Lecture 13 - Thoracic Spine Intervention

What is the definition of Scoliosis

- 3D curvature of the spine - curve in the frontal plane greater than 10 deg w/ a rotary component

you have a pt. with thoracic spine limitation into right rotation AROM and visually observe most restrictions at T5-6, which technique is appropriate for the patient A. Prone PA to left T5 TP B. Prone PA to right T5 TP C. Prone PA to left T6 TP D. Prone PA to bilateral T5 TP (central)

- A.

How do we determine whether to refer a patient if we detect scoliosis

- Adam's fwd bend test w/ greater than 7 deg on scoliometer

What assessment proves as one of the best for detecting scoliosis

- Adams/ Forward bend test

During CRLF when the patient's head is rotated left, what structure is being tested

- B. - bring right facet of C7 to first rib

Pt. reports right upper back pain worse w/ R rotation and deep inhalation. You localize the pain to the R costotransverse joint of T4. Which results of the rib spring test would lead you to believe that the pain is generalized from the rib. - A. p w/ PA pressure w/o stabilization of the TP - B. p w/ PA pressure w and w/o stabilization of the TP - C. p w/ PA pressure of the TP while the rib is stabilized - D. p w/ PA pressure while the contralateral TP is stabilized

- D. - not B. bc both regions could be implicated not just specific to the rib

What subjective symptoms would indicate the first rib as a potential source or contributing impairment? (3)

- Local reports of pain/stiffness unilaterally, near the base of the neck or - limitations in cervical ROM - complaints of pain along the medial forearm and hand related to potential TOS

Pectoralis Minor OI

- O - anterior surface of ribs 3-5 - I - coracoid process

What patient subjective reports would lead you to direct treatment to the cervico-thoracic junction? (2)

- Pattern of symptom referral to inferior angle of the scapula - Pain with cervical flexion, extension, or rotation

What are vascular contraindications to the T/S manipulation

- VBI - Aortic aneurysm - hemophilia

What is the goal for MWM T/S w/ Swiss Ball

- a more dynamic and funitonal manner to improve extension in desired segments of T/S

What test could you use to differentiate between structural and non-structural kyphosis

- adam's fwd ben test w/ cervical extension, if non structural the kyphosis will correct itself

For idiopathic scoliosis what is the most common age of onset

- after 10 years of age

What respiratory functions would one find challenging with rib dysfunction

- anything that contrasts the muscles between the ribs, such as breathing coughing and sneezing

What are some general MOI for T/S musculature (4)

- blunt trauma - strain/tear - overuse - poor posture

What are the onset of symptoms in Rib dyfunction typically related to (2)

- blunt trauma to chest wall - UE injury

Boyce has a 30 deg scoliotic curve and has a Risser sign 3 what is the indicated treatment for her

- bracing

What systems could possible refer to the thoracic region

- cardiovascular - gastrointestinal - renal

What is the difference between structural and postural scoliosis when we side bend

- curve will tend to correct w/ SB if non-structural

What is the process of determining whether a manipulation is appropriate (3)

- determine pt. Is appropriate for Pt in subjective - movement dysfunction in AROM - hypo mobility in segmental mobility

How do we categorize the type of scoliosis if detected

- direction by the side of convexity i.e. right, and region by the apex of the convexity i.e. thoracic

True or false: Using a thoracolumbar orthosis will reverse a scoliotic curve.

- false

rue or false: Postoperative scoliosis surgery, adolescents receive outpatient physical therapy.

