Thoracic spine - 1 Flashcards
what is TOS
compression or a tension event that compromises the neurovascular structures in the cervicoaxillary canal
what is the cervicoaxillary canal
Cervicoaxillary canal is bounded anteriorly by the clavicle, posteriorly by the scapula, and medially by the first rib.
what is Vascular TOS
compression of the brachial plexus and subclavian artery or vein
is it easy to treat vscular TOS
no, hard to treat vascular TOS conservatively
Arterial [ATOS] rare or common
rare
what are the signs and symtoms of Arterial [ATOS]
- Secondary to repetitive activities leading to claudication
- Pain, numbness in non-radicular pattern. Associated fatigue with activity that is relieved at rest
- Cramping in the hand with use
- Skin cool to touch; increased sensitivity to cold; Reynaud’s phenomenon
- Pale discoloration
what are the tests for o Arterial [ATOS]
- Allen’s test
what is the purpose of allens test
used to rule out distal arterial occlusion
what is the procedure of allens test
Position:
Arms should be on the table and the PT should be across from them
Procedure
Find the pulse in the radial and ulnar artery – either sides of the wrist
Occlude both hand and have PT open and close hand (hand turns white)
Open up on side – hand should return to red, do for the other side
how do we confirm Arterial [ATOS]
Confirmed through Doppler ultrasound and angiography
what are the symptoms of Venous [VTOS]
- Deep pain in chest, shoulder, & entire upper extremity
- Distal limb edema with paresthesia in hand & fingers; skin tightness; fatigue; cyanosis discoloration
- Venous distension and heaviness of extremity may be observed after activity – should diminish with rest. If not, then possible venous thrombosis - refer to MD
how do we confirm VTOS
lab tests
is VTOS rare or common
rare 3-5%
what is NTOS due to
compression of the brachial plexus
what is True neuro NTOS
symptoms + 2 provaction test
EAST test is always +
how do we confrim NTOS
neurophysiological testing (EMG, NCV)
what is Disputed neuro TOS
there is no confirmation from standard diagnostic testing
- Neurophysiological testing; negative vascular tests; negative imaging.
- Based on symptoms below & at least 2 (+) provocation tests. Cyriax Release test often (+).
what is NTOS often associated with
previous trauma
what are the general symptoms seen with TOS
Pain, paresthesia, numbness, and/or weakness
Cold intolerance (Reynaud phenomenon) due to Sympathetic over activity, not ischemia.
Decreased finger dexterity possible.
Upper Plexus Irritation (C5,6,7) NTOS
Occipital headache.
Pain and paresthesia in anterior chest, periscapular area, radial aspect of arm to dorsum of hand and index finger.
Provoked by head movements or lifting.
Lower Plexus Irritation (C8,T1) NTOS
Pain & paresthesia in suprascapular area, posterior neck, medial side of arm & forearm and ulnar digits of the hand.
Provoked by activities that depress the shoulders (lifting, carrying a brief case)
what are the two presentation of neuro TOS
compressor and releasor
compressor presentation
- Symptoms during the day, especially with overhead activities. Increase in tension or compression of the brachial plexus.
- Compression at costoclavicular &/or pectoralis minor spaces
- Usually no night pain unless sleep with arm overhead
- Occupation often involves working with arms overhead
- Since compression is intermittent, the blood supply returns when arm is lowered & symptoms are relieved
- Often unilateral
does releaser NNTOS have a good prognosis
yes
what are the signs and sym of releaser NTOS
- Brachial plexus under constant tension due to poor posture, weight of the arms during the day.
o Usually sedentary occupation; long periods of sitting doing repetitive activities (keyboard).
o Poor posture, especially shoulder girdle mal-alignment.
o May have large, heavy arms.
* Release phenomenon revealed during examination.
- In bed, the tension is released; blood flow returns; axonal flow returns; patient feels paresthesia.
o Symptoms at night, awakened with paresthesia.
