The Thoracic Spine Flashcards
(125 cards)
1
Q
What is the thoracic spine “Rule of 3’s”?
A
- T1 through T12 vertebrae are divided into 4 groups of 3 & classified by the orientation of the spinous process relative to the transverse processes
- at T1 through T3, the processes are at the same level
- at T4 through T6, the spinous processes are lower (about 1/2 a level)
- at T7-T9, the spinous processes are much lower (about one level)
- at T10 through T12, they go back to being at the same level
2
Q
Some manual therapy and osteopathic practitioners site rib angles as a landmark/site of rib cage dysfunction. Describe the theory and its validity
A
- the idea is that rib joint dysfunction causes muscular tension of the iliocostalis muscles & can cause pain / tenderness
- this type of rib cage dysfunction hasn’t been validated in clinical or laboratory research
- rib angle tenderness to palpation is found in healthy, pain-free subjects, so this sign needs to be carefully correlated with the patient’s chief complaints
3
Q
Contrast the ratio of intervertebral disc height to vertebral body height in the cervical, thoracic, and lumbar spine.
A
- cervical: disc is 2/5ths (40%) of body height
- thoracic: disc is 1/5th (20%) of body height
- lumbar: disc is 1/3rd (33%) of body height
4
Q
Which ribs attach to only one facet on their corresponding vertebra?
A
1st, 10th, 11th, and 12th ribs attach only to the vertebral body
5
Q
Which ribs are considered “true” ribs & why?
A
ribs 1-7; they attach directly to the sternum
6
Q
Which is the lowest rib that attaches directly onto the sternum
A
rib 7 is the last “true rib”
7
Q
Which ribs are considered “false” ribs & why?
A
ribs 8-12; they don’t attach directly to the sternum
8
Q
Which of the “false” ribs attach distally to the costochondral cartilage?
A
ribs 8-10 (11 & 12 are floating ribs)
9
Q
What are the 2 attachment sites on the vertebral body for the “typical” ribs 3 through 9?
A
- superior rib facet (superior vertebral body)
2. inferior rib facet (forms costovertebral joint at the same numerical vertebra, e.g. 3rd rib attaches to T3)
10
Q
Which ribs form costotransverse joints with the vertebrae?
A
ribs 1 through 10
11
Q
What is the relationship between the orientation of the costotransverse joints and breathing motions in the ribcage?
A
In upper thoracic spine (down to T5-6), the orientation of the costotransverse joints allows for more rotation/torsion. In the lower thoracic (T7 and below), the joint allows more planar/gliding motion. So, during breathing, the upper rib cage rises (flexes in sagittal plane) while the lower ribs widen (abduct in frontal plane)
12
Q
List the 8 key muscles / muscle groups that should be considered when assessing the thoracic spine.
A
- trapezius (upper, middle, & lower)
- iliocostalis thoracis
- iliocostalis lumborum (erector spinae muscles generally)
- serratus anterior
- pec major
- scalenes (anterior, middle, & posterior)
- pec minor
- the diaphragm (sternal, costal, & lumbar parts)
13
Q
What is the relationship between breathing and thoracic spine disorders?
A
lack of relaxed, diaphragmatic breathing is an impairment that often accompanies both acute & chronic spinal disorders and could contribute to thoracic spinal mobility restrictions
14
Q
How is it that the thoracolumbar junction can refer pain to the hip?
A
the Subcostal nerve supplies the skin of the abdominal wall, the lateral hip, and over the iliac crest, so nociceptive input at arising from T12 can result in hip pain
15
Q
How are spinal nerves numbered with respect to their corresponding vertebrae?
A
in cervical spine, spinal nerve exits above its vertebrae; then after C8 exits between C7 & T1, the spinal nerve exit below its corresponding vertebrae
16
Q
What area of the thoracic spine is known as the “critical zone” & why?
A
from T4 through T9, the spinal canal narrows & the local blood supply is reduced, so a large disc herniation can theoretically cause central spinal cord compression
17
Q
What is T4 Syndrome & what interventions may be useful in addressing it?