- false

T/F Danny has a 48 deg scoliotic curve and a Risser sign 5 therefore she is indicated for intervention

- false she would he if she was still skeletally immature, however for her maturity she would require curves greater than 50-55 deg

What is the general recommendation for population based screening of scoliosis

- females screened twice at 10 and 12 - males screened once at 13/14 - person screening should be performed by the pediatrician

What are the principles for MWM (4)

- forces applied parallel to the plane of motion - force sustained throughout movement until the joint returns to starting pos. - painless when force applied - and include active, passive and resisted movements

What are some general objective examination procedures you would perform for a n individual you suspect w/ scoliosis (6)

- general alignment i.e. shoulder/pelvic/ plum line - spinal alignment - fwd bend test - leg length measurement - strength and flexibility - pain - neuroscreen - DTR, UMN

At what point in time is a s/p posterior spinal fusion surgery pt. Referred to OP PT

- general not indicated

What is recommended for treatment of Sheuermann's disease in those patients that have less than 60 deg of kyphosis (3)

- improve postural alignment - increased trunk flexibility i.e. shortened anterior musculature - increase extensor muscle sterngth

What are contraindications for manipulations (4)

- lack of consent - lack of diagnosis - prepostioning can't be achieved - pt. Pregnant

Risser Sign

- locating the apophysis on the iliac crest to determine skeletal maturity this will inform management in scoliotic patients - ranges from 1 - 5 larger magnitude indicating more maturity 5 indicating full maturity

Irritability Based Intervention - High irritability

- modalities - heat/ice/electrical stim - Activity limitations - yes - ROM/Stretch - 1-5s, pain free, PROM --> AAROM - Manual Techniques - low grade - Strengthening - no - Functional Activity - no - Patient Education - +

Irritability Based Intervention - Moderate Irritability

- modalities - heat/ice/electrical stimulation - Activity limitations - yes - ROM/Stretch - 5-15s PROM --> AAROM --> AROM - Manual Techniques - low to high grade mobilization - Strengthening - no - Functional Activity - basic - Patient Education - yes

Irritability Based Intervention - Low Irritability

- modalities - n/a - Activity limitations - no - ROM/Stretch - end range w/ over pressure and longer durations - Manual Techniques - high grade mobilizations w/ sustained holds - Strengthening - low - high resistance w/ end range - Functional Activity - high demand - Patient Education- yes

What are neurological contraindications to manipulation (3)

- myelopathy - cauda equine - nerve root compression

if the pts. Pain is along the upper mid thoracic spine can we safely rule out cervical structures as the source of symptoms why or why not. If not explain how you can truly rule out the C/S

- no bc lower cervical C6/7 and C7/T1 can refer to the upper and mid thoracic region - perform C/S AROM, segmental mobility and whether symptoms are reproduced with any of these

Paul has a 28 deg scoliotic curve and is 25yo should we be concerned whether his scoliotic curve will progress why or why not

- no because the majority of curves less than 30 deg do not progress after skeletal maturity

What are the different types of scoliosis and indicate the most prevalent one (4)

- non-structural/postural - idiopathic ** - neuromuscular - cogenital

Gary has a 15 deg scoliotic curve based on this information what treatment should be indicated for home

- observation of the curve independent of his skeletal maturity

Wrt to bony pathology what are some contraindications for T/S Manipulation (11)

- osteoporosis, osteomalacia , RA - long term steroid use - tumor - infection - dysplasia - fracture - DJD, DDD, HNP

What are the different forms of hyper-kyphosis (3)

- postural - congenital - Sheuermann's

What 3 criteria in the clinical reasoning process must be met before performing an HVLA at the T/s

- pt consent - must be free of contraindications - must be appropriate for manip

What are key differences between providing a central PA and compared to MWM for the T/S w/ a Swiss ball

- pt. Is active - pt is WB - dynamic movement engaging muscles and joints - potential to incorporate other body joints

What should one to after performing an T/S manipulation

- re-asses ROM and segmental mobility to determine effect

Your suspect that your pt. Suffers from TOS, what are two STM techniques that you could perform that would be appropriate for treatment

- scalenes - pec minor

In what circumstances do we provide surgery as an intervention for scoliosis (2)

- skeletal immaturity - greater than 45 deg - skeletal immaturity - greater than 50-55 deg

How do we measure the magnitude of scoliosis

- using the cob's angle on Radiographs

What MSK structures can be the source of symptoms in the T/S (9)

- vertebral body - intervertebral disc - facet joints - Costovertebral joints - costotransverse joints - ribs - ligament - muscle - nerve

