Thoracic Spine and Ribs

Question 1

8a. Rule of Threes

Answer 1

• state T1-T3; T12 SP is in the same plane as TPs and vertbebral bodies
• state T4-T6; T11 SP is in a plane halfway b/n its TP and the TP of vertbra one level below
• state T7-T9; T10 SP is in plane of vertbral one level below
• states rule utilized to identify superficial anatomy to localize thoracic spine level being palpated

Question 2

8b. seated and prone eval for thoracic spine Type 1 SD, documentation, and TONGO

Answer 2

• Type 1 SD= TONGO (type, one, neutral, group (of vertebra), opposite (SB, R))
• Prone:
  
  • head in neutral
  • palpate TP, “load and spring” evaluating for ease/restrictions (PTPs)
  • state this is performed to evaluate R/L rt
  • evaluate pt in prone (flexion-fetal position) and prone (extension-on elbows)
  • state there is no change of end feels in F or E => Type 1 SD
  • state translatory glide can be used to evaluate SB at segmental level and that ease of translation from L=> R =SB_L and translaton from R=>L = SB_R
  • states noted in objective as T #-# N S_R/LR_R/L
• _​Seated
  
  • pt seated, evaluate TP T1-T12 for eases/hard end feels
  • state that assess in active flexion and extension
  • Assess in PASSIVE SB, dr. place flexed elbow on pt shoulder applying caudad P, while monitoring ipsi- TP
  • Assess PASSIVE Rt, dr. place flexed elbow on ant. shoulder w/ posterior F, while monitoring ipsi-TP w/ “load and spring”/anterior F
  • state able to assess N SD by noting ease of motion relative to SB and Rt as opposite
  • state noted in objective as T#-# N S_R/LR_R/L

Question 3

8c. seated and prone evaluation for thoracic spine TYPE 2 SD, documentation

Answer 3

• Type 2 SD: Non-Neutral (F/E), usually single vertebral unit, SB and Rt are to SAME side
• Prone:
  
  • “load and spring” TPs of T1-T12 noting ease/hard end feels (PTPs)
  • state performed to evaluate R/L Rt.
  • evaluate pt in F (cat back/fetal) and E (sphinx)
  • state if segment improves or rotational end feel becomes more symmetric in FLEXION/more restricted to Ext. => F SD
  • state if segment improves or becomes more symmetrical in EXT./more restricted to F => E SD
  • states translatory glide can be used to evaluate SB: L=>R = SB L and R=>L = SB R
  • state noted in objective as T# F/E S_R/LR_R/L
• _​Seated:
  
  • assess TP T1-T12
  • state assess during active F and E
  • Passive SB: dr. elbow pushes down on pt shoulder, while monitoring SB on ipsi-TP
  • Passive Rt: dr. apply posterior P on ant. shoulder w. eblow while monitoring ipsi TP w “load and spring”/anterior F
  • ask pt to slump forward/hunchback to assess segment in F noting ease/PTPs w/ “load and spring” state more symmetry/ease in F => F II SD
  • ask pt to puff chest out to assess segment in E noting ease/PTPs w/ “load and spring” state more symmetry/ease in E => E II SD
  • noted in objective as T # F/E S_R/LR_R/L

Question 4

9a. eval of upper ribs (1-2) for SD, documentation

Answer 4

• states Rib 1 50% bucket handle and pump handle
• state Rib 2 primarily pump handle
• pt supine
• place thumbs posteriorly on ribs 1
• index finger on supraclavicular fossa anterior to the trapezius
• monitor movement through respiration for bucket handle
• dr. place index finger posterior to clavicle over superior anterior aspect of rib 1 + middle and ring finger placed over ant. Rib 2
• monitor through respiration for pump handle
• note that if bilateral ribs 1-2 move into inhalation equally and L rib delays moving into exhalation =>L. Ribs 1-2 Inhalation group pump handle SD
• inferior rib treated for inhalation SD
• note that if Rib 1-2 on L delays moving into inhalation and R side is normal L. Ribs 1-2 Exhalation group, pump handle SD
• superior rib in exhalation SD treated
  *

Question 5

9b. eval of middle ribs (3-6) for SD, documentation

Answer 5

• ribs have mixed pump and bucket handle respiratory motion w/ more inferior ribs more bucket handle rib 6 (50% pump 50% bucket)
• pt. supine
• examiner uses thumb/ulnar aspect to palpate ribs 3-6 bilaterally costochondral articulations for pump handle motion and at midaxillary line w/ fingertips for bucket handle
• monitor through respiration
• state that while monitoring at costochondral junction if b/l ribs 3-6 move into inhalation equally, and L side delays moving into exhalation position => L ribs 3-6 groups inhalation pump handle SD
• state that while monitoring midaxillary b/l ribs 3-6 move into inhalation equally and L side delays moving into exhalation => L ribs 3-6 inhalation group bucket handle SD
• state most inferior rib targeted for inhalation SD
• state while monitoring costochondral junction, ribs 3-6 on L delays moving into inhalation, normal on R side, and b/l move into exhalation easily => L ribs 3-6 exhalation group pump handle SD
• state while monitoring midaxillary ribs 3-6 on L side delay moving into inhalation, move into inhalation normally on R side, and b/l move into exhalation easily => L ribs 3-6 exhalation group bucket handle SD
• state superior rib targeted for exhalation SD Tx

Question 6

9c. eval of lower ribs 7-10 SD and documentation

Answer 6

• ribs have primarily bucket handle motion but may have pump handle SD
• pt supine, ulnar/hypothenar aspect ribs 7-10 b/l at their costochondral articulations for pump handle and will contact midaxillary line w/ fingertips for bucket handle
• monitor through respiration
• monitor costochondral junction b/l ribs 7-10 movement into inhalation and L side delays moving into exhalation => L ribs 7-10 inhalation group pump handle SD
• monitor midaxillary line b/l ribs 7-10, move into inhalation equally L side of ribs delays moving into exhalation => L ribs 7-10 inhalation bucket handle SD
• bottom rib treated for inhalation SD
• monitor costochondral jt b/l ribs 7-10 move into exhalation equally, L side delays moving into inhalation, R side easily moves into inhalation => L ribs 7-10 exhalation pump handle SD
• monitor midaxillary line for b/l ribs 7-10 move into exhalation equally L side delays moving into inhalation and R side easily moves into inhalation => L ribs 7-10 exhalation bucket handle SD
• superior rib treated for exhalation SD

Question 7

9d. eval for floater ribs 11-12 and documentation

Answer 7

• ribs 11-12 have caliper motion
• pt prone
• use thumb to palpate posterior aspect and index+middle finger to palpate anterolateral aspect of ribs 11-12 b/l
• monitor through respiration
• b/l ribs 11-12 move into inhalation equally, L side delays moving into exhalation, R side easily moves into exhalation => L ribs 11-12 inhalation group caliper SD
• inferior rib treated for inhalation SD
• b/l ribs 11-12 move into exhalation equally, L side delays moving into inhalation, R side easily moves into inhalation => L ribs 11-12 exhalation group caliper SD
• top rib treated for exhalation SD
• states restriction of motion influences by quadratus lumborum