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MSPT II > T-Spine Manipulation- Cohen > Flashcards

T-Spine Manipulation- Cohen Flashcards

1
Q

T/S Pain

A
  • Viscera and T/S w/ shared innervation
  • pts w/ primary c/o T/S pain should have ht’d awareness for non msk disorder
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2
Q

Visceral referral pain to the T/S

A

see pics

  • Cardiac Ischemia
  • Dissecting thoracic aneurysm
  • Peptic ulcer
  • Cholecystitis
  • Renal infection and kidney stones
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3
Q

Serious Cond’s Causing T/S Pain

A

see pics

  • Fx
  • Neoplastic cond’s
  • Inflammatory disorders
  • Inflammatory or Systemic Dis’s
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4
Q

Pot sources of mechanical t/s pain

3

A
  1. Thoracic facet jts
  2. Thoracic IVD
  3. Soft tissue
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5
Q

Pot sources of mech. t/s pain

Thoracic facet jts

A
  • pain local to jt
  • may inc w/ closing
    • EXT and ipsilat s/b
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6
Q

Pot sources of mech. t/s pain

Thoracic IVD

A
  • more common in lower t/s, can refer to abdominals and hip
  • diffuse pain, may radiate ant.
  • thoracic nerve root lesions uncommon
  • possible directional preference of EXT
  • Thoracic disc herniation in imging is common in those W/OUT pain
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7
Q

Pot sources of Mech t/s pain

Soft tissue

A

trigger pts common in upper t/s and scapular region

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8
Q

NOTE about t/s mechanical sources of pain

A

Probably not possible, nor necessary to ID the exact structural cause of t/s pain and all MSK pain as multi-factorial causes

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9
Q

Mech sources of rib pain POSTERIORLY

2:

A
  1. Costovertebral jts
  2. Costotransverse jts
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10
Q

Mech sources of rib pain ANTERIORLY

2:

A
  1. Costosternal jts
  2. Costochondral jts
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11
Q

T/S pain referral patterns

A
  • Pain mapping shows that thoracic facet and costotransverse jts refer pain locally OR @ most 1 lvl above or below
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12
Q

Cervical referral patterns:

A
  • Cervical facet jts and discs refer pain to the thoracic and periscapular area
  • Cervical radiculopathy→ pts often report periscapular area pain
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13
Q

Cervical radiculopathy

Pts often report pain referral to_______

A

Periscapular area

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14
Q

Can mechanical t/s pain mimic visceral pain?

A
  • shared innervation and convergence of primary afferent into the spinal cord
  • Sympathetic division of ANS originates from T1-L2 (big region)
  • Viscera below diaphragm receive sympathetic innervation from below T5
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15
Q

Pseudo visceral pain

A

see pics

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16
Q

Pseudoanginal pain

A
  • T4-T7 segs freq’ly implicated in this phenomenon
  • 6 reports of anginal pain relived by manipulation of mid t/s segs
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17
Q

Mgmt of chest pain:

appraisal of most probable cause (“initial dx”)

A
  • Ischemic heart dis→ 50%
  • MSK pain→ 22%
  • Psychiatric dis/anxiety→ 12%
  • pulm dis→ 5%
  • dyspepsia→ 5%
  • GI dis→ 3%
  • other (arrhythmia, HTN crisis)→ 3%
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18
Q

Chest Wall Syndrome

A
  • Most common cause of Ant. chest pain in pts presenting to primary care is benign
  • Usually loc’d in ant chest wall and is MSK in nature
  • 20-45%
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19
Q

Abdominal pain of MSK origin

Responses to following questions predict that abdominal sx’s are likely of MSK origin:

A
  • YES to both:
    • Does taking a deep breath aggravate your sx’s?
    • Does twisting your back aggravate your sx’s?
  • NO to ALL 3:
    • Has there been any change in B&B habit since onset of sx’s?
    • Does eating foods aggravate your sx’s?
    • Has there been any wt change since onset of sx’s?
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20
Q

T4 Syndrome

RARE

Most hypOmobile segment

A

Clinical features:

see pics

21
Q

Assess of pt w/ T/S pain

A
  • assess for red flags
  • assess adj. regions
    • c/s
    • shoulder
    • L/S
  • ID t/s impairments
    • mvmt impairs
    • sensitivity to loading
22
Q

More assess of pt w/ T/S pain

A
  • Hx→ trauma vs overuse
  • Area of sx:
    • t/s vs ribs, c/s referred pain, visceral
  • Aggravating factors:
    • sustained postures vs dynamic acts.
  • Special ?’s:
    • night pain
    • chest pain
    • abdom. pain
    • neuro sx’s
23
Q

T/S and Rib Composite Exam

A
  • Observation/posture
  • Screen C/S
  • T/S AROM, AROM w/ overpressure
  • palpation
  • segmental mobility
    • Thoracic central and U/L PA glides
    • Rib PA’s and AP’s
  • muscle length
    • lats, pecs
  • muscle strength
    • mid/lower traps
    • Serratus ant.
24
Q

T/S Assessment

Mechanical T/S pain

*NOTE: usually rotation affected→ Facets, T/S

A
  • painful + restricted t/s ROM and t/s seg. mobility
  • AND/OR
  • pain w/ sustained t/s loading
25
Q

T/S Assessment

Mechanical Rib Pain

*NOTE: usually S/B→ rib issue, CV or CT jts

A
  • painful + restricted t/s ROM +/- painful breathing
  • painful + restricted rib seg. mobility
26
Q

