Thoracic Spine AOPT Questions
Case Scenario 4 A 35-year-old female patient presents via direct access to physical therapy with a primary complaint of right antero-lateral shoulder pain with concurrent interscapular pain. The symptoms began approximately 4 weeks ago following completing a local "boot camp" fitness class. The patient is a marketing representative for a local pharmaceutical company that involves desk-related work approximately 6 hours a day with intermittent driving. Her shoulder symptoms increase with performing push-ups, fastening her brassiere, sleeping on her right side, and reaching overhead. Her interscapular pain is worse with sitting or driving longer than 60 minutes. Her symptoms improve when she avoids these positions and when using nonsteroidal anti-inflammatories and ice as needed. She has no co-morbid conditions. She reports her shoulder numeric rating of pain scale is 1/10 on average and 4/10 with aggravating activities. She reports her interscapular pain as 3/10 and intermittent. She denies any previous history of this condition, but has had two bouts of neck pain in the past 5 years. She had physical therapy for her neck episodes, which was successful. Pertinent physical examination items include the following: • increased thoracic kyphosis; • rounded shoulder, protracted scapulae bilaterally; • active right thoracic rotation restricted x 25% with reproduction of the interscapular pain; • lower cervical hypomobility from C5-7; • thoracic hypomobility with spring testing (posterior to anterior glides) centrally from T4-8; • hypomobility of the posterior glenohumeral joint; • active range of motion of the cervical spine is full and painfree with overpressure applied; • active right shoulder flexion to 120° prior to onset of pain; • active right shoulder abduction to 110° prior to onset of pain; • passive range of motion of the right shoulder is full and painfree except with minor pain at end range of flexion; • resistive testing remarkable for 4+/5 bilateral shoulder abduction and external rotation; and • special tests: (+) Hawkins-Kennedy, (+) Neers, (-) Active Compression, (-) Biceps Load II. 1. Given the current patient presentation, which of the following is the most likely diagnosis? a. referred thoracic spine pain. b. referred rib pain. c. referred pain from the lower cervical spine. d. subacromial impingement syndrome.
The best answer is d. subacromial impingement syndrome . Based on the history, data including pain with overhead activities, location of symptoms, mechanism of injury, and lack of referral from adjacent regions, the most plausible diagnosis is primary impingement. Although the patient presents with impairments of the cervical and thoracic spine in addition to interscapular pain, her primary symptoms are not reproduced with clinical examination of these regions. Therefore answers "a" through "c" are incorrect.
You decide to refer the patient back for diagnostic imaging and she receives a radiograph and bone scan that were read as negative for a bone stress injury. The patient returns to physical therapy and your key examination findings are as follows: • increased thoracic kyphosis; • active right thoracic rotation restricted x 25% with reproduction of the anterior pain; • reduced excursion of the right middle ribs during inspiration; • thoracic hypomobility with spring testing centrally from T4-6; • rib hypomobility with spring posterior to anterior testing over the right fifth rib; and • severe pain and hypomobility with spring testing over the right fifth rib at the costosternal junction. 2. Which of the following is the best manual therapy intervention for this patient? a. non-thrust manipulation to the anterior aspect of rib 5. b. non-thrust manipulation to the posterior aspect of rib 5. c. thrust manipulation to the posterior aspect of rib 5. d. thrust manipulation to the T4-6 region.
The best answer is d. thrust manipulation to the T4-6 region . Despite the lack of evidence to support this notion, manipulation of the thoracic spine in the presence of a rib dysfunction is recommended first.7 Often this can relieve the pain from the rib dysfunction likely because the thoracic techniques have a regional effect and the rib may get mobilized during the techniques. Answer a is incorrect because there is significant pain with spring testing in an anterior to posterior direction over the costosternal junction and direct mobilization of this area has the potential to exacerbate the patient's symptoms. Mobilization of the anterior aspect of the rib could be used later in the course of treatment if there is less pain when mobilizing this area. Answers "c" and "d" are considerations and could be used after first addressing the thoracic spine hypomobility.
3. Given this patient's presentation and diagnosis, what should you recommend as the initial treatment intervention? a. cognitive intervention. b. therapeutic exercise. c. manual therapy. d. electrotherapy.
