Week 3 Thoracic Physmed 2024 Asynchronous .pdf

Orthopaedic Conditions & Assessment C o n d i t i o n s o f t h e T h o ra c i c S p i n e Dr. Albert Iarz, ND, RMT BMS 150 Lab Learning Objectives To understand the OHIPMNRS approach to MSK assessment To review/understand Thoracic anatomy and ROM To understand common Thoracic MSK conditions/ Inj...

Orthopaedic Conditions & Assessment C o n d i t i o n s o f t h e T h o ra c i c S p i n e Dr. Albert Iarz, ND, RMT BMS 150 Lab Learning Objectives To understand the OHIPMNRS approach to MSK assessment To review/understand Thoracic anatomy and ROM To understand common Thoracic MSK conditions/ Injuries and how they present To understand the common Thoracic orthopaedic tests and how to perform them Conditions that will be covered in this Lecture Postural Syndrome Rib Subluxation Scoliosis Thoracic Outlet Syndrome (TOS) Compression Fracture Scheuermanns Disease Vertebral Subluxation Special Orthopaedic Tests that will be covered in this Lecture Scapular protraction (winging) Elevated Arm Stress Test or “Hands-up” (ROOS) Costoclavicular test Wright’s Hyperabduction test Adson’s Test Halstead’s (Reverse Adson’s) Adam’s Sign Dural Slump Scapular Approximation Postural Dysfunction/Syndrome Definition: A condition that is usually due to poor posture, where normal spine curvature can become excessive and thus increase gravitational stress and cause undue wear and tear on joints. This causes pain in the lumbar and cervical regions. Even in the hips and legs can be involved. Differential Diagnosis: Headache (cluster, migraine, tension) Spinal Deformaties (Structural) Neoplastic, Traumatic Osteochondrodystrophies (A disease of bone and cartilage) Types of Postural Dysfunction Lordosis (Increased/Absent) Kyphosis (Increased/Absent) Postural Syndrome - Excessive Lordosis Presentation/Causes postural or functional deformity lax muscles, especially abdominal muscles in combination with tight muscles such as hip flexors heavy abdomen, weight gain pregnancy (Normal and only during pregnancy) compensation from another deformity such as kyphosis spondylolisthesis congenital problems, such as bilateral congenital hip dislocation failure of bone formation Excessive Lordosis 2 Main Types Pathological lordosis Excessive lumbar lordosis Sagging shoulders, medial rotation of arms if compensatory increase in kyphosis Head pokes forward Increased pelvic angle to 40 degrees (normal is 30) Mobile spine and anterior pelvic tilt Tight hip flexors and TFL, with WEAK abdominal Sway Back has pelvic in neutral or posterior tilt increase in kyphosis at lumothoracic junction increase at lumbosacral angle such that the entire pelvis shifts anteriorly Postural Syndrome - Excessive/ Decreased Kyphosis Sheuermann's disease o usually occurs in adolescence and causes vertebrae to take on a wedge shape rather than cylindrical o affects approx 10% of the population o usually between T10 an L2 Round back o long rounded curve with decreased pelvic inclina_on (less than 30 degrees) o trunk is o`en flexed forward with a decreased lumbar lordosis o _ght hip extensors, _ght trunk flexors, weak hip flexors and lumbar extensors Humpback (Gibbus deformity) o Localized, sharp posterior angula_on in the thoracic spine o Usually a sharp angula_on of the spine at a single vertebral level o commonly a structural deformity as the result of a fracture or pathology Flat back o Pathological reduc_on in the normal kyphosis is unusual o May be observed a`er surgery to correct thoracic scoliosis Dowager's hump o O`en in older patients o Caused by osteoporosis o Thoracic vertebral bodies degenerate and wedge anteriorly Congenital kyphosis o Curvature present at birth. o Vertebral bodies are triangular and o`en fuse anteriorly Postural Dysfunction/Syndrome Special Tests: No Special Tests Here Simple Observation/History of posture that was discussed last lecture Postural Assessment Checklist Postural Assessment Checklist Anterior View Lateral View Posterior View Lower Extremity: Feet evenly space from plumb line • Tibial crests: slight external rotation • Knees: evenly spaced from plumb line • (varum, valgum) Facing anteriorly • The lateral malleoli, fibular head and • iliac crest should be bilaterally equal ASIS (level, symmetry) • Lower Extremity: • Lateral malleolus: slightly posterior • The tibia should be parallel to the plumb line and the foot should be at 90* angle to the tibia • Greater trochanter: plumb line bisects Lower Extremity: • Feet evenly space from plumb line • Feet: Parallel • Knees: evenly spaced from plumb line • Gluteal Folds (level, symmetry) • PSIS (level, symmetry) Torso: Umbilicus, sternum, jugular notch: • plumb line bisects Torso: • Mid thoracic region: plumb line bisects Torso: • S2: plumb line bisects • Spinous processes: plumb line bisects • Paraspinals bilaterally symmetrical Shoulder: Acromion process: evenly spaced from • plumb line Shoulder heights equal • Deltoid, anterior chest musculature • bilaterally symmetrical and defined Shoulder: • Acromion process: