Thoracic Spine and Rib Cage Flashcards
What is STarT Back Screening Tool used for?
Determine risk of pain becoming chronic
T/F: STarT Back Screening Tool is validated for thoracic back pain
False, it’s been extensively researched for LBP
T/F: body mass index is associated with higher risk of thoracic spine pain in men/women
False
Risk factors for thoracic back pain
Male, >50 y/o, tall, frequent/sustained fwd trunk bending (>2hrs/day), unable to change position @ work, driving >4hrs/day
Vertebrae lined up with root (medial triangle) of the spine of the scapula
T3 spinous process
Vertebrae lined up with inferior angle of the scapula (IAS)
T7 spinous process
NOTE: one study found T8, can vary based on the individual
Rule of 3’s (spinous process vs transverse process)
T1-T3 = same
T4-T6 = 1/2 vertebral height below
T7-T9 = 1 full below
T10-T12 = same
Geelhoed’s rule vs Rule of 3’s?
Geelhoed’s rule > Rule of 3’s
Geelhoed’s rule
Spinous processes of ALL t-vertebrae are located in TRANSVERSE plane w/ transverse processes of adjacent caudal vertebra
True ribs
Ribs 1-7
False ribs
Ribs 8-12
Floating ribs
Ribs 11-12
Joint where rib and vertebral body connect
Costovertebral joint (has sup/inf demi-facets)
Joint where rib and transverse process connect
Costotransverse joint
Typical ribs
Ribs 3-9
Atypical ribs
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
T/F: ribs have an attachment to the thoracic disk
True, typical ribs (3-9) have a crest that attaches
Movement of upper vs lower ribs during inspiration (movement and in what plane)
Upper = rises (flexes) in sagittal plane
Lower = widen (abduct) in frontal plane
Ligaments/structures limiting: spinal flexion
- Ligamentum nuchae
- Interspinous and supraspinous ligaments
- Ligamentum flava
- Posterior longitudinal ligament
Ligaments/structures limiting: spinal extension
- Anterior longitudinal ligament
- Anterior annulus fibrosus
Ligaments/structures limiting: spinal side-bending
- Intertransverse ligaments
- Contralateral annulus fibrosus
- Facet joint capsules
Ligaments reinforcing costovertebral joint
Radiate & capsular ligaments
Ligaments reinforcing costrotransverse joint
Costrotransverse & superior constotransverse ligaments
Traps assist with coupling motion of the scapula including _____
Upward rotation and posterior tipping (during elevation of humerus)
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
Serratus Anterior assists with coupling motion of the scapula including _____
Protraction and Upward rotation and posterior tipping (during elevation of humerus)
3 attachments of origin of the pec major
Clavicle, sternum, costal cartilages of ribs 1-6
Portion of pec major that can help with GH flexion
Clavicular portion (works in conjunction with coracobrachialis and anterior deltoid)
Pec minor attaches to which ribs?
Ribs 3-5th
Shortening or hypertonicity of pec minor can cause what motion(s) of the scapula?
Protraction & anterior tipping
What cervical segments do the anterior, middle, and posterior scalenes attach?
Ant: C3-C6
Middle: C2-C7
Post: C4-C6
Scalene(s) that attach to the 1st rib
Anterior and middle
Scalene(s) that attach to the 2nd rib
Posterior
3 portions of the diaphragm
Sternal (back of xiphoid process), costal (internal coastal cartilages lower 6 ribs), lumbar (first 2-3 lumbar vertebrae)
Do the thoracic spinal nerves exit above or below its respective segment?
Below
Which muscles contribute to transverseospinalis
- Rotatores
- Multifidus
- Semispinalis
Thoracic posterior rami: Medial branch of UPPER 6 segments innervates
Semispinalis and multifidus muscles, skin of the upper back
Thoracic posterior rami: Medial branch of LOWER 6 segments innervates
Transversospinalis & longissimus
NOTE: eventually becomes cutaneous
Thoracic posterior rami medial branch has ascending/descending branches to which structures?
Facet joints (above & below)
Thoracic posterior rami lateral branch innervates
Longissimus and iliocostalis muscles and constotransverse joints
Thoracic anterior rami become which nerves?
Intercostal nerves
12th anterior rami forms which nerve?