A
- constellation of signs and symptoms such as upper or lower quarter neurologic & sympathetic signs (e.g. bilateral extremity paresthesia & sweating)
- origin unknown, but likely to be a result of amplified nociceptive input into the peripheral & central nervous systems
- interventions targeting mobility impairments at/around T4 level may result in a temporary reduction of symptoms
18
Q
Which thoracic spine articulation(s) can refer pain to the anterior chest wall & sternum?
A
Facet (zygapophyseal) joints at T3/4 & T4/5
19
Q
What are typical pain referral patterns from the facet joints?
A
at C7-T3 facets, superior angle of scapula, between scapulae toward inferior angle
- at T3-T11 facets, at or up to 2.5 segments below the joint (never above), slightly lateral to the joint
(data from subjects with only unilateral pain that does not radiate)
20
Q
What are typical referral patterns from the costotransverse joints? What is the exception?
A
mostly at the joint, but T2 may refer up to C7 vertebral level & some may have pseudovisceral pain (osteophytes at the joint that encroach on the thoracic sympathetic chain)
21
Q
What is the incidence of asymptomatic thoracic disc protrusions?
A
37%
22
Q
Which cervical spinal levels have the potential to lead to referred upper and/or middle thoracic spine pain? Which structures?
A
facet joints and/or intervertebral discs of C5-6 and C6-7 segments can refer to upper thoracic and interscapular pain
23
Q
What is the relationship between thoracic flexion/extension and rib rotation?
A
When the thoracic spine flexes, the corresponding rib rotates anteriorly. When it extends, the rib rotates posteriorly
24
Q
What is the relationship between thoracic spine motion and shoulder elevation?
A
End-range active bilateral shoulder elevation is coupled with end-range thoracic extension (lower thoracic spine contributes the greatest degree)
25
How does thoracic motion in the sagittal, frontal, and transverse planes change from T1 to T12
Flexion/extension & side-bending motion increase from T1-2 to T12. Rotation decreases significantly.
26
What motion occurs at thoracic segments during inspiration?
extension
27
How is the thoracic sympathetic chain tensioned?
flexion, contralateral rotation, and contralateral side-bending (further in slump)
28
Which neurologic structures could be potentially injured as a result of a whiplash-type injury?
thoracic posterior primary rami and/or thoracic sympathetic chain
29
Name 3 neurogenic symptoms in the region of the thoracic posterior rami that may indicate the involvement of these nerves.
1. burning
2. itching
3. paresthesias
30
What thoracic spinal level is reported to be a neural "tension point"?
T6 (motion of the spinal cord relative to the canal converges in different directions
31
List the 4 most common clinical signs of T4 Syndrome
1. headaches
2. neck pain
3. upper extremity pain
4. bilateral "stocking glove" paresthesia
32
Where do flexion movement impairments most commonly occur in the thoracic spine?
upper to middle thoracic spine regions (approximately T3/4 through T6/7)
33
Which movements might be limited and/or painful in a patient with a unilateral thoracic flexion movement impairment?
flexion, contralateral rotation, contralateral sidebending
34
Which movements might be limited and/or painful in a patient with a unilateral thoracic extension movement impairment?
extension, ipsilateral rotation, ipsilateral sidebending
35
Where do extension movement impairments most commonly occur in the thoracic spine?
upper thoracic spine and cervicothoracic junction (C7 through T2)
36
List 3 common pathologies that are linked to an increased thoracic kyphosis
1. vertebral compression fractures
2. spinal extensor muscle weakness
3. degenerative changes of the thoracic spine
37
Thoracic spine mobility deficits are associated with what two variables in older adults?
reduced quality of life & increased risk of falls
38
What is the most likely site of neurovascular entrapment in patients diagnosed with thoracic outlet syndrome?
between the first rib and the clavicle (theory is the 1st rib is subluxated/elevated, but soft tissue tension / muscle guarding is more plausible)
39
What are the 3 areas of the middle and lower ribs at which motion may be reduced?
1. costovertebral joint
2. costotransverse joint
3. costosternal joint
40
Osteopathic manual medicine often describes mechanical rib joint dysfunctions, including those involving breathing (bucket / pump handle) and traumatic subluxation. What is the current state of the evidence concerning these dysfunctions?
the existence of these dysfunctions or a clinician's ability to diagnose them has not been subjected to peer reviewed research
41
What percentage of spine pain is thoracic? What does this mean for evaluating a patient with non-mechanical pain?
only approximately 15% of all spine pain, so non-mechanical thoracic spine or chest wall pain is extra suspicious (pay extra attention to the medical screening form)
42
What are the 2 broad categories of conditions that cause thoracic spine pain that would require a medical referral?
visceral causes & serious causes
43
List 6 visceral conditions that can refer pain to the thoracic spine.