The correct answer is a. cognitive intervention. The patient will require and benefit from an initial intensive cognitive intervention concerning the nature of her disorder, pain neurophysiology, accurate information and reassurance about her imaging findings, and how fear, worry, and anxiety could heighten her overall sensitivity. This intervention should be "front loaded" with the majority of the education and discussion taking place in the initial and perhaps second consultations. Ongoing discussion and reinforcement of these concepts at each follow-up session would likely also be useful. Once the patient understands the nature of her condition, she is likely to be more accepting of and better tolerate exercise and manual therapy targeting the patient's movement impairments. For example, manual interventions directed towards the movement impairments involving the T3-8 region could provide a temporary reduction in symptoms and increase in mobility. Subsequently, the patient could be taught active mobility and postural awareness exercises. However, the therapist should carefully consider, in collaboration with the patient, whether the patient is open to and would tolerate these interventions and not experience an increase in symptoms. Patients with central sensitization can have impaired descending modulation.71 Descending modulation is one of the mechanisms that normally leads to inhibition or modulation of nociceptive input and is a purported mechanism of the pain reduction associated with manual therapy and exercise.99 If descending modulation is impaired, manual therapy and other inputs that normally lead to a reduction in symptom can be either ineffective or lead to an increase in symptoms.
Case Scenario 1 A 35-year-old male presents with a chief complaint of middle thoracic spine pain for the past 3 weeks. The patient is employed as an information technology specialist and spends 8 to 9 hours per day on his laptop computer. He reports the symptoms began after a particularly stressful period during which he was working up to 12 hours per day. He reports that the pain is located in the center of the middle thoracic region and does not radiate from this area. The patient reports that his symptoms increase with movements of his middle back including bending backwards and rotating to either side. His symptoms are relieved with stretching, exercise, and lying down. The patient reports that his general health is good with a family history of diabetes. Besides intermittent neck stiffness associated with prolonged sitting, this is his first episode of thoracic spine pain. The patient is active recreationally and enjoys golf, tennis, and running. He reports that he is not very concerned about his condition and thinks it will get better with time and stretching. Although his job is stressful, he enjoys it, generally sleeps well (about 7-8 hours per night), and is happily married with 2 young children. Current average pain on the Numeric Pain Rating Scale is 6/10, his Oswestry Disability Index is 24%, and his STarT Back Screening Tool score indicates a low risk category. 1. Given this patient's history, what is the prognosis for a full and rapid recovery? a. excellent. b. good. c. fair. d. poor.
The correct answer is a. excellent. This patient presents with acute, mechanically patterned thoracic spine pain. There are no indications of underlying serious or specific pathology. He is generally healthy, has no major psychosocial factors, and has a stable job and family life. His STarT Back Tool score indicates a low risk for poor recovery. Based on these findings, we can reasonably predict that this patient will recover rapidly with reassurance and appropriate management. One potential barrier to his recovery is that his job is stressful and involves prolonged sitting. However, this functional problem can be easily addressed with appropriate ergonomic advice and activity modification.
3. Based on the history and examination findings, what is this patient's primary movement related impairment? a. thoracic spine mobility deficits. b. thoracic spine loading impairments. c. thoracic spine motor control impairments. d. thoracic spine postural impairments.
The correct answer is a. thoracic spine mobility deficits. The patient also presents with reduced thoracic range of motion into extension and stiffness with mobility testing indicating a thoracic spine mobility impairment. There are no indications from the history or clinical examination that the loading, motor control, or mobility impairments are involved to a large extent.
3. Assuming the patient had a thoracic spine compression fracture, based on current evidence, what is the best initial treatment option for this patient? a. bed rest until the fracture heals. b. conservative care including physical therapy. c. kyphoplasty procedure. d. vertebroplasty procedure.
The correct answer is b. conservative care including physical therapy. Randomized trials have shown that medium to long-term outcomes are identical with vertebroplasty versus conservative management.68 Due to the decreased costs and risks associated with more conservative care including physical therapy, this should be the first treatment option for this patient; therefore, answers "c," kyphoplasty, and "d," vertebroplasty, are incorrect. If initial conservative care fails to reduce the patient's symptoms and they remain severe and disabling, then percutaneous procedures such as vertebroplasty are a viable treatment option. Answer "a" is incorrect as bed rest would lead to deterioration in overall health from the effects of inactivity and immobilization.
