Unit 2 Week 5 Review

Question 1

What is meant by “intrinsic” muscles of the posterior trunk?

Answer 1

muscles that control spinal movement and position

Superficial and intermediate layers are extrinsic – meaning they originate or insert onto non-spinal structures. They are functionally related to scapular/shoulder movement and ventilation. The Deep layer is composed of “intrinsic” muscles which are separated further into 3 layers – these control spinal movement and position directly (originate and insert on the spine (and ribs)).

Question 1

Which is an important anatomical feature of the nervous system found in the thoracic region?

Answer 1

sympathetic ganglia

Sympathetic chain (autonomic nervous system) is just anterior to rib heads, T4-9 level of the canal is known as the critical zone due to relative narrowness and reduced relative blood supply. T6 is a tension point of the cord where there is minimal motion of the cord in the canal and it can be pulled cranially or caudally through motions above or below this point.

Question 2

What is the neurovascular bundle that passes through the thoracic outlet?

Answer 2

subclavian artery and trunks of the brachial plexus

Borders of the TO: Clavicle, 1st rib and scapula. The neurovascular bundle that passes through the TO is made up of the trunks of the brachial plexus and the Subclavian Artery.

Interscalene interval is bordered by the anterior scalene, first rib and middle scalene.

Question 3

A patient is being seen in an outpatient physical therapy clinic for neck and upper back pain. Observation reveals a forward head and increased thoracic kyphosis. Which of the following MOST accurately describes the length of the muscles?

Answer 3

Pectoralis major too short, lower trapezius too long

Thoracic kyphosis is excessive flexion that will shorten/tighten the flexors of the trunk and shoulders while the extensors become long and weak. This commonly results from prolonged periods of sitting at a desk with poor posture. Thus the correct answer is pectoralis major too short, lower trapezius too long.

Question 4

What is meant by saying a person has a non-structural scoliosis?

Answer 4

secondary cause outside the spine

The cause of the scoliosis is due to some secondary cause outside the spine itself and isn’t a defect of the spine’s structure itself– for example a leg length discrepancy, muscle guarding or spasm in the trunk, habitual asymmetrical postures (behavior).

Question 5

What is the usual pain referral pattern of thoracic facet joint dysfunction?

Answer 5

localized to the immediate area

Usually the pain is localized to the immediate area, about one half a level above, to 2-3 levels below.

Question 6

The stages of thoracic spondylosis follow the same progression as the stages of cervical spondylosis.

Answer 6

True

Question 7

What red flags should you screen for before performing thoracic grade 5 thrust manipulation as an intervention? (select all that apply)

Answer 7

cancer
inflammatory or systemic disease
myelopathy
structural instability

Question 8

A patient presents with upper trapezius pain and both fatigue and swelling of upper extremity when reaching overhead. Which of the following ADDITIONAL findings from the exam would suggest that these reports are due to thoracic outlet syndrome as opposed to subacromial shoulder impingement or cervical radiculopathy?

Answer 8

Temperature changes in hand when sustained overhead activity performed

Since TOS does affect arterial and possibly venous (except scalene which does not affect venous) temperature changes with overhead activity is critical for diagnosis of TOS. Special tests for impingement and cervical spine are allowed to be negative despite having a condition as the sensitivity is not perfect. Generally speaking paresthesia at the T1-T2 and T8 are often from TOS.

Question 9

Which of the following exercises SHOULD NOT (NOT) be performed for a patient who has costoclavicular syndrome and symptom reproduction with the costoclavicular test?

**Ok to assume there are no extra (rudimentary) cervical ribs

Answer 9

Postural instruction to maintain scapular retraction and depression with sitting and shoulder exercises

Scapular retraction and depression would perpetuate problem. Retraction alone is ok. 90/90 stretch is not a great stretch for anything but with that being said costoclavicular syndrome is not a precaution to do the stretch. If trying to stretch pec minor there are much better stretches but again this is not incorrect unless of course patient had anterior shoulder instability. 1st rib mobs are needed most likely and absence of a rudimentary rib does not change this as we don’t mob extra rib.

Question 10

A patient presents with a physician based diagnosis of thoracic outlet syndrome. During the exam ALL of the special tests for TOS are positive as is the ulnar biased ULTT, however, radiographs are negative for a rudimentary rib and patient does not report arm fatigue or swelling with hand overhead. Which of the following interventions is MOST likely going to be effective?