1. myocardial ischemia
2. dissecting thoracic aortic aneurysm
3. peptic ulcer
4. acute cholecystitis (gallbladder inflammation)
5. renal colic (kidney stones)
6. acute pyelonephritis (kidney / UT infection)
44
What is the most accepted theory behind the mechanism for referred pain?
convergence of primary afferent neurons to the same second-order neuron in the spinal cord
45
Where is pain from a dissecting thoracic aortic aneurysm felt? How do symptoms often present?
- usually in the chest & can radiate to the back (if the descending aorta is involved
- pain is usually sudden, unrelenting, & not relieved by position change
46
What is the appropriate course of action to take if you suspect that a patient's chest and radiating back pain are due to a dissecting thoracic aneurysym?
recommend the patient receive emergency care (high likelihood of mortality if the condition goes untreated)
47
List 3 of the typical clinical signs of myocardial ischemia?
1. anterior chest pain or heaviness
2. occasional nausea
3. sometimes pain radiating to the back
48
Contrast exertional vs variant myocardial ischemia. What are these conditions are also known as?
- exertional: pain/sx related to exertion, but reduced with rest
- variant: pain/sx
are random or unpredictable, unrelated to activity
- a.k.a stable vs unstable angina
49
What are the variables in the clinical prediction rule for the detection of coronary artery disease in primary care?
1. age/sex: males older than 55, females older than 65
2. known clinical vascular disease (coronary artery, occlusive vascular, or cerebrovascular disease)
3. pain worse during exercise
4. pain not reproducible by palpation
5. patient assumes pain is of cardiac origin
50
What are two things that might make you suspect that a patient's thoracic pain is referred from a peptic ulcer of the posterior wall of the stomach or duodenum?
- boring pain from the epigastric area to the middle thoracic spine that is better when eating
- prolonged use of NSAIDs
51
Where does inflamed gallbladder pain usually refer? List 3 other signs and symptoms are often present? When do symptoms usually occur?
- right upper quadrant of thoracic spine / right infrascapular region
1. moderate fever
2. nausea
3. vomiting
- sx often occur 1-2 hours after a heavy meal
52
What is The Murphy sign?
- palpation of the right subcostal region + inhalation is painful
53
Where in the thoracic spine does pancreatitis usually refer?
the thoracolumbar junction
54
Pain at the thoracolumbar junction can be referred from what visceral structure(s)/condition(s)?
pancreatitis (inflammation of the pancrease)
55
Pain in the chest with or without radiating pain to the thoracic spine can be referred from what visceral structure(s)/condition(s)?
dissecting thoracic aortic aneurysm or myocardial ischemia (stable vs unstable angina)
56
Pain from the epigastric area to the middle thoracic spine can be referred from what visceral structure(s)/condition(s)?
peptic ulcer
57
Pain in the right upper thoracic quadrant and/or in the right infrascapular region can be referred from what visceral structure(s)/condition(s)?
cholecystitis (gallbladder inflammation)
58
Where is kidney or renal pain usually referred? List 4 other signs/symptoms that are typically present
- costovertebral angle or flank area
1. fever
2. nausea
3. vomiting
4. renal colic
59
Pain in the costovertebral angle and/or flank area can be referred from what visceral structure(s)/condition(s)?
pyelonephritis (infection of the kidney) or renal stones
60
What is renal colic?
flank pain accompanied by lower abdominal pain that spreads into the labia in women & into the testicles in men
61
List 4 "serious" causes of thoracic spine pain.
1. infection
2. fractures
3. neoplasms
4. inflammatory disorders (ankylosing spondylitis)
62
What is the most common form of cancer in the thoracic spine?
```
spinal metastases (usually secondary to primary breast, lung, or colon cancer)
- primary thoracic spine tumors are less common
```
63
List signs that might make you suspicious that a patient's thoracic spine pain is caused by ankylosing spondylitis.