2. Given the patient's current area of symptoms, aggravating factors, and chief complaints what is the most likely diagnosis? a. mechanical rib cage dysfunction. b. mechanical thoracic spine pain. c. thoracic facet joint inflammation. d. thoracic spine disk herniation.
The correct answer is b. mechanical thoracic spine pain . While the source of the patient's pain could be either the thoracic disk or facet joint, it is difficult from the history and physical examination to determine the pathoanatomical cause of the pain. Furthermore even with diagnostic imaging, perhaps displaying a herniated thoracic disk, it would be difficult to determine that the imaging findings are the source of the patient's symptoms. This is due to the frequent finding of thoracic disk herniation in an asymptomatic population. Rib cage dysfunction is unlikely due to the location of the patient's symptoms in the middle thoracic region. Patients with rib dysfunction often report pain located further laterally in the region of the costovertebral or costotransverse joints. Patients with rib dysfunction also often report pain with deep inspiration or expiration. The patient presents with hypomobility, and pain in the T6-9 region with posterior to anterior spring testing, and restricted and painful active thoracic extension and bilateral rotation.
As the physical therapist sets the patient up for the supine middle thoracic thrust manipulation procedure, the patient complains of posterior shoulder pain bilaterally when anterior-posterior pressure was applied through the elbows. The physical therapist repositions and places a towel roll between the sternum and elbows; however, the bilateral posterior shoulder symptoms remain. 3. Based on this information, what is the most appropriate action for the physical therapist? a. discontinue the manual therapy to the thoracic spine. b. perform a prone middle thoracic thrust procedure. c. perform an active thoracic mobility exercise. d. perform non-thrust manipulation to the lower cervical spine.
The correct answer is b. perform a prone middle thoracic thrust procedure. In clinical practice, it is common that a patient will report posterior shoulder pain during the set-up of the supine technique. The supine technique requires force to be applied through the elbows in an anterior-to-posterior direction that places force on the posterior aspect of the shoulder. If a patient reports these symptoms, the thrust should not be performed and the physical therapist should attempt repositioning procedures and may require a towel roll to be used. If these maneuvers are unsuccessful in reducing the posterior shoulder pain during the set-up, an alternate technique should be used, such as the prone technique. The prone technique places no strain through the shoulders and can produce similar effects with the supine technique. The alternate answers may be implemented in clinical practice, but the physical therapist may first attempt to find a comfortable position that will allow for a thrust procedure to the middle thoracic spine.
4. You decide to perform a seated, followed by a prone thrust manipulation to the middle thoracic region. Afterwards the patient displays increased thoracic spine extension and bilateral rotation with less pain. Which of the following exercises would be the best to immediately follow? a. thoracic postural re-education. b. self-extension mobilization. c. lower trapezius strengthening. d. sidelying trunk rotation.
The correct answer is b. self-extension mobilization . The self-extension mobilization exercise most closely matches the patient's presenting impairments in addition to the manipulation techniques. Furthermore the patient could potentially perform this in his chair during working hours by extending his spine over the back of his chair. The additional interventions of lower trapezius strengthening, postural re-education, and trunk rotation may all also be beneficial to this patient but do not directly complement the manual therapy intervention or address a key patient impairment.
2. Given the above presentation, what is the dominant pain mechanism involved in this patient's presentation? a. peripheral nociceptive. b. peripheral neurogenic. c. central sensitization. d. functional pain syndrome.
The correct answer is c. central sensitization . While peripheral pain mechanisms are also involved with this patient, she most closely fits the criteria for central sensitization. The pertinent features include a widespread region of symptoms without a discrete location and with less of a mechanically patterned behavior. She also presents with associated cognitive and psychosocial factors including fear of movement, negative and unhelpful beliefs about her condition, and a history of an anxiety disorder. She reports irritable bowel syndrome, which also is common in individuals with chronic, widespread pain. It is important to note that there does appear to be local, movement-related impairments of the thoracic spine and addressing these as part of her program may be very useful. However, a multimodal, comprehensive intervention approach will likely be necessary due to the complexity of her presentation. Answer "d" functional pain, is a related disorder but refers to abdominal pain of unknown origin and is thought to occur as a result of central sensitization.
