also more likely to have beliefs/fears/cognitive patterns. IBS often associated.
73
Q

What is important to consider with rehab following spontaneous fx in a pt w/ osteoporosis?

A
  • bone density; i.e., loading. Important to load the skeletal structure as tolerated to reduce further lose of bone density.
  • thus resistance training is likely more important than aerobic conditioning or stretching/ROM from this perspective.

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