1. stiffness longer than 30 minutes
2. improvement in pain with exercise, but not with rest
3. awakening because of pain during the 2nd half of the night only
4. alternating buttock/sacroiliac pain
5. morning pain
6. stiffness / peripheral joint involvement
64
Which biological sex is more likely to suffer from ankylosing spondylitis? Which age range?
- males (3x greater than females)
| - 15-40 years old (age of onset)
65
What is HLA-B27? What is its clinical utility in treating musculoskeletal pain?
- Human Leukocyte Antigen B27
- protein found on the surface of white blood cells associated with ankylosing spondylitis
- most (90%) of people with A.S. are HLA-B27 positive, but only some (10%-20%) of people who are HLA-B27 positive have A.S.
- poor specificity (a.k.a. high false positive rate)
66
What is an HLA?
- proteins found on the surface of white blood cells (antigens) that help the body's immune system tell the difference between its own cells and foreign, harmful substances
67
How common is infection as a cause of thoracic spine pain?
very uncommon (less than 0.01% of cases)
68
What are the two divisions of thoracic vertebral fractures?
traumatic & osteoporotic fractures
69
List 7 risk factors for the development of osteoporosis.
1. Caucasian race
2. history of smoking
3. early menopause
4. thin body build
5. sedentary lifestyle
6. steroid treatment
7. excessive consumption of caffeine and/or alcohol
70
Caucasian race, history of smoking, early menopause, sedentary lifestyle, and excessive consumption of caffeine and/or alcohol are all risk factors for the development of which condition associated with thoracic spine pain?
osteoporosis (associated with thoracic vertebral fracture)
71
At what age should an osteoporotic thoracic vertebral fracture be considered as a source of acute thoracic pain?
60 or older
72
If a patient is 60 or older, which condition should be considered as a source of thoracic spine pain?
osteoporosis / osteoporotic vertebral fracture
73
What percentage of thoracic vertebral fractures are symptomatic?
only about one third
74
What is the current state of the evidence regarding vertebroplasty to manage vertebral compression fractures?
recent double-blind placebo controlled trials show no significant difference in pain, function, disability, quality of life, or perceived improvement between vertebroplasty and sham procedure at 1- and 6-months post-op
75
What is a vertebroplasty? Kyphoplasty?
- image-guided (typically fluoroscopy) injection of a cement mixture into a fractured vertebral body through a hollow needle
- in a kyphoplasty, a balloon is first inserted into the fractured bone through the hollow needle to create a cavity or space
76
What is the state of the evidence regarding vertebroplasty vs conservative management for osteoporotic thoracic vertebral fractures?
- poor evidence that vertebroplasty is more effective than sham procedures in reducing pain or quality of life at 1- and 6-months post-op
- One RTC (Blasco et al) found similar outcomes at 1-year, though surgical group had less pain at 2-months but increased risk for another fracture
- limited evidence to guide conservative management, but a pilot RTC of people with stable fracture had weekly PT (education, postural taping, manual therapy, ROM exercise, & back extensor strengthening) had less pain & improved function after 10 weeks
77
What did Wood et al discover about thoracic spine MRI abnormalities in pain-free people? About thoracic disc herniations specifically?
- about 3/4 (73%) has some type of abnormality like a disc protrusion, disc / annulus tear, spinal cord deformation, etc.
- about 1/3 (37%) had a painless disc herniation
78
If a thoracic intervertebral disc were protruding and compressing a thoracic nerve root and creating a compression radiculopathy, what symptoms would you expect to see?
- decreased sensation in the corresponding thoracic dermatome
- stabbing pain in the corresponding thoracic dermatome
79
If a postmenopausal female presents with thoracic spine pain, what condition should be considered immediately?
compression fracture
80
List 6 the most common items that, in combination, raise red flags that a patient's pain is due to cancer or metastases
1. personal history of cancer
2. family history of cancer
3. recent significant weight loss
4. unrelenting night pain
5. history of / current smoking
6. older than 50
81
List 6 the most common items that, in combination, raise red flags that a patient's pain is due to infection.
