Thoracic Spine and Rib Cage Flashcards
1
Q
What is STarT Back Screening Tool used for?
A
Determine risk of pain becoming chronic
2
Q
T/F: STarT Back Screening Tool is validated for thoracic back pain
A
False, it’s been extensively researched for LBP
3
Q
T/F: body mass index is associated with higher risk of thoracic spine pain in men/women
A
False
4
Q
Risk factors for thoracic back pain
A
Male, >50 y/o, tall, frequent/sustained fwd trunk bending (>2hrs/day), unable to change position @ work, driving >4hrs/day
5
Q
Vertebrae lined up with root (medial triangle) of the spine of the scapula
A
T3 spinous process
6
Q
Vertebrae lined up with inferior angle of the scapula (IAS)
A
T7 spinous process
NOTE: one study found T8, can vary based on the individual
7
Q
Rule of 3’s (spinous process vs transverse process)
A
T1-T3 = same
T4-T6 = 1/2 vertebral height below
T7-T9 = 1 full below
T10-T12 = same
8
Q
Geelhoed’s rule vs Rule of 3’s?
A
Geelhoed’s rule > Rule of 3’s
9
Q
Geelhoed’s rule
A
Spinous processes of ALL t-vertebrae are located in TRANSVERSE plane w/ transverse processes of adjacent caudal vertebra
10
Q
True ribs
A
Ribs 1-7
11
Q
False ribs
A
Ribs 8-12
12
Q
Floating ribs
A
Ribs 11-12
13
Q
Joint where rib and vertebral body connect
A
Costovertebral joint (has sup/inf demi-facets)
14
Q
Joint where rib and transverse process connect
A
Costotransverse joint
15
Q
Typical ribs
A
Ribs 3-9
16
Q
Atypical ribs
A
Ribs 1, 10-12th
NOTE: rib 2 attaches to T1-T2 but considered atypical because fo the attachment to the junction of the manubrium/sternum
17
Q
T/F: ribs have an attachment to the thoracic disk
A
True, typical ribs (3-9) have a crest that attaches
18
Q
Movement of upper vs lower ribs during inspiration (movement and in what plane)
A
Upper = rises (flexes) in sagittal plane
Lower = widen (abduct) in frontal plane
19
Q
Ligaments/structures limiting: spinal flexion
A
- Ligamentum nuchae
- Interspinous and supraspinous ligaments
- Ligamentum flava
- Posterior longitudinal ligament
20
Q
Ligaments/structures limiting: spinal extension
A
- Anterior longitudinal ligament
- Anterior annulus fibrosus
21
Q
Ligaments/structures limiting: spinal side-bending
A
- Intertransverse ligaments
- Contralateral annulus fibrosus
- Facet joint capsules
22
Q
Ligaments reinforcing costovertebral joint
A
Radiate & capsular ligaments
23
Q
Ligaments reinforcing costrotransverse joint
A
Costrotransverse & superior constotransverse ligaments
24
Q
Traps assist with coupling motion of the scapula including _____
A
Upward rotation and posterior tipping (during elevation of humerus)
25
Spinal extensor weakness/reduced muscular density has been associated with?
Thoracic hyperkyphosis, osteoporosis, decreased quality of life, and increased risk of falling in older adults
26
Serratus Anterior assists with coupling motion of the scapula including _____
Protraction and Upward rotation and posterior tipping (during elevation of humerus)
27
3 attachments of origin of the pec major
Clavicle, sternum, costal cartilages of ribs 1-6
28
Portion of pec major that can help with GH flexion
Clavicular portion (works in conjunction with coracobrachialis and anterior deltoid)
29
Pec minor attaches to which ribs?
Ribs 3-5th
30
Shortening or hypertonicity of pec minor can cause what motion(s) of the scapula?
Protraction & anterior tipping
31
What cervical segments do the anterior, middle, and posterior scalenes attach?