Answer 10

Scalene stretch (with rib stabilization), 1st rib caudal glide, pec minor stretch, nerve glides ulnar bias

This is more of an exercise for taking tests. Most certainly we all could probably (with a complete exam in front of us) justify a majority of the choices with each answer. However, I am asking which would be most effective for TOS thus which choices can be DIRECTLY linked to TOS and patient presentation. In the clinic I would absolutely do an upper thoracic thrust manip, however, I wouldn’t choose this over a direct TOS intervention if answering a test question asking specifically about TOS.

Question 11

A patient presents with upper trapezius pain and non specific pain referred into right arm and forearm (posterior and medial). Denies temperature changes and swelling. States arm fatigues when sustained overhead activity is performed, however no pain with arm overhead activity that is of short duration. Reports feeling worse when doing back exercises at gym. No pain with pec deck or chest flies. Reports ipsilateral neck and upper trapezius pain as well. Pec minor measurement is 4cm bilaterally. Scalene flexibility is symmetrical (WNL) and comparable with arms at side and when performed with arms passively elevated to 90 degrees. Rib mobility test shows restricted caudal glide on the right. Has been working on improved posture but does not seem to help. Radiographs are unremarkable for rudimentary rib and no evidence of cervical DDD or DJD. MRI shows a disc bulge at C5-6. PMH: Clavicle fracture, HTN

Which of the following two test would be best to perform to rule out cervical radiculopathy?

What do you think is the most likely diagnosis for this patient? (not part of the multiple choice, just a question to reflect on)

Answer 11

ULTT A

The ULTT A has a high Sn so a negative test is likely to be truly negative or help rule it out. Cervical spine radiculopathy is by far most common source of arm pain etc, Given symptoms with back exercises and hypomobile rib it suggests costoclavicular likely an issue (posture didn’t help and may be worsening if too much retraction and depression). Scalene and pec minor flexibility are seemingly normal and pec deck exercises don’t provocate pain. This is definitely a grey question that may require more info. A prior clavicle fracture further suggests a potential costoclavicular syndrome.

Question 12

In all age groups, __________________________of the vertebral bodies are the most common spinal injuries detected on radiographs.

Answer 12

anterior compression fracture

Question 13

Refer to the figure. What vertebrae has undergone complete destruction?

Answer 13

T 1 vertebra

Question 14

The radiologic evaluation of scoliosis uses the erect side-bending views to assess:

Answer 14

Structural versus nonstructural curves

Question 15

Refer to the figure. What imaging modality and view is this?

Answer 15

Sagittal MRI

Question 16

Your patient completes a Patient Specific Functional Scale (PSFS) Outcome measure at initial evaluation and 4 weeks later at his re-evaluation. Here are your results

Activity Initial evaluation Re-evaluation
1. Turning to the left check blindspot while driving 5 7
2. Reaching both arms overhead 4 5
3. Carrying groceries such as a 15 lb bag of dog food 4 7
Totals 13/3 = 4.3 17/3 = 5.7

Based on what you know about this tests metrics including the minimal detectable change, you determine the following comparing the patient’s initial scores to the scores at re-evaluation:

Answer 16

For the single items, the patient demonstrates meaningful change only for carrying groceries

For the PSFS

MDC for average score = 2 points

MDC for single activity score = 3 points

So, the patient demonstrates meaningful change by achieving greater than the MDC of 2 points for the average score at re-evaluation.

In terms of single items, the patient meets the MDC of 3 points only for item #3, but not for items #1 and 2

Question 17

A 60-year-old man presents with mid-thoracic spine pain that radiates into epigastric region. Pain is not influenced by a specific time of day; however, pain is decreased with slouched sitting. Patient reports a recent diagnosis of diabetes mellitus and recently saw internist due to malaise and a loss of appetite with weight loss. The internist ordered radiographs which showed degenerative disc disease at the thoracic spine. Socially, the patient is a smoker who has high daily alcohol consumption. Thoracic active range of motion is grossly limited with extension, rotation, and lateral flexion. Tenderness is present at thoracic paraspinals bilaterally from T4–T9. What is the MOST likely source of the patient’s pain and how should the physical therapist proceed?

Answer 17

Refer the patient back to his internist as he presents with a risk for pancreatic cancer

Pancreatic cancer is associated with advanced age, male gender, smoking and alcohol consumption, diabetes mellitus, epigastric pain, as well as pain that is improved with slouched or still sitting. Unexplained weight loss and a loss of appetite would further the suspicion for pancreatic cancer.