1. fever
2. chills
3. night sweats
4. recent infection such as pneumonia
5. current IV therapy or drug use
6. recent surgery
82
List 5 the most common items that, in combination, raise red flags that a patient's pain is due to visceral or gastrointestinal disorder
1. bowel & bladder dysfunction
2. abdominal pain
3. reflux
4. excessive use of NSAIDs
5. excessive alcohol consumption
83
List 5 the most common items that, in combination, raise red flags that a patient's pain is due to cardiopulmonary disorders
1. chest pain with physical exertion
2. shortness of breath with physical exertion
3. personal history of cardiovascular disease
4. family history of cardiovascular disease
5. "throbbing" or "pulsing" thoracic or chest wall pain/sensation
84
List 6 the most common items that, in combination, raise red flags that a patient's pain is due to cancer or metastases
1. bilateral paresthesia (arm, leg, or trunk)
2. bilateral weakness
3. bilateral sensory loss
85
List 9 general psychosocial & biomedical factors that should be attained during every patient interview to develop hypotheses & guide the physical exam.
1. thoughts & beliefs about their condition
2. expectations about the future
3. expectations about their ability to recover/improve
4. expectations for treatment
5. current stage of the disorder
6. presence or absence of specific thoracic spinal pathology
7. hypothesized dominant pain mechanism
8. specific activity limitations
9. movement-related impairments
86
What is the current state of the evidence regarding thoracic pain and posture?
no relationship between pain frequency/severity & the severity of postural abnormalities (forward head / shoulder, thoracic kyphosis) in all but the most severe cases
87
How can using a symptom modification procedure help to assess the influence of posture on thoracic symptoms?
active or passive taping modification to encourage more neutral thoracic spine posture & assess the patient's symptoms during the painful activity
88
How do you measure thoracic kyphosis using inclinometers? At which angle is it considered a hyperkyphosis?
- one inclinometer at T1-2 & the other at T12-L1
- add the two angles to get a gross measurement
- probably more reliable with 2 or 3 measurements
- hyperkyphosis is angle (Cobb angle) greater than 50°
89
Describe the order of procedures in the ROM assessment of the thoracic spine.
- active flexion, extension, right & left sidebending, right & left rotation
- if AROM is painless, apply overpressure in each direction
- if overpressure is painless, test quadrant positions / combined ROM (AROM first, then overpressure)
90
How might you adjust your ROM assessment for a right-handed tennis player who reports thoracic pain with reaching for an overhead shot?
- assess active thoracic extension, right rotation, & right sidebending
- if pain-free, apply overpressure
91
Describe the Cervical Rotation Lateral Flexion Test. What is the test designed to assess? What is the hypothesized mechanism?
- cervical rotation away from testing side
- cervical flexion (ear to chest)
- (+) when ear to chest is limited or blocked
- reduction in motion is suggestive of an elevated 1st rib on the testing side
- theory is that the motion is limited because the transverse process of T1 is under / blocked by the superiorly-positioned 1st rib
92
What are the 3 dominant pain mechanisms that can be used to guide management of a patient's symptoms?
1. peripheral nociceptive
2. peripheral neurogenic
3. central sensitization
93
Describe the category of a "peripheral neurogenic" pain mechanism
involve direct injury or pathology of the peripheral nervous system (e.g. radiculopathy)
94
Describe the category of a "peripheral nociceptive" pain mechanism.
nociceptive signals from peripheral tissues are the dominant "driver" of the disorder
95
Describe the category of a "central sensitization" pain mechanism
the patient's symptoms are predominantly perpetuated and mediate within the central nervous system
96
How will a patient with "peripheral nociceptive" pain tend to present?
- more discrete region of symptoms
| - mechanically patterned symptom behavior
97
With which dominant pain mechanism do patients with nonspecific thoracic spine or rib cage pain tend to present?
peripheral nociceptive
98
How will a patient with "central sensitization" pain tend to present?
- less discrete, more widespread pain
- constant and/or unpredictable pattern
- additional co-morbid symptoms (sensitivity to temperature, smells, chemicals, or light; extreme fatigue; G.I. complaints; mental health disorders)
99
List 7 co-morbidities are most common in patients that develop central sensitization pain
1. fatigue
2. gastrointestinal complaints
3. mental health disorders
- sensitivity to
4. temperature
5. smells
6. chemicals
7. lights
100
List 5 lifestyle factors that have are associated with a poor recovery from a pain disorder
1. high stress job
2. family or marital issues
3. sedentary lifestyle
4. substance abuse
5. poor sleep
101
List 3 psychological factors that are associated with a poor recovery from a pain disorder.