Subcostal nerve
Which nerves innervate the abs?
Terminal branches of the anterior rami of spinal nerves (aka intercostals) T7-T11 & subcostal nerve (T12)
T/F: The superior part of the first intercostal (T1) forms part of the brachial plexus?
True
Which nerve originates from the 2nd intercostal nerve?
Intercostobrachial nerve (lateral cutaneous branch)
Responsible for: sensation to floor of axilla
Sinuvertebral nerve (aka Luschka nerve) is sensation for
Supplies dura, disck, medial aspect of facet joints, and PLL
What is the “critical zone” of the t-spine and importance
T4-T9; narrowest part of spinal canal
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.
T/F: There are several studies reporting the symptom referral pattern for thoracic disc pathology
False, there are no studies
Motion in the thoracic sagittal plane is what
Flexion/extension
NOTE: Increased ROM caudally
Thoracic forward flexion causes superior vertebra to move _____?
Translates fwd (transverse plane), rotates fwd (sagittal plane)
NOTE: rib forwardly rotates (hypothesis)
Thoracic extension causes superior vertebra to move _____?
Posterior translation (transverse plane), rotates posteriorly (sagittal plane)
NOTE: rib rotates posteriorly (hypothesis)
Thoracic side-bending causes superior vertebra to move _____?
Small ipsilateral lateral translation (horizontal plane)
Right side-bending causes which motion of superior vertebra inferior facets (R & L)?
R inf facet glides: inferolaterally
L inf facet: glides superomedially
Does thoracic rotation cause contralat or ipsilat coupling during side-bending?
Neither, lack of agreement in studies
Which part of the thoracic spine rotates the most?
Upper segments, significantly reduced in lower
NOTE: one study found middle was most (T4-T8)
Upper ribs (1-7) move in which motion during inspiration?
Pump-handle (anterior ribs rise)
Lower ribs (8-10) move in which motion during inspiration?
Bucket handle (ribs move laterally and superiorly)
Floating ribs (11-12) move in which motion during inspiration?
Caliper motion (posterior and lateral during inspiration)
Which part of the thoracic spinal cord segment is reported to be a tension point?
T6 region
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)
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)
A unilat thoracic spine flexion impairment could be evident during combined motion testing involving:
Flexion, contralateral rotation, contralateral side-bending
A unilat thoracic spine extension impairment could be evident during combined motion testing involving:
Extension, ipsilateral rotation, ipsilateral side-bending
T/F: Thoracic spine limitations is associated with decreased quality of life and increased risk of falling.
True
Cause of 1st rib elevation
Exact mechanism unknown, plausible by soft tissue tension as opposed to jt subluxation
Primary thoracic spine pain makes up what % of spinal pain and more common in which sex?
15%, more common in women
Common visceral conditions that cause thoracic pain
MI, dissecting thoracic AA, peptic ulcer, acute cholecystitis, renal colic, and acute pyelonephritis
Majority of visceral organs are innervated by what?
Thoracic spinal nerves
Condition with symptoms: Chest pain with radiation into t-spine, sudden onset, unrelenting, unrelieved by position changes
Dissecting thoracic aneurysm
Symptoms of peptic ulcer
“Boring” type pain in epigastric region, triggered or relieved by eating
Symptoms of cholecystitis
Right upper quadrant and infrascapular pain, moderate fever, N&V, occur 1-2hrs post ingestion of heavy meal
Murphy’s test
For cholecystitis
- Inhale & hold a deep breath while palpating the right subcostal area (under ribs)
Referral of pain to what region with pacreatitis
TL junction
Referral of pain to what region with pyelonephritis and renal stones
Costovertebral angle or flank area
- Typically accompanied by fever, N&V, renal colic
What is renal colic?
Flank pain accompanied by lower abdominal pain and spreds into the labia or testicles
What risk factor has the highest probability of thoracic spine cancer?
