Thoracic Ax and Rx Flashcards
SQs
- Previous History of TB- TB can manifest itself years later as thoracic spine pain- combine with other red flag questions eg fatigue, night sweats etc
- Rash (TB)
- Deep breath + Cough/sneeze blood (Lung Ca + other Ca signs)
- Eating or drinking (tumour?)
- Lying down, positional changes does not change pain (Ca, Dissecting Thoracic Aneurysm)
- Night symptoms (Ca)
- Osteoporosis- especially in patients with increased kyphosis.
- Bone density test esp. female post-menopause (wedge # risk)
- Menstrual history – anorexia (OP risk, increasing risk of wedge/stress #), ammenorrhea
- Loss of height esp. female post-menopause (wedge # risk)
- Family history (OP, Ca)
- Young adults/teenagers – sudden growth spurts (further investigation if not had already)
- Exertion &/or SOBOE
- Blood tests (inflammatory disorders)
- Drug history – immuno-suppressants, steroids
- Severe stiffness esp. proximal joints (A.S, RA)
- Recent fractures, minimal trauma
- 24 hour pattern: morning stiffness < 30 mins (spondylosis), > 30 mins (A.S)
Observation
- postural alignment noting any asymmetry- scoliosis/kyphosis/flattened thoracic region, deviations of the SPs, shoulder levels, shoulder girdle, scapula position, GH joint position, level of the pelvis, limb position
- Muscle bulk and tone (compare sides, hand dominance)
- Soft tissues (Skin colour and quality, Swelling, scars)
- Gait (Trendelenburg gait, short leg gait)
- Maladaptive movement patterns/postures - fear avoidance, bracing, guarding
Functional assessment
- examples of what pts present with eg. Reaching for seatbelt (restricted T spine rotn/ext), looking up, transferring from sit to stand, picking something up from the floor, getting on and off the bed, Lying on shoulder/ back, Dressing/putting on bra, lifting one or both arms overhead, and any other movements that aggravate or relieve symptoms.
- While the patient performs these movements watch for any deviations, compensations, or discrepancies between sides.
- Use as * to reassess post intervention
AROM
what position are we going to Ax in? sitting to fix pelvis, neutral L.spine. Possible standing if symptoms only experienced in that position
What movements are we going to examine? flexion, extension have hand behind neck elbows forwards; side flexion hand side of neck elbows facing outwards; rotation arms crossed
What are we looking for? Quality, range (Flex 0-45deg, Extension, Rotation 0-40deg), pain on moevement, end feel (firm), =/- overpressure
What else can we do to explore the possible ranges of motion? Sustained, repeated, combined +/- deep breath
Why might we look at shoulder elevation? Associated T. spine ext & side flexn
PPIVM
Palpate with pad of index/middle finger. Looking at movement or lack of movement at different levels-judge- end feel, pain, range.
C7 – T4:
- Flexn/exten palpates the undersurface of the interspinous space
- Lateral flexion feel for movement between two adjacent spinous processes
- Rotation movement of upper spinous process in relation to distal one
T4 – T11:
- Flexn/exten Sitting with hands clasped around neck palpate with finger on far side of interspinous space to feel adjacent vertebrae
- Lateral flexion finger in interspinous space. Push away from you
- Rotation Pt Side lying hand on shoulder. Pad of middle finger facing upwards, feel spinous process push into it.
PAIVM
- Central PA on SP to help with Thx Ext by opening facet joints
- Unilateral PA on facet joint - SF/Rot
- Tranverse glides on SP
- Unilateral PA on CTJ
- Unilateral PA on rib angles
Looking for pain and referred pain, stiffness or hypermobility.