1. depression
2. fear of movement
3. pain catastrophizing
102
What is pain catastrophizing?
the tendency to assign a greater threat value to pain, to ruminate on it more, and/or to feel more helpless about the experience
103
During thoracic spinal manipulations, cavitation can occur up to how far from the targeted segment?
up to 4 segments above/below the target segment
104
Describe the performance of the supine upper thoracic thrust manipulation.
- PT stands at the patient's side
- patient is supine, arms crossed with opposite arm on top & elbows aligned
- push through patient's arms to test for shoulder discomfort (use towel roll as needed)
- targeted segment is T1-2
- roll patient toward you and region of hand proximal to 2nd MCP at T2
- apply skin lock by pulling down & deviating wrist ulnarly
- roll patient back and pull down with contact hand to put upper thoracic spine in extension
- apply pressure through patient's arms & make minor adjustments ("crisp" endfeel)
- may have patient bridge to bring upper thoracic spine up into the contact hand
- patient inhales/exhales and thrust is delivered straight down toward the table
105
Describe performance of the seated thoracic/CTJ thrust manipulation.
- patient sits on table with hands clasped behind the neck (as low on cervical spine as possible)
- loop hands through patient's arms and place them over the patient's clasped hands
- don't let their elbows drop forward & don't apply pressure on the cervical spine into flexion
- lean backward to take up slack in superior direction
- thrust is delivered by the legs, upwards towards the ceiling to create a distraction force
106
A history of which condition should preclude the use of the seated upper thoracic / cervicothoracic junction thrust manipulation?
history of anterior shoulder instability
107
Describe the performance of the seated middle thoracic spine thrust manipulation.
- patient sits on table with arms across body, elbows in parallel
- test for shoulder discomfort by applying posterior pressure through the patient's arms (use towel roll as needed)
- place sternum on the patient's middle thoracic spine (can also use towel roll on the lower vertebra of the target segment)
- reach around and grasp patient's elbows
- take up slack by adducting arms, retracting shoulders, and push chest towards the spine
- thrust posteriorly through patient's elbows/arms
- don't try to distract/lift the patient & be careful not to direct thrust through the patient's diaphragm
108
What is the relationship between movement impairments and lower trapezius activity?
movement impairments of the middle to lower thoracic spine can be associated with lower trapezius inhibition
109
Describe the performance of the supine middle to lower thoracic spine thrust manipulation.
- PT stands at the patient's side
- table should be low enough that you can place your body over the patient
- patient is supine, arms crossed with opposite arm on top & elbows aligned
- push through patient's arms to test for shoulder discomfort (use towel roll as needed)
- roll patient over and place the thenar eminence & region of hand proximal to 2nd MCP over the targeted thoracic region, applying skin lock with ulnar deviation of wrist
- make sure you haven't placed your hand too laterally
- roll the patient back over and flex the head & neck down to the targeted segment (better to use pillows or the table than to life the patient passively)
- patient inhales/exhales and thrust is delivered from the chest through the elbows towards the contact hand
110
Describe the performance of the seated thoracolumbar thrust manipulation.
- patient is seated, straddling the end of the treatment table, if possible (stabilizes the pelvis) with arms crossed
- stand on the treatment side
- put pillow between your shoulder (right shoulder if treating right side) and the treatment-side armpit
- reach under patient's arms and place your hand on the posterior aspect of the opposite shoulder or rib cage
- sidebend away a moderate amount using your shoulder while also translating toward you (toward treatment side)
- place your other hand on T12 (hypothenar eminence on the far transverse process) and secure with skin lock
- walk around behind patient, rotating the trunk to the treatment side & apply traction force with the hand on T12
- once behind the patient, thrust with thoracic hand in anterior/superior direction (distraction/rotation force)
111
Pain in what three areas can result from dysfunction at the thoracolumbar junction?
