t-spine intro

Question 1

physiologic motion of the t-spine is influenced by:

Answer 1

the stabilizing forces and movements of the ribs

*rib cage and sternum add strength and stability to the t-spine

Question 2

normally, inter-rib motions stop BEFORE

Answer 2

intervertebral motion

endranges of osteokinematic motion involve motion of the TP on a “FIXED” rib

Question 3

costotransverse joint

Answer 3

has a convex/concave relationship with ribs 1-7/8 and is flat for ribs 8-10

this relationship can guide both rib motion and segmental motion

Question 4

flexion

Answer 4

0- (25-45) degrees

tape change= ~2.7cm

Question 5

opening segmental motion limited by:

Answer 5

supraspinatus
infraspinatus
capsular ligaments
posterior longitudinal ligament

posterior force on the nucleus

Question 6

motion of the rib cage during flexion/extension

Answer 6

costovertebral
sternocostal
costochondral

Question 7

extension

Answer 7

0-(25-45) degrees

tape change= ~2.5 cm

Question 8

closing segmental motion limited by:

Answer 8

approximation of spinous processes

anterior forcé on the nucleus

Question 9

lateral flexion

Answer 9

0- (20-40) degrees

Question 10

opening and closing lateral segmental motion is limited by:

Answer 10

lateral and rib cage structures

lateral forces on the nucleus

Question 11

motion of the ribs during lateral flexion

Answer 11

motion on the convex side: intercostal spaces widen- enlarges cage

motion on the concave side: intercostal spaces narrow

Question 12

rotation

Answer 12

0-(35-50) degrees

“twisting and rotation” of the disc (rather than shear like in the lumbar spine) leads to greater ROM (3 degrees per segment compared to 1 degree in lumbar spine)

Question 13

opening and closing rotational segmental motions limited by:

Answer 13

rib cage deformations

axis through the body of the vertebra (lumbar spine axis posterior to SP)

Question 14

motion of ribs in rotation

Answer 14

bends ribs and costal cartilages- these structures help limit motion

Question 15

ribs

Answer 15

connected to the vertebrae by synovial joints

• costovertebral joints
• costotransverse joints

Question 16

costovertebral joint

Answer 16

head of rib (convex) articulates with both vertebral bodies (concave) and annulus.

consider as 2 pairs of articular facets separated by an interosseous ligament enclosed by a single capsule reinforced by the radiate ligament running forward to both vertebral bodies and annulus.

stable d/t interlocking joint surfaces

Question 17

costotransverse joint

Answer 17

convex rib tubercle on concave transverse process for ribs 1-7 or 8; flat for 8-10 stabilized by 3 costotransverse ligaments:

• interosseus
• posterior costotransverse
• superior costotransverse

Question 18

rib movement

Answer 18

occurs through an axis through both joints

UPPER RIBS: “Pump handle”
Axis lies closer to the frontal plane; raises sternum, expands A-P dimension of rib cage

MIDDLE RIBS:
Axis through roughly 45 degrees to frontal plane-transition, both types of motion present

LOWER RIBS: “Bucket handle”
Axis lies closer to the sagittal plane; expands medial/lateral dimension of rib cage and changes angle at sternocostal joint

INFERIOR RIBS: (11 &12)
“Caliper motion”

Question 19

superficial layer of posterior muscles

Answer 19

traps
rhomboids
latissimus dorsi

Question 20

2nd layer of posterior muscles

Answer 20

splenius

serratus posterior

Question 21

3rd layer of posterior muscles

Answer 21

iliocostalis
longissimus
semispinalis

Question 22

deepest layer of posterior muscles

Answer 22

levator costorum
interspinalis
intertransversarii
multifidii
rotatores

Question 23

rib muscles

Answer 23

intercostals:

• external for inhalation
• internal for exhalation

levator costae: elevates ribs (inhalation)

sternocostalis (retrosternal location): exhalation

diaphragm: increases all 3 dimensions of the rib cage

Question 24

impairment based classification system for t-spine

Answer 24

*(see olsen page 204)