T/S pain evidence for mgmt:

A
  • NO high qual evidence for mgmt of primary t/s or ribcage pain
    • 1 low qual RCT suggests benefit of man tx + ex for pts w/ primary t/s pain
  • Regional interdependence
    • mod evidence for t/s manipulation in mgmt of indiv’s w/ neck pain
    • conflicting evidence for shoulder disorders
27
Q

T/S and C/S Connection

A
  • Mvmt of C/S associated w/ mvmt of T/S
    • T1, T6, T12 segs all move during C/S mvmts***
  • excursion from full c/s protraction to retraction involves 30% and 10% contributions from lvls C4-T4 and T5-T12 respectively
28
Q

Evidence for T/S Manipulation in Neck Pain

A
  • T/S manip usually included as part of multi-modal tx package
    • diff to separate out effects
  • Cond’s studied:
    • mech. neck pain
    • C/S radiculopathy
    • WAD
  • Majority studies show + effects compared to:
    • competing intervents
    • sham manip→ just putting them into pos.
    • controls
29
Q

T/S Manipulation for Neck Pain Rationale***

A
  • Potentially safer than C/S manip
    • tx neck pain w/out tx neck
  • Can be used when neck is irritable
    • acute c/s radiculopathy
  • Acute WAD or neck pain
30
Q

T/S Manipulation

Huisman 2013

10 studies (677 pts)

A
  • 8/10 studies showed sig reduction in pain and disability for pts w/ mech. neck pain
31
Q

T/S Manipulation for C/S Radiculopathy

Young et al and Cleland

A
  • Included @ least one manual tx tech targeting upper and mid t/s in multimodal tx package for pts w/ c/s radiculopathy
32
Q

Does the technique matter?

A
  • All studies done on pts w/ neck pain
  • TS manips may have greater short term effect compared to mobs
  • TS manip + CS manip/mobs may have greater short-term effect compared to CS manip/mobs alone
  • Choice OR direction of tech. does not affect immediate outcomes
    • seated, supine, prone
33
Q

Regional Interdependence:

Thoracic spine and Shoulder

A
  • Upper t/s Ext and ipsilateral s/b REQUIRED for end-range shoulder Flex
  • Restricted t/s mobility→ subAC patho
  • Restricted upper rib mobility→ s/s consistent w/ subAC impingement or TOS***
34
Q

T/S and Shoulder Girdle

A
  • Incd T/S kyphosis leads to reduced shoulder elevation ROM
    • assoc’d w/ pain?
  • Full B/L shoulder elevation assoc’d w/ on avg 12 degs of t/s Ext (lower>upper)
    • close to total amt of t/s Ext available***
35
Q

T/S Kyphosis and Shoulder Elevation

A
  • Taping to reduce t/s kyphosis lead to inc in shoulder flex and scap plane ABD in some people w/ and w/out shoulder pain
  • Pain was unchanged in people w/ sx’s
    • Deg of elevation where they reported pain was higher
36
Q

T/S Manip and Shoulder Pain

A
  • Part of multimodal program in pts w/ shoulder pain
  • Pilot studies found immediate effects of TSM on shoulder pain and/or ROM
  • No diff in indiv’s w/ SubAC impinge
37
Q

Shoulder Pain and the Upper Ribs

A

see pics

38
Q

T/S and Tennis Elbow

A
  • 70% indiv’s w/ tennis elbow reported c/s or t/s pain compared to age match controls
  • Local pain in elbow was elicited w/ TS spring testing in almost half pts w/ tennis elbow
39
Q

T/S Neurodynamics **

A
  • Phys health and mobility of TS may effect spinal neurodynamics
  • Consider assess of TS in pts w/ sx’s brought on by neurodynamic testing
    • Ex. Slump Test
40
Q

Mech. Effects of TSM

A

see pics

41
Q

Neurophysiological Effects of TSM

A

see pics

42
Q

T/S Summary

A
  • Primary T/S or Rib pain should alert clinician to possible Red Flags
    • SCREEN!
  • Lower c/s frequently refers to Upper t/s
  • Mgmt of MSK t/s disorders→ focus on impairs w/ mobility deficits
  • Regional interdependence of T/S and neck pain and shoulder pain
43
Q

T/S PA’s

Spring Testing

A

see pics for instructions

Used for assessment and mobilization

44
Q

T/S Manipulation

INDICATIONS (DO)

A
  • Neck pain
  • c/s radiculopathy
  • c/s HAs
  • WAD
  • t/s pain
  • shoulder pain
  • Lat elbow pain
  • stiffness w/ t/s testing
  • restricted CS and TS ROM
45
Q

TS Manips

CONTRAINDICATIONS (DO NOT DO)

A
  • Osteoporosis (known or @ risk for)
  • Hx of OR active neoplasm
  • Fx of TS
  • Spinal infection
46
Q

Manual Therapy Clinical Decision Making

A
  • Functional test/pain score/location of sx’s→ basic manual exam→ manual intervent→ reassess functional tests/pain score/loc of sx’s
  • *Consider:
    • safety
    • irritability
    • pt comfort
    • pt expects
    • clinician skills
  • Baseline outcome measures→ reassess @ follow-ups
    • PSFS
    • NDI
    • NPRS
47
Q

Seated Mid-TS Thrust Manip

A

see pics

48
Q

Prone TS Manip w/ Thrust

A

see pics

49
Q

CTJ Distraction Manipulation w/ Thrust

*Full Nelson one

A

see pics

MSPT II (20 decks)

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