Thoracic Spine and Rib Management Lab

Question 1

Considerations:

Answer 1

mobility
posture

Question 2

Regional interdependence:

Answer 2

Thoracic spine management plays a role in the management of conditions in other regions

> UQ – C-spine, shoulder, elbow

Question 3

Pain reduction:

Answer 3

Sympathetic chain lies anterior to the vertebral bodies

Question 4

Where to start?

Answer 4

Pt education
> Avoiding sustained postures
> Encouraging movement

Gentle vs aggressive

How to progress?

Question 5

Thoracic PA mobilization =

Answer 5

Moving the caudal segment = Aka “gapping” the segment

Fingertips on transverse processes

Using hypothenar eminences

Using thenar eminences

Question 6

Rib mobilization =

Answer 6

Patient prone

Drop arm over the table

Stabilizing hand on the contralateral TP

Mobilizing hand on the rib = Can also use heel of hand

Push ventral, slightly lateral

Follow the breath out with expiration, can hold with deep inspiration to enhance the mobilization

Question 7

Supine 1st Rib mobilization

Answer 7

Patient Supine
> C Spine positioned in R) sidebend and R) rotation

Therapist
> L) hand cradles Occiput and upper C-spine to maintain stability
> R) hand proximal phalanx of index finger (Movement Hand) contacts 1st rib near costotransverse articulation

Procedure
> During exhalation, apply a caudal and anteriorly directed force (35-45o angle)
> Use your body to generate mobilization force

Question 8

Indications for Supine 1st Rib mobilization =

Answer 8

Upper thoracic, lower cervical, upper rib hypomobility, limited deep inspiration

Question 9

1st rib self management =

Answer 9

Place belt or sheet just
lateral to the transverse
process of T1 and anchor toward opposite hip

To emphasize 1st rib caudal mob, side bend away

To emphasize scalene stretch, rotate toward

Question 10

Traditional mobilization grades

Answer 10

BP = beginning point in range of motion to PL = point of limitation
> Grades I-IV

PL to AL = anatomical limit
> Grade V

Question 11

Grade I and II –

Answer 11

small and large amplitude mobilizations at the beginning of the range

> oscillatory
pain modulation

Question 12

Grade III and IV –

Answer 12

large and small amplitude mobilizations up to the end of the range (into the tissue resistance)

> oscillatory or sustained hold
mobility

Question 13

Thoracic manipulation: Predictor variables

Answer 13

Symptoms < 30 days (strongest predictor)

No symptoms distal to shoulder

Looking up does not aggravate symptoms

FABQPA score <12

Diminished upper thoracic spine kyphosis (T3-5)

Cervical extension ROM < 30o (inclinometer)

Question 14

Thoracic manipulation: probability of success

Answer 14

probability of success = 86% when 3/6 variables are present

probability of success = 93% when 4/6 variables are present

Question 15

Contraindications to High Velocity Thrust techniques

Answer 15

Osteoporosis
Pregnancy
Fracture
Active infection in the area
Ligamentous laxity
Malignancy

Question 16

Thoracic HVT =

Answer 16

Supine manip – Thoracic Dog, pistol grip

Prone manip – prone gapping, cross hand thrust

Question 17

Supine “Thoracic DOG” (HVT facet gapping) = upper thoracic

Answer 17

> Patient is supine, arms across chest
For upper thoracic patient clasps hands behind lower neck.

Therapist stabilizes inferior vertebra of motion segment to be mobilized.
> For upper thoracic aim between T1-4

Procedure
Therapist’s body weight applies HVT through patient’s arms and sternum.

Question 18

Supine “Thoracic DOG” (HVT facet gapping) = mid thoracic

Answer 18

> Patient is supine, arms across chest
For middle thoracic patient places arms across chest, grasping shoulders if able

Therapist stabilizes inferior vertebra of motion segment to be mobilized.
> For mid thoracic aim between T5-8

Procedure
Therapist’s body weight applies HVT through patient’s arms and sternum.

Question 19

Supine “Thoracic DOG” (HVT facet gapping)

Answer 19

Hand placement = Transverse processes on thenar eminence and middle phalanx of middle finger
“pistol grip”

Instruct the patient to take a deep breath in and out

Let them expel ALL the air from their lungs

Move with the patient ALL the way to end range

Deliver the thrust at the “bottom” of the breath

Therapist directs force through the patient’s elbows.

Question 20

Thoracic PA Manipulation/HVT (commonly called the crosshand thrust)

Answer 20

patient = prone (arms at side or off edge of bed)

therapist = at side of bed at the level to be treated

> head and shoulders over the midline of the patient

> To manipulate T6-7, place hands on T7

> Right hypothenar eminence over left transverse process of level to be manipulated.

> Left hypothenar eminence over right transverse process of level to be manipulated.

Apply a low amplitude, high velocity PA thrust force through both arms onto the transverse processes at right angles to the plane of the facet joint at end of patient’s exhalation.

Question 21

Thoracic PA Manipulation/HVT (commonly called the crosshand thrust): indications

Answer 21

Treat mid thoracic hypomobility &/or pain

Question 22

Mobilization wedge =

Answer 22

can be used effectively for thoracic spine mobilization and even manipulation.

The draw back is that the therapist can not feel the joints during positioning or treatment.

Some patients like to use them at home in place of a rolled towel for self mobilization.

Question 23

CTJ Mobilization (mid CSP and upper TSP)

Answer 23

Can be performed bilaterally over articular pillar if spinous process is painful

Especially useful in upper thoracic spine

Cranial hand stabilizes the head, caudal hand provides a PA glide

Can have the patient lean fwd – therapist mobs the caudal segment anteriorly while moving the patient into extension

Question 24

MWM (bilateral transverse glide) CSp/TSp with CSp rotation

Answer 24

Patient = sitting

Therapist = stand behind pt

Perform a transverse glide at C7 and T1 spinous processes

> to restore L) rotation: mob C7 to R) and T1 to L)

> Combine this with the patient performing active cervical L) rotation and adding over pressure at end of range.

> Maintain the mobilization until the patient has returned to the neutral position.

Question 25

MWM (bilateral transverse glide) CSp/TSp with CSp rotation: indications

Answer 25

Another method to restore rotation

Most effective in the lower CSP and upper TSP

Question 26

Neuromodulation of pain = what grades?

Answer 26

(grade I-II)

Question 27

Mobility = what grades?

Answer 27

(grade III or IV)

Reassess after every few reps

Continue if pain &/or ROM is improved

Discontinue for the session when significant improvement has been achieved, or when improvement plateaus

> 30 seconds to 2 minutes of mobilization (Kisner & Colby)

> 4-5 minutes of mobilization (Kisner & Colby)

Follow with resisted isometrics or AROM into the newly gained range 5-10 reps immediately afterward, and every 2-3 hours that day, and 3-4 times subsequent days until next therapy session

Question 28

MWM or HVT = what grades?

Answer 28

(grade V)

If using MWM
> 6-10 reps 2-3 sets, re-assess after each set
> Follow up with self MWM at home 6-10

If using HVT
> Prepare the tissue using STM, AROM, active warm up….
> 1-2 reps only on each joint
> Follow up with AROM, resisted isometrics in new range