Ant: C3-C6
Middle: C2-C7
Post: C4-C6
32
Scalene(s) that attach to the 1st rib
Anterior and middle
33
Scalene(s) that attach to the 2nd rib
Posterior
34
3 portions of the diaphragm
Sternal (back of xiphoid process), costal (internal coastal cartilages lower 6 ribs), lumbar (first 2-3 lumbar vertebrae)
35
Do the thoracic spinal nerves exit above or below its respective segment?
Below
35
Which muscles contribute to transverseospinalis
1. Rotatores
2. Multifidus
3. Semispinalis
36
Thoracic posterior rami: Medial branch of UPPER 6 segments innervates
Semispinalis and multifidus muscles, skin of the upper back
37
Thoracic posterior rami: Medial branch of LOWER 6 segments innervates
Transversospinalis & longissimus
NOTE: eventually becomes cutaneous
37
Thoracic posterior rami medial branch has ascending/descending branches to which structures?
Facet joints (above & below)
38
Thoracic posterior rami lateral branch innervates
Longissimus and iliocostalis muscles and constotransverse joints
39
Thoracic anterior rami become which nerves?
Intercostal nerves
40
12th anterior rami forms which nerve?
Subcostal nerve
41
Which nerves innervate the abs?
Terminal branches of the anterior rami of spinal nerves (aka intercostals) T7-T11 & subcostal nerve (T12)
42
T/F: The superior part of the first intercostal (T1) forms part of the brachial plexus?
True
43
Which nerve originates from the 2nd intercostal nerve?
Intercostobrachial nerve (lateral cutaneous branch)
Responsible for: sensation to floor of axilla
44
Sinuvertebral nerve (aka Luschka nerve) is sensation for
Supplies dura, disck, medial aspect of facet joints, and PLL
45
What is the "critical zone" of the t-spine and importance
T4-T9; narrowest part of spinal canal
46
T4 syndrome
Paresthesias (can be "stocking glove"), numbness, neck and/or UE pains associated with/without HA and upper back stiffness.
In addition, no hard neurological signs are present.
47
T/F: There are several studies reporting the symptom referral pattern for thoracic disc pathology
False, there are no studies
48
Motion in the thoracic sagittal plane is what
Flexion/extension
NOTE: Increased ROM caudally
49
Thoracic forward flexion causes superior vertebra to move _____?
Translates fwd (transverse plane), rotates fwd (sagittal plane)
NOTE: rib forwardly rotates (hypothesis)
50
Thoracic extension causes superior vertebra to move _____?
Posterior translation (transverse plane), rotates posteriorly (sagittal plane)
NOTE: rib rotates posteriorly (hypothesis)
51
Thoracic side-bending causes superior vertebra to move _____?
Small ipsilateral lateral translation (horizontal plane)
52
Right side-bending causes which motion of superior vertebra inferior facets (R & L)?
R inf facet glides: inferolaterally
L inf facet: glides superomedially
53
Does thoracic rotation cause contralat or ipsilat coupling during side-bending?
Neither, lack of agreement in studies
54
Which part of the thoracic spine rotates the most?
Upper segments, significantly reduced in lower
NOTE: one study found middle was most (T4-T8)
55
Upper ribs (1-7) move in which motion during inspiration?
Pump-handle (anterior ribs rise)
56
Lower ribs (8-10) move in which motion during inspiration?
Bucket handle (ribs move laterally and superiorly)
57
Floating ribs (11-12) move in which motion during inspiration?
Caliper motion (posterior and lateral during inspiration)
58
Which part of the thoracic spinal cord segment is reported to be a tension point?
T6 region
59
Flexion movement impairments:
- Inability to do what?
- Common region
- Etiology
- Inability of the spinal unit to rotate forward in the sagittal plane
- Upper to middle
- Rear-impact collision (whiplash-type)
60
Extension movement impairments:
- Inability to do what?