what is the postive test for releaser NTOS
Cyriax Release Test
what test do you for NTOS
- Roos Test (EAST Test)
- Adson’s – Scalene triangle
- Costoclavicular (Military Brace) –
- Wright’s (Hyperabduction) –
- Upper Limb Tension (ULTT) –
how do you the cyriax release test
pt seated with arms flexed 90 deg
supported on the table
wrist and forearm in neutral
therapist support arms to create scapular elevation
hold this position for 2-3 minn
what is a positive cyriax release test
recreation of the patient parathesis
(this is unloading the plexus and allowing blood flow return)
what is the procedure fro EAST (roos test)
pt sitting with arms 90 abd, ER, and head position in neutral
therapist can manually depress shoulders while patient open and closes fist
what is a positive EAST (roos test)
unable to hold elvated arm position due to pain, para, and heaviness (fatigue)
(this is loading the brachial plexus through the TOS container)
what does a positive TOS tell us
that the patients problem is more TOS the cervogenic
what is the procedure for adsons test
assess the radial pulse
deep inhalation and hold
extend and rot that neck towards the tested side and extend your shoulder
hold this position for 1 min
do we like the adsons test
no because we are looking for something neuro related by looking at vasculature
there needs to be a big change in for it to be relevant
what does a positive adsons test look like
the absence of a radial pulse or the onset of symtoms
what is the procedure for wrights test
assess the radial pulse with the pt arm at there side
passivly abd shoulder 90 and horizontally abd
hold this position for 1 min
what is a positive wright test
chnage in the pulse or a chnage in the patients sym
what is wright test testing
the retropectorial minor space
how do we do a ULTT - median nerve
arm - 90 abd, arm ER, forearm supination, thumb and index and wrist into ext
pull the elb out into felxion
what approach is best for NTOS
conservative approach
what is the sensitivity of a cluster of two TOS test
.90
what is the basis fro the conservative treatment for TOS
based on anatomy posture and biomechanics
- there is no standard of treatment
- comprehensive indivdual approach
what are the signs and symptoms of a rib or thoracic segment displacement
- Pain is often local to the area of involvement
- Radicular pain: Follows the intercostal space around the trunk to one side.
- Not as common, the viscera and the ribs protecting
what can be wrong with the ribs
they can be elvated or depressed
what ribs do we normally focus on
4-8
what are the signs and symptoms of rib dysfunction
Has MOI
o Painful onset – sharp pain
o Sudden change in status – fine to painful quickly
Patient has difficulty taking a deep breath without increasing local pain.
o Increases with inhalation.
Pain lingers – cannot get to the source of pain
what can be wrong with the segments in the thoracic region
flexed bilat
ext bilat
rotated L or R
what are signs and sym of segmental issue with the thoracic region
Pain may be less localized
o Until the segment is palpated and mobilized during examination.
Gradual (insidious) onset
o No specific trauma
Breathing not affected
Postural/repeated loading
o Stiff, sore, persistent pain
what is some of the dermatone testing you can do in the thoracic region
T4, 5
T7,8
T10, 11
T12
T4, 5 local
nipple region in adult males
T7,8
in the epigastric area
below the xphoid process
T10, 11
umbillicus in the lower abdominal areas
T12
abdominal areas near the the level of the ASIS
what is the additional reflex testing we do for
superficial abd relfex
UMN
LMN DTR
what is the superficial abd relfex used of for
T7-T12
how do we perfrom the superficial abd reflex test
we stroke the four quadrents of the abdominal wall in a diagonal fashion from around the belly button
what is normal response for the superficial abd reflex test
the skin and belly button should twitch in the direction of the stroke
thoracic and UMN signs
should be absent
thoracic and LMN sigsn
bilaterally different
what are the steps in the examination of a thoracic
AROM - neck, shoulder, Tspine (PROM)
MARM
spring testing
positional testing
what is MARM
manuel assessment of the respiratory muscles
hands on the ribs - looking at how the rib cage contracts and relaxes with breathing
what are we spring testing
the ribs - collective and indivdual
segments
what does if feel like if a segment is rotated right
Right TP more shallow and left TP more deep
what are the interventions for a misaligned segment - rot
mid thoracic thrust
PA thrust
what does the mid thoracic thrust look like
o Prone, piston grip over effected segment, side lying, roll over and apply A-P
Knuckle – TP, shallow side
- Turn hand 45-degrees
Finger gun space – SP (galaxy dot)
o Pt cross arms, tuck chin, and curls up
o Take up the slack and apply a thrust
what other movement diagram do we use mid thoracic thrust
restricted flexion
what is the procedure for a Costo-transverse Thrust - hand position
Approximate thumb and index finger
* Intersection between thumb and pointer – costo-transverse joint (green dot)
* Tip of index – over a SP
* Thenar eminence over rib
o Descending angle of hand (angle of rib)
what is the procedure for a Costo-transverse Thrust - thrust part
o Pt rolls to side to face PT, then rolls on back
Places hands around their shoulders
o PT SB pt away from them at the thoracic level
o Pt curls up and rotates on top of PT hand
o PT takes up the slack and then applies a thrust
o Side: want to work directly on the skin