Upon returning to physical therapy, the patient reports some ongoing thoracic spine pain and that she has been limiting her activities as a result of the pain and concern over injuring herself further. She is now 6 weeks out from the fracture and is having pain with sitting for greater than 30 minutes, standing greater than 10 minutes, bending forward, and lifting light objects to shoulder height. On examination, she has a thoracic hyperkyphosis, her bilateral shoulder elevation is limited to 140°, and her active thoracic extension is very limited. 4. What is the best physical therapy intervention for this patient? a. aerobic conditioning. b. aquatic therapy. c. progressive resistance training for the spinal extensor muscles. d. stretching and range of motion exercises.
The correct answer is c. progressive resistance training for the spinal extensor muscle strengthening. Several clinical trials have shown that extensor strengthening improves health related quality of life and decreases the incidence of future fractures in women with osteoporotic compression fractures.122 In addition to spinal extensor strengthening, it is recommended that patients also perform resistance training exercises for the whole body including the upper and lower extremities. This is done not only for the purposes of mitigating a decrease in bone mineral density but also decreasing fall risk in this vulnerable population. These exercise programs can involve home-based programs with minimal equipment, supervised exercise using equipment such as weights and machines, or group classes led by exercise professionals. Answer "b," aquatic therapy, is incorrect as weight-bearing exercise has been shown to be most beneficial for bone mineral density. Answer "d," stretching and range of motion, is incorrect, while this may be beneficial, it does not address deficits in bone mineral density. However, thoracic mobilization exercises and stretching of the muscles on the anterior side of the body such as the pectoral and hip flexor muscles could theoretically assist the patient with achieving a more upright and neutral posture. As discussed in this monograph, an increased thoracic kyphosis has been linked to reduced quality of life, and risk of falling and stretching in addition to strengthening may assist with reducing the degree of thoracic spine kyphosis. Aerobic conditioning, answer "a," is incorrect because although aerobic conditioning is important for overall health, it will not directly address the bone mineral density.
Case Scenario 3 A 72-year-old female presents to physical therapy with a chief complaint of middle thoracic spine pain. The symptoms began after she bent down to pick up a laundry basket two days ago. She was referred by her primary physician who diagnosed her with a thoracic spine strain. She reports constant pain in the middle thoracic region that worsens with sitting, standing, and walking. Her pain eases with lying down. The pain does not radiate and she does not report any neurological complaints. She has a history of smoking, having smoked one pack per day until 10 years ago. Her health history indicates she has chronic shortness of breath, hypertension, and she is postmenopausal. The patient denies a history of cancer or surgery. Her Oswestry Disability Index is 52% and she rates her pain on the analog pain scale as an 8/10. 1. Based on the above presentation which of the following is the most likely diagnosis? a. cardiac ischemia. b. mechanical thoracic spine pain. c. thoracic compression fracture. d. thoracic spine bone metastases.
The correct answer is c. thoracic compression fracture . Given the patient's age, gender, history of smoking, and sudden onset of symptoms after a trivial strain, a thoracic compression fracture is a high probability. Answer "d," bony metastasis, is a possibility due to her history of smoking but usually there are additional red flags present, the primary being a history of cancer.47 Answer "a," cardiac ischemia, is possible due to her history of shortness of breath and hypertension; however, this usually presents with chest pain upon exertion also known as angina. Mechanical thoracic spine pain or a thoracic spine strain is possible, but given the patient presentation, a fracture should be ruled out before making this diagnosis.
Following the manipulation to the middle thoracic spine, the patient has improved painfree active right shoulder flexion to 140° with 1/10 pain at end range. 4 Given this improvement in pain and active range of motion, what exercise would be best to maintain these changes between sessions? a. sidelying "sleeper" stretch. b. scapular retraction exercises. c. thoracic extension over a chair. d. pectoralis major stretching.
The correct answer is c. thoracic extension over a chair. Following manual therapy including thrust manipulation to the thoracic spine, the best exercise to augment this technique would be a mobility exercise targeting that region. Answer "a" would target the capsule of the glenohumeral joint and likely not affect thoracic mobility. Scapular retraction (answer "c") would target the muscle strength of the retractors that are located in the thoracic region; however, would have little effect on the mobility of the thoracic spine. Answer d would be helpful in assisting with postural deficits, but mainly targets muscle flexibility.