- Common region
- Etiology
- Inability of the spinal unit to rotate backward in the sagittal plane
- Upper t-spine/CT junction, can be lower
- Age related changes (wedging, DDD)
61
A unilat thoracic spine flexion impairment could be evident during combined motion testing involving:
Flexion, contralateral rotation, contralateral side-bending
62
A unilat thoracic spine extension impairment could be evident during combined motion testing involving:
Extension, ipsilateral rotation, ipsilateral side-bending
63
T/F: Thoracic spine limitations is associated with decreased quality of life and increased risk of falling.
True
64
Cause of 1st rib elevation
Exact mechanism unknown, plausible by soft tissue tension as opposed to jt subluxation
65
Primary thoracic spine pain makes up what % of spinal pain and more common in which sex?
15%, more common in women
66
Common visceral conditions that cause thoracic pain
MI, dissecting thoracic AA, peptic ulcer, acute cholecystitis, renal colic, and acute pyelonephritis
67
Majority of visceral organs are innervated by what?
Thoracic spinal nerves
68
Condition with symptoms: Chest pain with radiation into t-spine, sudden onset, unrelenting, unrelieved by position changes
Dissecting thoracic aneurysm
69
Symptoms of peptic ulcer
"Boring" type pain in epigastric region, triggered or relieved by eating
70
Symptoms of cholecystitis
Right upper quadrant and infrascapular pain, moderate fever, N&V, occur 1-2hrs post ingestion of heavy meal
71
Murphy's test
For cholecystitis
- Inhale & hold a deep breath while palpating the right subcostal area (under ribs)
72
Referral of pain to what region with pacreatitis
TL junction
73
Referral of pain to what region with pyelonephritis and renal stones
Costovertebral angle or flank area
- Typically accompanied by fever, N&V, renal colic
74
What is renal colic?
Flank pain accompanied by lower abdominal pain and spreds into the labia or testicles
75
What risk factor has the highest probability of thoracic spine cancer?
Hx of cancer
76
Cancers that commonly spread to the thoracic spine
Breast, lung, colon
77
Predictor variables for ankylosing spondylitis
- AM stiffness >30 mins
- Less back pain with exercise but not rest
- Waking up at night (SECOND half only)
- Alternating buttock pain
2 + = Sen 0.7/Spec 0.81
3+ = Sen 0.33/Spec 0.94
78
What is the key physical exam finding of ankylosing spondylitis
Limited chest expansion (<2.5cm, NORM = 5cm)
79
Ankylosing spondylitis risks:
- Sex
- Age
- Gene involvement
- Males (3:1)
- 15-40 y/o
- HLA-B27 (gene test has high false +)
80
Hallmark sign in cases of spinal infection
Fever
81
Risk factors for osteoporosis
- Caucasian
- Hx of smoking
- Early menopause
- Thin
- Sedentary lifestyle
- Steroid tx
- Excessive consumption of caffeine or alcohol
82
Effectiveness of vertebroplasty
No significant difference in pain, function, disability
83
What imaging is recommended where cancer or infection of the thoracic spine region is suspected
MRI and bone scan
84
RED flag items for cancer
- Personal/family hx of cancer
- Significant unexplained weight loss
- Unrelenting night pain
- Hx smoking
- >50 y/o
85
RED flag items for infection
- Fever
- Chills
- Night sweats
- Recent infection (i.e. pneumonia)
- IV therapy or drug use
- Recent surgery
86
- RED flags for visceral or GI disorders
- Bowel/bladder dysfunction
- Abdominal pain
- Reflux
- Excessive NSAID use
- Alcohol abuse
87
RED flags for cardiopulmonary issues
- Chest pain or SOB w/ physical exertion
- Personal/family hx of cardiovascular disease
- Thoracic/chest wall pain that is throbbing or pulsatile
88
Association between abnormal posture (using CT) and pain
No association
89
Example of Symptom Modification Procedure (SMP)
Using tape on thoracic back pain patient, symptoms eased can guide tx
90
Hyperkyphosis of thoracic spine is said to be a Cobb angle of what?
