Thoracic Flashcards
How many articulations does EACH vertebrae have? What are they called?
- Eight
- 4 Facet Joints (zygapophyseal joints)
- 2 Costovertebral joints
- 2 Costotransverse joints
Thoracic Motion: Flexion/Extension
Flexion:
- Inferior articular process slides on the inferior articular process by sliding up/forward and open
- Tensions the interspinous and supraspinous ligaments
Extension:
- Inferior articular process slides on the inferior articular process by sliding down/back and closing
- Tension placed on the anterior longitudional ligament
Thoracic Motion: Rotation
- 35-45 degrees relative to the pelvis
Thoracic Motion: Side bending
- 45 degrees; Not much motion due to the rib cage
- SB to the right:
– R Inferior slide down on the R superior
– L inferior slides up on the L superior
Muscles of the Thoracic Region
Deep: Transversospinal mm (Rotator brevic, rotator longus, Multifidus, Semispinalsis thoracis)
Superficial: Erector Spinae (Iliocostalis thoracis, Longissimus thoracis, spinalis thoracis)
More Superficial: Latissimus Dorsi and Lower Trapezius
Most superficial: Rhomboids
Effects of kyphosis on muscle and joints
- Increased kyphosis creates a greater external moment arm for thoracic flexion torque
- This results in greater activity of thoracic extensors (no change in internal moment arm) to maintain upright position
- Results in increased work and tone of muscles
Effects of kyphosis on rib expansion
- Increased kyphosis causes ribs rotate anteriorly and depress
- Leads to increased difficulty for costal expansion and thus deep breathing
Innervation of Thoracic Spine
- Facet innervated by the medial branch of the dorsal ramus.
- Costotransverse joints and intercostal mm innervated by the Anterior branch of ventral rami
- Note: Proximity to the paravertebral sympathetic ganglia and the sympathetic chain to the thoracic spine articulations (RSD)
Thoracic Facet Joint Referral Patterns
You are very much less likely to have ____ related symptoms in the thoracic than compared to cervical or lumbar
dermatome
Thoracic Evaluation: Red and Yellow Falgs for Thoracic Pain
Referral Pain from Visceral structures:
* Cardiac conditions (upper thoracic/shoulder)
* Stomach/esophagus (mid thoracic and inf. scapula)
* Liver/Gall bladder/PANCREAS (especially right side) (mid thoracic and inf. scapula)
* Kidney (lower thoracic, lower parts of ribs)
* Appendix (lower thoracic)
Vertebral Fractures
Herpes Zoster
Start to think this if they can’t pinpoint a spot.
Medical Screening - Purpose
Must determine if there is a “mechanical nature to the pain”
Medical Screening Questions
Do you have any pain associated with foods you eat?
Change in stool appearance?
Unexplained weight loss?
Night pain?
Hx of trauma?
Chest pain?
SOB?
Pain associated with increased activity?
Able to find comfortable position?
Hx of Osteoperosis?
Hx of Steroid use?
Hx of Cancer?
BOLDED NEED TO BE ASKED.
Last 3 referencing more for Fracture
Medical Screening Palpation
Abdominal Quadrant Screen
Referal Pain
The pancreas refers as…
Lower thoracic pain and thoracolumbar region
The pancreas refers as…
Lower thoracic pain and thoracolumbar region
Differential diagnosis: Vertebral Fx
- Most common at lower thoracic spine (T7 and below)
- Risk factors:
– >50 y/o
– Osteoperosis
– Steroid use
– Hx of CA - Radiograph assessment: Often see anterior wedge compression fractures or burst fractures
- Present with midline thoracic pain. Will not respond to interventions. Should be referred.
Differential Dx: Herpes Zoster
- Symptoms will wrap around the rib cage (like a dermatomal pattern)
- Describe burning, numbness and tingling
- May be accompanied by fatigue, fever, headache
- ASSESS INTEGUMENT! Pt’s may not know they have rash as it can be on there back!
- Symptoms will NOT have a mechanical nature to them
Scoliosis - Functional vs Structural
- Functional: Due to increase muscle tone or imbalance causing structural curve or leg length discrepancy
- Structural: Ideopathic, C or S curve. Shows up on side of convexity (rounded side
Names of Scoliosis based on location
How is scoliosis confirmed?
Plain film radiographs
Clinical Presentation - Scoliosis
What is a measure for scoliosis
Cobb Method of measuring angle
Scheuermann’s Kyphosis
- Idiopathic increased wedging of the anterior vertebral bodies of the thoracic spine; Spinous proccesses line up but major kyphotic curve
- Cracks in vertebral end plate
- Confirmed by plain film radiographs
- Associated with postural and mobility deficits
- KEY: Education about posture and MAINTAIN thoracic extension ROM!
- We cannot improve the kyphosis but try to minimize the effects of the kyphosis
Typically identified in 10-18 year olds.
Similar to scoliosis in the fact it cannot be changed.
Acute Mobility Deficits
Subjectively
* “Woke up with pain” or can recall a specific incident
* Acute pain, more irritable and intense
* Local and referred pain (2 scenarios)
– Around rib cage – OR –
– “feels like a knife through my chest”
* Pain with deep breathing
Objective
* AROM and mobility testing: Symptom response to AROM and with PA mobility of thoracic region (increased pain)
* Palpation: increased tone
High irritability
Often described as a “Facet Joint Syndrome” or “Costotransverse-costovertebral syndrome”
Often pain with breathing (costovertebral joint). Very guarded.
Chronic Mobility Deficits
Subjectively
* More persistent/chronic
* Tends to be lower irritability, lower intensity of pain. Takes more to come on (less irritable)
* Aching pain in thoracic with occasional bouts of sharp pain
Objectively: Joint, soft tissue or neurodynamic mobility
- ROM:
– Limited extension and/or rotation ROM
– End range pain into motions - Low irritability with motion
* Joint mobility assessment: Hypomobility of thoracic and ribs with PA
* Soft tissue mobility assessment: Increased tone and/or tenderness in long “superficial” mm - Symptomatic
* Neurodynamic mobility assessment: may have reproduction of symptoms with slump testing
* Motor assessment: altered motor coordination of “deep” mm – poor activation, strength or endurance
* OFTEN : Associated with neck and shoulder pain
Lower Irritability
Thoracic Interventions Options
- Education
- Posture
- Joint Mobility: Mobilizations
– PA Thrust and Non-thrust mobilizations
– Thrust mobilizations - Soft tissue mobility: I-STM or M-STM
- Neurodynamic: Gliding or Tensioning
- Ther Ex
– Self-Mobilizations into extension
– Self-Stretching
– Neurodynamic activities
– Motor Coordination/Strengthening
Bright Red Stool means..
Lower GI bleed
Darker red stool means…
Upper GI bleed
Ribbon like stool means…
Tumor
When might a stomach/ulcer referral pattern occur?
Aggravated after eating certain foods
If someone does not fit the pattern for thoracic pain, what should you do?
REFER