plumb line bisects Shoulder: • Scapular borders: evenly spaced from plumb line • Acromion processes: evenly spaced from plumb line • Deltoid, posterior muscular bilaterally symmetrical • Shoulder heights equal Head and Neck : Head, nasal bridge and frontal bone: • plumb line bisects Head and Neck: • Cervical bodies: plumb line bisects • Auditory meatus: plumb line bisects Head and Neck • Cervical spinous processes (C7)& • EOP: plumb line bisects Rib Subluxation/Slipping Rib Syndrome When abnormal movement of a rib, usually a false rib, occurs due to an unstable cartilaginous attachment. This can cause impingement of an intercostal nerve It can also be known as: Clicking Rib Displaced Rib Painful Rib Syndrome Rib Subluxation/Slipping Rib Syndrome Characteristics/Symptoms Pain in the lower chest (minor to moderate) Pain in the upper abdominal region Flank Pain Pain usually preceded by an activity such as sitting and leaning forward Intermittent sharp stabbing pain then followed by constant dull pain that can last for hours to weeks Worsened with certain movements (Lifting, Bending, etc) Can also cause visceral pain due to location of nerves Rib Subluxation/Slipping Rib Syndrome Special Tests: Hooking Manoeuvre (Not taught in this class) Other Investigations Palpation where tenderness is felt above the costal margin or a painful click is sometimes felt over the tip of costal cartilage involved History of recent trauma or certain postures. SCOLIOSIS Definition: A lateral CURVATURE of the spine within the vertebral column Labelled as C-Curves(1 curve) or S-curves(2 curves) Described according to the side of the CONVEXITY Primary Curvature is where the Vertebrae become misaligned Secondary Curvature is where above and below the curve tries to compensate to maintain normal head and pelvis position To measure the curve in degrees of the spine, “The Cobb angle” is used. Typically, a Cobb angle of 10 Degrees is regarded as a minimum angulation to define scoliosis. Can be FUNCTIONAL or STRUCTURAL Structural vs Functional Structural Curves • Fixed due to bony changed • Wedge vertebrae • Hemivertebra • Resulting in: Asymmetric side bending • May be progressive • Curve does not disappear on forward flexion • Cannot be corrected without SURGERY or BRACING (Harrington Rods) Functional Curves • Not fixed and mainly due to posture/muscle imbalances • Can be corrected with voluntary effort • Caused by: • Postural problems • Nerve root irritation • Compensated leg length discrepancy • Resulting in: Symmetric side bending • Not progressive • Curve disappears on forward flexion Figure 8. Clinical Massage Therapy pg 570 SCOLIOSIS Differential Diagnosis: More frequent in XX vs XY Idiopathic is MC (90%) but can be Congenital (Vertebrae fail to form properly) Neuromuscular: UMN or LMN Lesion Postural: Leg Length, Muscle Imbalances/Spasm Neoplastic, Traumatic Osteochondrodystrophies (A disease of bone and cartilage) Scoliosis History: Back Pain (Upper, Mid, and Lower) Trouble Breathing (If curvature is really bad) Muscle Fatigue Weakness/Numbness down lower body (If nerves are involved) Trouble finding comfortable sitting /laying positions Headaches (possibly) Scoliosis Physical: Back Pain due to Curvature Visible or Palpable Curvatures Asymmetry with shoulder height when bent forward Leg Length Discrepancy Scapulae are more visible, Flank Crease due to side bending, and an Asymmetric Pelvis Scoliosis Special Tests: Adam’s Sign (Test) (+) Structural when Bending makes curve more obvious (+) Functional, when Bending makes curve go away Other Investigations X-Ray is Best to measure Cobb Angle Treatment Depends on Cobb Angle <25 Degrees, Observe only >25 Degrees, Bracing (many types) also controversial >45 Degrees, Surgical Correction (Rods or Spinal Fusion) Due to possible respiratory problems and cosmetically unacceptable Thoracic Outlet Syndrome Definition: A Collection of syndromes that cause compression of the neurovascular bundle Brachial plexus C8 and T1 nerve roots Subclavian artery The BRACHIAL plexus and its accompanying artery can be compressed: Between the Anterior and Middle Scalenes Between the Coracoid Process and Pectoralis Minor Between the Clavicle and the First Rib Compression causes Neuropraxia (Loss of nerve conduction) Thoracic Outlet Syndrome Differential Diagnosis: Acromioclavicular Joint Injury Cervical Disc Injuries Cervical Radiculopathy Clavicle Fractures Elbow and Forearm Overuse Injuries Shoulder Impingement Syndrome Thoracic Disc Injuries Thoracic Outlet Syndrome Causes: Tight anterior and/or middle scalene Tight pectoralis minor musculature Approximation between clavicle and 1st rib Contusions due to trauma Clavicular fractures from trauma Whiplash from trauma Internal (Bony Callus or Cervical Rib) External Compression (Crutches) Poor Posture or Prolonged Poor Positioning Trauma or Joint Subluxation Systemic or Metabolic Disorders (RA, DM, etc) Pregnancy (Fluid retention and postural changes) Thoracic Outlet Syndrome Presentation Vascular Symtoms Swelling and puffiness