Hx of cancer
Cancers that commonly spread to the thoracic spine
Breast, lung, colon
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
What is the key physical exam finding of ankylosing spondylitis
Limited chest expansion (<2.5cm, NORM = 5cm)
Ankylosing spondylitis risks:
- Sex
- Age
- Gene involvement
- Males (3:1)
- 15-40 y/o
- HLA-B27 (gene test has high false +)
Hallmark sign in cases of spinal infection
Fever
Risk factors for osteoporosis
- Caucasian
- Hx of smoking
- Early menopause
- Thin
- Sedentary lifestyle
- Steroid tx
- Excessive consumption of caffeine or alcohol
Effectiveness of vertebroplasty
No significant difference in pain, function, disability
What imaging is recommended where cancer or infection of the thoracic spine region is suspected
MRI and bone scan
RED flag items for cancer
- Personal/family hx of cancer
- Significant unexplained weight loss
- Unrelenting night pain
- Hx smoking
- > 50 y/o
RED flag items for infection
- Fever
- Chills
- Night sweats
- Recent infection (i.e. pneumonia)
- IV therapy or drug use
- Recent surgery
- RED flags for visceral or GI disorders
- Bowel/bladder dysfunction
- Abdominal pain
- Reflux
- Excessive NSAID use
- Alcohol abuse
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
Association between abnormal posture (using CT) and pain
No association
Example of Symptom Modification Procedure (SMP)
Using tape on thoracic back pain patient, symptoms eased can guide tx
Hyperkyphosis of thoracic spine is said to be a Cobb angle of what?
> 50° on lateral XR
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
Validity of Cobb angle vs dual inclinometer
Requires further study
Reliability for quantification of forward bending and R/L side-bending using inclinometers
Moderate reliability
Minimal detectable change for thoracic rotation ROM
6°
T/F: Increases in cervical ROM within a tx session predicts an increase in cervical ROM between tx sessions
True
What test if negative effectively rules OUT cervical radiculopathy?
ULTT A - median nerve
Reliability of spinal segmental motion palpation?
Poor to fair reliability
Best test to assess 1st rib dysfunction
Cervical rotation lateral flexion test
+ = limited side-bending
Best tx approach for low-medium risk of prolonged thoracic pain
Exercise & manual
Best tx approach for high risk of prolonged thoracic pain
Education, cognitive therapy, exercise interventions to reduce maladaptive movement (breathing etc)
Tietze syndrome
Unilat pain in specific upper rib PLUS swelling at costosternal region
Costochondritis
Bilat pain involving multiple ribs and NO swelling
Tietze’s syndrome typically affects which ribs
2nd-3rd ribs
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
Young female athlete, lower chest wall pain, clicking and sharp
Slipping rib syndrome
Test for slipping rib syndrome
Hooking maneuver (hook fingers under lower ribs), + = pain and possible click
NOTE: unknown diagnostic accuracy
Rehab for older adults w/ thoracic pain
Exercise programs: spinal extensor musculature strengthening, upper/lower quarter stretching, postural awareness, balance, t-spine mobs
When dealing with rib pain, which manual therapy tx should come first: thoracic or rib
Typically thoracic as ribs tend to be highly irritable
Osteoporosis t-score
-2.5 or more SD below reference standard
Osteopenia t-score
-1 to -2.5 or more SD below reference standard
You can manipulate a single segment
Manips likely produce forces to the REGION as opposed to specific segment
T/F: manips in the opposite or pain-free direction often leads to a decrease in pain and restoration of movement
True
Movement impairments of the middle and lower thoracic spine can be associated with which muscle inhibition?
Lower traps
What is the TLS test?
Timed loaded standing test for osteoporosis, holding 2# dumbbells at 90° flexion, assesses extensor endurance
When should patient perform exercises when in conjunction with manual therapy?
Immediately afterwards working into movement previously restricted or painful ROM
Purpose of barrel-hug stretch
Improve or maintain thoracic flexion in upper/middle t-spine
Evidence for use of t-spine manips in treating shoulder pain
Conflicting evidence
Evidence for use of t-spine manips in treating cervical pain
Positive results, no technique is superior to another
T/F Majority of primary t-spine pain is specific?
False, primarily non-specific in pathobiological diagnosis
Chest wall pain patients can benefit from what type of treatment
Targeted rehab involving exercise and manual therapy
Which ribs can be implicated in posterior shoulder girdle and supraclavicular pain
1st-2nd ribs
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
Pain around T6 and also pain with deep inhalation.. Think what visceral pathology to rule out
Cholecystitis