Dr. Anderson Keep Saying think about regional interdependence when it comes to treating the T/S what does he mean by this

- we can indirectly treat a lot of other regions via treating the T/S i.e. C/S, upper L/S shoulder

What are the s/p precations for posterior spinal fusion w/ instrumentation and bone graft

- widely vary based on the surgeon

Describe the ratio of males to females with respect to increasingly larger degrees of scoliosi

1. 1:1 for curves less than 10 deg 2. 1:5 for curves greater than 20 deg 3. 1:10 for curves greater than 30 deg

What non MSK systems can refer pain to T/S, what exact region is this pain referred to and how do the symptoms present.

1. CV - between the scapula symptoms get worse w/ exertion 2. GI - duodenal ulcers get better w/ food and gastric ulcers get worse w/ food 3. Renal - kidney stones can lead to full/voiding bladder and appears as flank pain

1. What assessment would one utilize to assess whether their pt. Has an elevated or hypomobile first rib 2. You suspect that your pt. Has this on the right side briefly describe the procedure on how you would assess using this technique 3. What finding indicates a positive finding

1. Cervical Rotation Lateral Flexion 2. Rotate to the L (away from the rib being tested) and lateral flex the pts. Head to their chest 3. Limited lateral flexion

1. What is the nature of the pain for a costotranverse joint dysfunciton 2. Referrals pattern (2)

1. Deep dull ache 2. Ipsilateral and local to the segment

Rib Spring Test 1. Purpose 2.You perform a rib spring and the patient has pain, then you block the corresponding TP of that rib and find the patient still has pain therefore what structures are likely the source of the patients pain 3. With stabilization the rib spring is no longer painful what does this suggest as the course of pain

1. Differentiate between whether the T/S facet joint or Costovertebral/costotransverse joint is the source of pain 2. Costovertebral/costotranverse joint bc this blocks the movement of the facet joints 3. T/S facet joints

What is the proper sequence for performing T/S AROM

1. Establish resting symptoms 2. Ask pt. To move in desired direction 3. Observe quantity and quality mov. 4. Ask for change in symptoms 5. Reflect on findings 6. Repeat for another mov.

1. How soon after posterior spinal fusion surgery with instrumentation and bone graft do PTs get the patient moving 2. How soon after do they go back to full activity

1. First day 2. 3 mos.

What patient objective findings would lead you to direct treatment to the cervico-thoracic junction? (4)

1. Hypomobile CT junction 2. Upper thoracic kyphosis (if ROM is lack of extension) 3. Flattened upper thoracic spine (if ROM is lacking flexion) 4. Prominence of transverse process on the side contralateral to a rotation restriction

What are they goals of T/S STM

1. Increase ROM 2. Decrease P 3. Increase joint mobility

1. In the inferior glide of the 1st rib when first performing this as an assessment/treatment which direction should the pts. Head be positioned and why 2. In progressing this as a treatment which way should the patients head be side bent

1. Ipsilateral side bend to put scalene muscles and upper trapezius on slack 2. Contralateral SB

1. When are general exercises recommended as treatment for scoliosis 2. What is the goal of these exercises

1. Mild curves less than 20 deg 2. Improve trunk/pelvic strength + muscle length

1. What technique would one utilize to mobilize the costotranverse joint 2. Briefly describe the procedure, Make sure to discuss the orientation of this articulation and how it replies to the manual Techniques you imply

1. Rib "Springs" Mobilization 2. Cross arms and block the corresponding T/S segments w/ one hand while providing a P/A to the rib of interest w the other hand. For upper ribs the P/A can as such however as you travel causally the ribs angle more inferiorly therefore utilizing a inferior and lateral glide is indicated in these regions

Postural Kyphosis 1. Normal Observation 2. Radiographic findings (2)

1. T/S Kyphosis less than 60 deg that will correct itself to 20-40 deg (normal) w/ hyperextension 2. No disc involvement and normal height of vertebra

Sheuerman's Disease 1. Observation 2. When is bracing indicated 3. Radiographic finding 4. When is surgery indicated 5. Minimum daily require in brace