You performed a supine manipulation to the T4-6 region followed by a prone thrust to the right fifth rib. The patient now has full, painfree thoracic rotation and inspiration. 3. What of the following exercises is best to now teach the patient? a. pectoralis major stretching. b. serratus anterior strengthening. c. thoracic extension over a foam roller. d. thoracic flexion, barrel hug.
The correct answer is c. thoracic extension over a foam roller . The patient presents with an increased thoracic kyphosis and is also involved in an activity, rowing, involving repetitive thoracic flexion. Teaching the patient a thoracic extension mobilization would address the postural deficits and the hypomobility found on the examination. Answer "d," thoracic flexion barrel hug, would be more appropriate for the patient who lacks thoracic flexion. Answers "a" and "b" could be appropriate but these impairments were not reported as part of the physical examination.
Case Scenario 2 The patient is a 42-year-old female with a chief complaint of thoracic spine pain, headaches, and bilateral upper extremity paresthesia. She reports an insidious onset of these symptoms beginning 6 months ago. Her symptoms are aggravated by sustained postures such as sitting and driving for longer than 15 minutes, lifting or carrying objects such as a laundry basket or grocery bags, and sustained overhead activity such as when styling her hair. She denies night pain, weight loss, chest pain, shortness of breath, or a history of cancer. She had a thoracic MRI that revealed a disk bulge in the lower thoracic region T8-9. Her medical history and screening indicates a general anxiety disorder and irritable bowel syndrome. She reports that she is worried about her pain getting worse and that she has been limiting her activities because she is concerned about hurting herself. Upon further discussion, it seems that most of her concerns about injuring her back stem from the MRI findings of the disk bulge. A screening examination including assessment of vital signs and an upper quarter neurological exam is normal. On observation, she displays a reduced thoracic kyphosis in the T3-6 region and bilateral scapular winging. She displays an upper chest breathing pattern and hypertonicity of her accessory breathing muscles. Cervical range of motion is slightly limited in all directions but this does not reproduce her pain. Bilateral shoulder elevation is limited to about 150° and reproduces her mid thoracic pain and upper extremity paresthesia. Her active thoracic movements are guarded, reduced by about 50%, and reproduce her thoracic spine pain in all directions. During posterior to anterior spring testing applied to the upper to middle thoracic region T4-8 region, there is local pain, hypomobility, and her bilateral upper extremity paresthesia are reproduced. The slump test is positive for a reproduction of her thoracic spine pain and headache that eases with cervical extension. Her Neck Disability Index is 38% and her average pain on the Numerical Pain Rating Scale is 6/10. The STarT Back Screening Tool designates her in the high risk category. 1. Given the above presentation, which of the following diagnoses is most likely? a. cervical myelopathy. b. thoracic discogenic pain. c. thoracic outlet syndrome. d. T4 syndrome.
The correct answer is d. T4 syndrome . The patient presents with the constellation of signs and symptoms consistent with this disorder including thoracic spine pain and stiffness, headaches, and bilateral upper extremity paresthesia with a normal neurological examination. Cervical myelopathy is a possibility but less likely due to the normal neurological examination and that cervical extension eases her symptoms during the slump test. With cervical myelopathy, symptoms are often worsened during cervical extension due to the narrowing of the cervical canal in this position. Thoracic outlet syndrome is another possibility; however, the distribution of symptoms with this syndrome is usually unilateral and located towards the ulnar region of the distal upper extremity. In addition, involvement of the thoracic spine is more likely to occur in the upper thoracic spine (T1-2) and first rib region as opposed to the upper to middle thoracic region. A thoracic disk bulge could potentially contribute to this patient's symptoms, but it is difficult to determine the relevance of the MRI findings for this patient given that high frequency of disk pathology found on MRI in individuals without symptoms. Furthermore, the disk bulge is located in the lower thoracic spine and her clinical examination indicates involvement of the upper to middle thoracic spine.
2. Which of the following is the best plan of treatment given this patient's presentation? a. continue physical therapy respecting her pain tolerance. b. refer her to an orthopaedic surgeon for a surgical consultation. c. refer her to the primary physician with a recommendation for magnetic resonance imaging. d. refer her to the primary physician with a recommendation for radiographs.