low back, low thoracic, and/or hip pain
112
Describe the performance of the seated 1st rib thrust / non-thrust manipulation
- patient is seated
- stand behind the patient and support the opposite side of treatment
- place webspace of hand on posterior border of 1st rib (roll hand slightly backward to move upper trap out of the way)
- translate T1 to opposite side, which results in sidebending toward treatment side (puts muscles on slack)
- patient inhales/exhales
- during exhale, translate further into barrier and thrust laterally/downward at end-range
113
Describe the performance of the seated 2nd rib thrust / non-thrust manipulation
- patient is seated
- stand behind the patient and support the opposite side of treatment
- place webspace of hand on posterior border of 1st rib (roll hand slightly backward to move upper trap out of the way) & place thumb on the shaft of the 2nd rib
- translate T1 to opposite side, which results in sidebending toward treatment side (puts muscles on slack)
- rotate sightly away from treatment side
- patient inhales/exhales
- during exhale, translate further into barrier and thrust laterally/downward at end-range
114
Describe the performance of the supine rib thrust manipulation
- table should be low enough that you can place your body over the patient
- patient is supine, arms crossed with opposite arm on top & elbows aligned
- push through patient's arms to test for shoulder discomfort (use towel roll as needed)
- roll patient over and place the thenar eminence over the targeted rib medial to the rib angle, applying skin lock with ulnar deviation of wrist
- roll the patient back over and flex the head & neck down to T4-5 (better to use pillows or the table than to life the patient passively)
- patient inhales/exhales and thrust is delivered from the chest through the elbows towards the contact hand / targeted rib
115
What are two effects of spinal manipulation that might make active movement re-education more effective?
- temporarily decreased pain
| - reduced muscle guarding
116
What exercise is recommended to improv or maintain upper/middle thoracic flexion?
the barrel-hug stretch
117
What is the purpose of the barrel-hug stretch exercise? Which spinal manipulation technique is typically performed in conjunction with this exercise?
- purpose is to improve/maintain upper and/or or middle thoracic spine flexion
- typically given immediately following the supine flexion manipulation
118
Describe the performance of the barrel-hug stretch exercise
- patient is asked to imagine that there is a 55-gallon drum (no more, no less) on their lap & they are trying to get their arms around it
- stretch one side of the upper back by rotating slight to the opposite side and placing weight on the opposite hip
- patient should be bent forward slightly
- apex of the curve should be at the area where the greatest flexion or "opening" is desired
119
Describe an exercise to increase thoracic spine extension.
- patient lies supine over a towel or foam roll, supporting head with hands
- patient produces a graded mobilization of the targeted region by extending and flexing over the roll
- mobilization can be enhanced by having the patient inhale while extending
120
Describe the performance of the lower trapezius muscle re-education exercise.
- patient is prone with one arm off the table
- patient flexes arm in the plane of the scapula with thumb toward the ceiling
- facilitate activation of lower trap by tapping on the muscle belly & cueing patient to bring the shoulder blade into retraction/depression
121
If a patient has difficulty firing the lower trapezius, list 4 manual techniques that you might chose to employ?
manipulation targeting the middle or lower region (can facilitate lower trap firing):
1. seated middle thoracic manipulation
2. prone middle or lower thoracic manipulation
3. supine middle or lower thoracic manipulation
4. seated thoracolumbar junction manipulation
122
Describe the performance of the serratus anterior muscle re-education exercise
- patient assumes quadruped or push-up position at wall
| - patient is instructed to protract the scapulae and flex the upper to middle thoracic spine
123
What motion of the thoracic spine does the serratus anterior muscle re-education exercise facilitate?
upper / middle thoracic flexion
124
Describe the performance of the sidelying trunk rotation exercise
- patient lays on their side with hips and knees bent to 90°
- small pillow can be placed under the head
- top hand is either placed on the rib cage or the arm & shoulder are extended into horizontal abduction
- patient is instructed to rotate the trunk, head, and shoulder to the opposite side
- deep breathing and self-mobilization into the restricted ranges is encouraged
125
Describe the performance of the prone trunk lift exercise
- patient lays prone with a pillow placed under the abdomen
- patient lifts chest up & squeezes the shoulder blades together
- start with 10 repetitions of 5-second holds, once per day
- can be progressed using a weighted backpack