>50° on lateral XR
91
Locations of inclinometers for assessing thoracic kyphosis
T1-T2 and T12-L1
NOTE: Perform 3x, average numbers, sum of 2 angles is gross measure of kyphosis
92
Validity of Cobb angle vs dual inclinometer
Requires further study
93
Reliability for quantification of forward bending and R/L side-bending using inclinometers
Moderate reliability
94
Minimal detectable change for thoracic rotation ROM
6°
95
T/F: Increases in cervical ROM within a tx session predicts an increase in cervical ROM between tx sessions
True
96
What test if negative effectively rules OUT cervical radiculopathy?
ULTT A - median nerve
97
Reliability of spinal segmental motion palpation?
Poor to fair reliability
98
Best test to assess 1st rib dysfunction
Cervical rotation lateral flexion test
+ = limited side-bending
99
Best tx approach for low-medium risk of prolonged thoracic pain
Exercise & manual
100
Best tx approach for high risk of prolonged thoracic pain
Education, cognitive therapy, exercise interventions to reduce maladaptive movement (breathing etc)
101
Tietze syndrome
Unilat pain in specific upper rib PLUS swelling at costosternal region
102
Costochondritis
Bilat pain involving multiple ribs and NO swelling
103
Tietze's syndrome typically affects which ribs
2nd-3rd ribs
104
Slipping rib syndrome:
- location of pain
- age
Pain in lower chest wall, most common in children and young adults
Cause: irritation of intercostal nerve, 9th to 10th rib
105
Young female athlete, lower chest wall pain, clicking and sharp
Slipping rib syndrome
106
Test for slipping rib syndrome
Hooking maneuver (hook fingers under lower ribs), + = pain and possible click
NOTE: unknown diagnostic accuracy
107
Rehab for older adults w/ thoracic pain
Exercise programs: spinal extensor musculature strengthening, upper/lower quarter stretching, postural awareness, balance, t-spine mobs
108
When dealing with rib pain, which manual therapy tx should come first: thoracic or rib
Typically thoracic as ribs tend to be highly irritable
109
Osteoporosis t-score
-2.5 or more SD below reference standard
110
Osteopenia t-score
-1 to -2.5 or more SD below reference standard
111
You can manipulate a single segment
Manips likely produce forces to the REGION as opposed to specific segment
112
T/F: manips in the opposite or pain-free direction often leads to a decrease in pain and restoration of movement
True
113
Movement impairments of the middle and lower thoracic spine can be associated with which muscle inhibition?
Lower traps
114
What is the TLS test?
Timed loaded standing test for osteoporosis, holding 2# dumbbells at 90° flexion, assesses extensor endurance
115
When should patient perform exercises when in conjunction with manual therapy?
Immediately afterwards working into movement previously restricted or painful ROM
116
Purpose of barrel-hug stretch
Improve or maintain thoracic flexion in upper/middle t-spine
117
Evidence for use of t-spine manips in treating shoulder pain
Conflicting evidence
118
Evidence for use of t-spine manips in treating cervical pain
Positive results, no technique is superior to another
119
T/F Majority of primary t-spine pain is specific?
False, primarily non-specific in pathobiological diagnosis
120
Chest wall pain patients can benefit from what type of treatment
Targeted rehab involving exercise and manual therapy
121
Which ribs can be implicated in posterior shoulder girdle and supraclavicular pain
1st-2nd ribs
122
Which functional outcome measure is best for thoracic dysfunction?
Unknown, research validated outcome measures are lacking
Can use: upper t-spine (NDI), lower t-spine (Mod oswestry), PSFS, NPRS, TLS test
123
Pain around T6 and also pain with deep inhalation.. Think what visceral pathology to rule out
Cholecystitis
124