The correct answer is d. refer her to the primary physician with a recommendation for radiographs. This patient should be referred for a radiograph due to the high likelihood of a thoracic spine compression fracture. Response "c" is incorrect because magnetic resonance imaging is more expensive and is not usually required to make the diagnosis of a compression fracture. She could be referred to an orthopaedic surgeon (answer "b") but only after she has had the radiograph; invasive surgery is not always required for this injury. While physical therapy could still be indicated, imaging is required in order to effectively and safely implement a plan of care for this patient.
Case Scenario 5 The patient is a 23-year-old female who presents to physical therapy with a chief complaint of right anterior chest wall pain. The symptoms began about 6 weeks ago and have progressively increased. The patient is a collegiate rower and believes that the pain is related to her rowing activities. The patient reports pain located on the right anterior chest wall in the region of the costosternal junction. Symptoms increased with deep inspiration, rowing, push-ups, and with direct pressure to the region of pain. Symptoms ease with rest, ice, and ibuprofen. Treatment by the team trainer has consisted of electrothermal modalities and stretching exercises. This has not changed the patient's symptoms. Past medical history is unremarkable. Average pain on the numerical rating of pain scale is 6/10 and the composite score on the Patient- specific Functional Scale is 5/10. 1. Give the current patient presentation which of the following serious conditions is most likely? a. cardiac ischemia. b. gall bladder disease. c. penetrating ulcer. d. rib stress fracture.
The correct answer is d. rib stress fracture . The patient engages in heavy, repetitive activity involving use of the musculature attached to the rib cage. Rib stress injuries are common in rowers. Answer "c," penetrating ulcer, is a possibility but the patient's symptoms are mechanical in nature and there are no other indications in the history that would suggest an ulcer. Answer "a," cardiac ischemia, is a possibility but the patient's younger age and symptom presentation do not match with this diagnosis. Answer "b," gall bladder disease, usually presents with right-sided periscapular pain that is associated with ingestion of a fatty meal.
4. Which of the following is theorized to cause the constellation of signs and symptoms associated with T4 syndrome? a. compression of the thoracic spine cord. b. peripheral neuropathy of thoracic nerve roots. c. referred mechanical thoracic pain. d. sympathetic nervous system dysfunction.
The correct answer is d. sympathetic nervous system dysfunction . Due to the proximity of the sympathetic chain to the thoracic spine, it is thought that mechanical movement impairment of the thoracic spine could lead to altered sympathetic nervous system function. However, it should be recognized that the signs and symptoms associated with T4 syndrome likely represent enhanced sensitivity of and subsequent "output" from the central nervous system. This case is a good representation of this concept as there are multiple stressors or "inputs" involved in this patient's case leading to sensitization of the peripheral and central nervous systems and altered sympathetic nervous system activity is one of many resulting outputs. Answer "b" is incorrect because thoracic spine peripheral neuropathy would present with pain or paresthesia along the sensory distribution of the thoracic nerve roots in the chest wall region. Answer "a" is incorrect because compression of the thoracic spine cord would lead to symptoms below the level of the compression and the patient would be more likely to present with neurological signs and symptoms in the lower quarter region. Answer "c" is incorrect because pain mapping studies have shown that the thoracic spine refers pain locally or within one segment above or below and does not typically create widespread symptoms in the upper extremities or headaches. However, it should be recognized that nociceptive input from the thoracic spine involving any of the structures such as the disks and facet joints could potentially lead to the central sensitization.
2. The physical therapist elects to perform posterior glenohumeral mobilizations grade III for 3 bouts of 30 seconds. Upon re-testing of painfree right shoulder flexion, no difference in range of motion or pain is noted. Based on this response, what would be the next best manual therapy intervention to attempt with this patient? a. grade III inferior manipulation to the right glenohumeral joint. b. grade II posterior manipulation to the right acromioclavicular joint. c. grade III posterior-anterior manipulation of C5-7. d. supine thrust manipulation to the middle thoracic spine.
The next best manual therapy procedure to attempt would be d. supine thrust manipulation to the middle thoracic spine. All of the other answers may be potential manual therapy techniques that could be used. Based on patient presentation and concurrent interscapular pain, a thrust technique to the middle thoracic spine may provide symptomatic improvements to the shoulder. Based on the physical examination data, answers "a" and "b" were not indicated as pertinent physical examination findings. Answer "c" could be implemented, but the lack of reproduction during spring testing and during active range of motion testing would make this a secondary option to thoracic spine.