• thoracic hypomobility
• TS hypomobility w/ UE referred pain
• TS hypomobility w/ neck pain
• TS hypomobility w/ LBP
• thoracic clinical instability

Question 25

thoracic hypomobility

Answer 25

*common TS condition - TS manipulation shows promise in the literature to increase movement and decrease pain complaints - differentiate from rib hypomobility by MOTION TESTING - rib and TS hypomobility can occur concurrently; treat the SPINE first, then address any lingering RIB hypo mobility

Question 26

differentiate rib vs TS hypomobility by...

Answer 26

motion testing

Question 27

TS hypomobility w/ UE referred pain

Answer 27

AKA " T4 syndrome" =UE paresthesia and pain w/ or w/out CS pain - findings include T4 region stiffness, +ULTT - ?sympathetic nervous system referral to CS, head and UEs - evidence shows good success with upper TS manipulation followed by movement (level 4/case study level of evidence)

Question 28

TS hypomobility w/ neck pain

Answer 28

Cleland CPR for TS manip for CS pain -symptoms <30 degrees if 3/6 present successful outcome increases from 54-86%

Question 29

TS hypomobility w/ shoulder impairments

Answer 29

- decreased upper TS mobility may predispose RC impingement - check PIVM of the TS - observe TS during active elevation; re-checl with manual retraction of the scapula - include mob/manip and postural re-education

Question 30

TS hypomobility w/ LBP

Answer 30

- lower TS stiffness may increase demand on the lumbar spine - remember the linkage of the thoraco-lumbar fascia - manipulation of the TS may help inhibit hyperactive T/L musculature

Question 31

thoracic clinical instability

Answer 31

Less common than hypomobility conditions Look for ache w/ sustained upright posture, relief with recumbent positions, aberrant movement w/ AROM, and hypermobile PIVM Associated with: - systemic hypermobility - severe postural deviations - S/P trauma - S/P TS surgery

Question 32

Red flags/risk factors

Answer 32

- minor trauma (osteroporosis/cortisone use) - major trauma - fever, pm sweats, risk factor for infection - hx of malignancy, age >50, no improvement w/ treatment, unexplained weight loss, pain at multiple sites, pain at rest, pm pain - chest pain/heaviness, no mechanical link to pain, abdominal pain, SOB, cough

Question 33

patho-anatomical considerations

Answer 33

SPRAINS/STRAINS - overuse/posture: most common reason for TS pain - trauma THORACIC PAIN D/T PROBLEMS EXTERNAL TO TS - referral from abdominal and thoracic organs - referral from CS THORACIC DISC LESIONS - root pain can mimic fractured rib or chondral problems; r/o w/ AP pressure on sternum=no pain w/ disc lesion - also mimics visceral disease (angina, gall bladder, colitis, etc) ``` VERTEBRAL PROBLEMS Fractures: 3 columns: -anterior= usually not big problems -middle= usually BIG problems -posterior= instability not uncommon -Schmoral's nodes= usually no problems Segmental Problems: instability/hypermobility -surgical: rods, plates,, pedical screws -conservative: stabilization exercises, orthoses, corsets, strapping ```

Question 34

rib dysfunction: fractures

Answer 34

fractures: ribs and costal cartilage usually treated conservatively w/out immobilization-watch for pnuemothorax

Question 35

rib dysfunction: costochondritis

Answer 35

usually trauma or infection (diff dx from MI) - painful swelling of costochondral junction - localized, palpable swelling - pressure on sternum or lateral border elicits pain at junction - pain w/ deep breathing/coughing conservative tx: NSAID, rest, occ injected

Question 36

posture

Answer 36

assess along w/ C-spine, shoulder girdle, lumbar spine and LE alignment

Question 37

proprioceptive cues for posture

Answer 37

- corsets | - taping