in the arm/hand Bluish discolouration of the hand Feeling of heaviness in the arm/hand Pulsating lump over the clavicle Deep, boring toothache-like pain in the neck and shoulder region, that increases at night Superficial vein distention in the hand Neurological Symtoms Paresthesia along the inside forearm and palm Muscle weakness and atrophy of gripping muscles and small muscles of the hand Difficulty with fine motor tasks of the hand Cramps of the muscles of the inner forearm Pain in the arm and hand Tingling and numbness in the neck, shoulder region, arm, and hand Thoracic Outlet Syndrome Special Tests: Roos Test (General compression test) (+) pain, heaviness, or profound arm weakness or numbness and tingling of the hand Costoclavicular Test (Compression by the 1st rib and the clavicle) (+) disappearance or diminution of the pulse, or if symptoms are elicited Wright’s Hyperabduction Test (Compression behind the pec minor muscle and under the coracoid process) (+) disappearance or diminution of the pulse, or if symptoms are elicited Adson’s Test (Compression due to tight scalene muscles) (+) disappearance or diminution of the pulse, or if symptoms are elicited Compression Fracture Definition: A fracture or break in bone that is due compressive forces This usually occurs in the vertebrae and at the front of them Eventually causing the body to lean forward Compression Fracture Causes Osteoporosis Compression type injury Tumours (Due to bone weakening) Compression Fracture Symptoms Back pain that is slowly worsening over weeks or months Standing making the pain worse vs laying down making it better Decrease in height Stooped over posture Other issues that may arise due to nerve damage from the fracture: Weak muscles Problems walking Bladder or bowel issues Numbness or tingling Compression Fracture Special Tests: No special tests More of a history taking rule in/out type of pathology Postural assessment and gait Need imaging (X-Ray) If suspecting a compression fracture, then refer to doctor to refer to imaging Scheuermanns Disease Definition: A pathological condition that may result in structural hyper-kyphosis Inflammation of the bone and cartilage occurs around the ring epiphysis of the vertebral body Often leads to anterior wedging of the vertebra A growth disorder usually diagnosed around 12-17 years of age, that affects around 10% of the population Most cases, several vertebrae are affected (T10-L2) is most common Scheuermanns Disease Scheuermanns Disease Differential Diagnosis: Functional Kyphosis Flat Back Hump Back Round Back Dowager’s Hump Scheuermanns Disease Causes Unclear They believe that their is a hereditary component Scheuermanns Disease Symptoms Characteristics/Symptoms Exaggerated Kyphosis Age 12-17 around Pain in the back (Upper, Middle, and Lower) Blood work showing inflammatory markers raised Scheuermanns Disease Special Tests: No special tests More of a history taking rule in/out type of pathology Postural assessment and gait Need imaging (X-Ray) If suspecting a compression fracture, then refer to doctor to refer to imaging Blood work would also help Vertebral Subluxation Definition: The alteration of the normal dynamic, anatomic, or physiologic relationships of contiguous (touching) articular structures. A motion segment in which alignment, movement integrity, or physiologic function is altered, although the contact between the joint surfaces remains intact. NOT A DISLOCATION Vertebral Subluxation Causes: Tight muscles that connect with the vertebrae (Mulifidis, Erectors, etc) An injury Chronic Compensation due to pain or injury Vertebral Subluxation Symptoms Characteristics/Symptoms Pain in the vertebral area Decrease AROM Possible muscle weakness or compensation Vertebral Subluxation Symptoms Special Tests: No special tests really More assessment of AROM, posture and gait A different type of assessment (Spinal Functional Movement Assessment) This will be taught next semester Thoracic ROM AROM: • Flexion = 20 - 45 degrees • Patient Seated or standing • Have them reach for their toes • Extension = 25 - 45 degrees • Patient seated or standing • Place hand at small of back to add stability • Extension should be straight and even with no side bending or rotation • Side bending = 20 - 40 degrees • Patient standing will slide hand down side of the leg • Patient seated will laterally bend • Rotation = 35 - 50 degrees • Seated to avoid hip movement • cross arms over shoulders and rotate Passive ROM • Patient seated • Examiner applies an over pressure to the end of each active ROM to assess end feel Resisted ROM • Patients is seated and in neutral • Examiner resists all of the thoracic spine AROM • Assess for weakness Thoracic Orthopaedic Tests Please refer to your lab manuals for all tests. These will be demonstrated in your practical labs Scapular protraction (winging) Elevated Arm Stress Test or “Hands-up” (ROOS) Costoclavicular test Wright’s Hyperabduction test Adson’s Test Halstead’s (Reverse Adson’s) Adam’s Sign Dural Slump Scapular Approximation