Muscle tests
Muscle strength:
Scapular stabilisers: Lower and Middle Traps, Rhomboids, Serratus Anterior
Prone: resist in shoulder elevation (lower traps), thumbs down (rhomboids), thumbs up (middle traps)
Supine: resist protraction (serratus anterior)
Muscle length:
- Latissimus Dorsi
- Pec major and minor
- Trapezius
- Levator Scapulae
- Scalene
Palpation
Palpate temperature, muscle tone, muscle bulk, tissue mobility, and bony alignment. Palpate spinous processes and transverse processes for any tenderness or hypomobility. Any pain provocation or hyperalgesia
Rule of 3’s
- T1-T3 - sp level with tp
- T4-T6 - tp approx ½ level above sp
- T7-T9 - tp approx 1 level above sp
- T10 - tp 1 level above sp
- T11- tp ½ level above sp
- T12 - sp & tp level with each other
Ribs:
- Rib 2 - inferior and lateral to T1 SP
- Rib angles medial to medial border scapula
- Rib 7,8 above and below inferior angle of scapula respectively
- Rib ll - sl inferior, very lateral to T12 SP
- Rib 12 - very inferior, sl. lateral to T12 SP
Special Tests
Adson’s Manoever:
- Tests: Thoracic Outlet Syndrome
- Positive sign: No pulse (vascular), paraesthesia (neural)
- Procedure: Locate radial pulse, Rotate head towards, Patient ext head, Therapist ext & lat rot shoulder with forearm supination, Deep breath in (elevate 1st rib causing greater compression)
Reverse Adson’s test
- Tests: Thoracic Outlet Syndrome
- Positive sign: No pulse (vascular), paraesthesia (neural)
- Procedure: As Adson’s but with Cx Rotn the opposite direction
Modified Costoclavicular Manoeuvre (Military Brace position):
- Tests: Stresses costoclavicular interval entrapping artery, vein & brachial plexus
- Positive sign: obliteration of radial pulse
- Procedure: exaggerated Scap retraction and depression, Palpated radial pulse, Stresses costoclavicular interval entrapping artery, vein & brachial plexus
Wrights Test/Hyperabduction Manoeuvre:
- Tests: Thoracic Outlet Syndrome
- Positive sign: Monitor symptoms & changes to radial (Implicates vessels & plexus as stretches around coracoid process pectoralis minor impingement)
- Procedure: Head forwards, Passive GH abd & LR to 90° , Elbow to no more than 45° flexion. Hold x 1 minute, Monitor symptoms & changes to radial (Implicates vessels & plexus as stretches around coracoid process pectoralis minor impingement), Repeat in EOR Abd (Implicates costoclavicular interval)
Roos Stress Test - EAST (Elevated Arm Stress Test):
- Tests: Stresses all 3 intervals of Thoracic Outlet Syndrome:- Scalene, Costoclavicular & Axillary
- Positive Sign: dropping of arms +/- cyanosis (venous compression); pallor with arm elevated and reactive hyperaemia when arm lowered (arterial); paraesthesia in fingers and forearm (neural)
- Procedure: Head in neutral, Arms in GH abd & LR to 90°, Elbow flexed to 90°, Flex & extend fingers x 3 minutes.
Autonomic Slump Test:
- Tests: impingement of dura and spinal cord or nerve roots
- Positive Sign: reproduction of neural symptoms
- Procedure: Slump test with Cx extn. Can add thoracic rotn to sensitise
What is thoracic outlet syndrome
Describes compression of the neurovascular structures as they exit through the thoracic outlet
State borders of the thoracic outlet
Anterior border = anterior scalene
Posterior border = middle scalene
Inferior border = 1st rib
What are the types of Thoracic Outlet Syndrome (TOS)
ATOS/VTOS - Vascular compression (arterial or venous)
NTOS - Neurological compression
Compression of these structures can occur as a result of:
Congenital abnormalities, trauma to the first rib or clavicle, and structural changes in the subclavian muscle or the costocoracoid ligament, hypertrophy or shortened scalenes, trapezius, lev. Scapulae or pectoral muscles.
Clinical presentation of TOS
- Pain, paresthesia, numbness, and/or weakness, fatigue, a feeling of heaviness in the arm and hand
- Blotchy or discoloured skin with/out change in temperature
- Aggs - arm is abducted overhead and externally rotated with the head rotated to the same or the opposite side, i.e. overhead throwing, serving a tennis ball, painting a ceiling, driving, or typing
- Eases: shaking arm and hand brings back sensation
Thoracic back pain is more likely to be caused by:
serious underlying pathology than neck or low back pain.