1. Thoracic kyphosis greater than 60 deg 2. Brace if the curve is less than 60 deg and the pt. Is still in skeletal immaturity 3. Anterior wedging of the vertebra 4. If T/S kyphosis is greater than 75 deg 5. 22 hours

Postural Scoliosis 1. Most Common Cause 2. Clinical Exam Findings (4) 3. Possible top down cause

1. True leg length discrepancy 2. Leg length discrepancy, uneven pelvis height, rib hump in standing that diminishes w/ sitting 3. CMT

1. T/F In the unilateral PA w/ Cervicothoracic rotation mobilization we use coupled motion of the C/S to localize a segment in the upper T/S 2. If we are using this technique to improve L rotation of T2-3 how would we achieve the desire preposition

1. false we use non-coupled motion 2. SB right to T2, Rotate L to T2

1. You assess your pt. First rib mobility and determine some limitation what technique could you use to mobilize this 2. Briefly describe the procedure for this treatment

1. first rib inferior glide 2. Pt. Is supine, you can ipsilaterally SB Their head and provide an inferior glide toward the contra hip at the first rib **** this can also be done in seated

1. In what context do we provide bracing as treatment for scoliosis 2. How long does the brace have to be work generally to have a meaningful effect 3. What is the goal of bracing

1. for mild curves between 25-45 deg 2. 13 hours 3. Maintain the curve and decrease rate of progression not correct curve q

What is a good management framework to use for the thoracic spine and given an example in each domain

1Educate - ergonomics Unload - bracing, taping postural modifcation Reload - Therapeutic exercise Prevent

What is the most common age for scoliosis to start? A. Adolescent B. Infant C. Child

A.

What percentage of children will be diagnosed with scoliosis? A. 2-3% B. 5-10% C. <1%

A.

During a seated assessment of CT junction mobility, it is determined that the patient has mobility deficits when turning right at C7. You decide to treat the patient in the same position w/ an MWM. How do you proceed w/ treatment A. apply overpressure to C7 SP toward your right as the patient turns their head right B. apply overpressure to C7 SP towards your left as the patient turns right C. apply overpressure to T1 SP toward your right as the patient turns right D. apply overpressure to T1 SP toward your left as the patient turns right

B.

A 14yo pt. presents with chief concerns of rib cage and upper back stiffness. You notice uneven shoulder height and TS prominence on the L when standing. Which of the following examination findings would support your hypothesis of postural scoliosis A. uneven pelvis in standing, uneven pelvis height in sitting, abnormal T/S prominence in sitting and standing B. Uneven arm windows in standing and sitting, uneven pelvis height in sitting, Xrays showing wedged T/S vertebrae C. true leg length discrepancy, uneven pelvis height in standing, no abnormal T/S Prominence or curvature in sitting D. excessive T/S kyphosis, back pain w/ trunk flexion, no reversal of T/S kyphosis when asked to look up during adams test

C.

At what degree on a scoliometer during the Adam's forward bend test do you refer to an orthopedic surgeon? A. 5 degrees B. 10 degrees C. 7 degrees

C.

What type of scoliosis is the most common? A. Congenital B. Neuromuscular C. Idiopathic

C.

What is the best treatment option for an idiopathic thoracolumbar curve of 35 degrees for a 12-year-old female? A. Observation B. Surgery C. Bracing

C. this is a moderate curve

What 2 assessment techniques could you perform prior to performing interventions directed at the first rib?

CRLF, first rib inferior glide assessment

How do you distinguish between postural kyphosis and Scheuerman's kyphosis using the Adam's forward bend test?

If postural, reversal of kyphosis if asked to look up during Adam's forward bend test; if Scheuermann's kyphosis, no reversal of kyphosis if asked to look up during Adam's forward bend test.

In general terms, list 5 potential local neuromusculoskeletal sources that can cause thoracic spine symptoms.

• Zygapophyseal joint • Costovertebral joint •Costotransverse joint - rib - vertebral body - muscle - nerve - ligament