L28: Skills Prac 19-20

Question 1

What are the 3 main clinical pointers in the thoracic spine?

Answer 1

1. C7-T4
   
   1. The head cannot move fully in the presence of hypomobility in the upper thoracic region
   2. examine with neck movements
   3. examine with unilateral arm movement
   4. treatment movements (passive, active)
      
      • Consider using head or arm movements
2. T4-8 - bilateral arm elevation → 15˚ thoracic ext
   
   1. restriction of rib movement can restrict segmental movement
   2. utilize breathing pattern when treating rib dysfunction
3. T8-L1
   
   1. transitional area- behaves a bit more like lumbar
      
      • note rotary instability

Question 2

What are the 3 main clinical pointers in the thoracic spine (C7-T4)?

Answer 2

The head cannot move fully in the presence of hypomobility in the upper thoracic region

1. examine with neck movements
2. examine with unilateral arm movement
3. treatment movements (passive, active)
   
   • Consider using head or arm movements

Question 3

What are the 2 main clinical pointers in the thoracic spine (T4-T8)?

Answer 3

bilateral arm elevation → 15˚ thoracic ext

1. restriction of rib movement can restrict segmental movement
2. utilize breathing pattern when treating rib dysfunction

Question 4

What are the 2 main clinical pointers in the thoracic spine (T8-L1)?

Answer 4

1. transitional area- behaves a bit more like lumbar
2. note rotary instability

Question 5

What are 4 characteristics of rib movements?

Answer 5

1. Breathing
2. Accompanies movements of the vertebrae
3. effect of rib cage on thoracic movements
4. inter-dependence of arm and thoracic motion

No problem –> angle mobilisation on costal transverse to facilitate that

Question 6

What is the Th flexion of rib movement?

Answer 6

Th Flexion: anterior rib rotation

Question 7

What is the Th extension of rib movement?

Answer 7

Th Extension: posterior rib rotation

Question 8

What is the Th rot (R) of rib movement?

Answer 8

Th Rot (R): posterior rotation (R) rib

Question 9

What is the Th LF (R) of rib movement?

Answer 9

Th LF (R): anterior rotation (R) rib

Question 10

What is the direction of movement restriction (C, Th spine)?

Answer 10

Question 11

What is the indication of segemental rotation mobilisation?

Answer 11

Th LF (R): anterior rotation (R) rib

Question 12

What is the indication of segemental lateral flexion?

Answer 12

loss of LF or Rot

Question 13

What is the indication of cervical lateral glide?

Answer 13

nerve tissue technique - treatment of painful C5, C6 nerve roots

Question 14

What is the indication of transverse glide (thoracic region)?

Answer 14

deficits in thoracic segmental rotation

• Lateral flexion??

Question 15

What is the indication of traction?

Answer 15

in relation to NR pathology or general hypomobility

• Enhance flexion or extension

Question 16

What are 3 techniques for the CV, CT joint in thoracic motion segement influenced by mobility of the ribs?

Answer 16

1. PA glides: performed over the joint or angle of the rib
   
   • The PA performed in a caudad direction for a rib restriction in external rotation (inhalation) and in a cephalad direction for a restriction in internal rotation (exhalation)
2. Technique for SC joints: AP glides
3. Note: at least 15 of thoracic extension is used in full shoulder elevation
   
   • Active arm elevation can assist manual therapy treatment of the thoracic region

Question 17

What are the 7 managements of this patient?

Answer 17

1. Techniques:
   
   1. accessory movements
   2. physiological movements
   3. Long axis movement
   4. Combined movements
2. Position in range
3. Grade
4. Specific treatment for CT,CV joints
5. Use of arm movements
6. Progression
7. Exercise

Accessory:

• PA unilateral
• Transverse glide (towards the head –> ant rotation or can be done when breathing in)

Physiological:

• Rotation PPVIMS (towards or away depending of pain)
• LF

High velocity manipulation (for thoracic spine) –> segmental (useful)

Question 18

What are 3 indications of high velocity manipulation (HVT)?

Answer 18

Can be overused —> not necessarily used (need to open sometimes instead of compressing joint)

1. When subtle spasm is not allowing movement of a joint and mobilisation is aggravating pain
2. Residual hypomobility not responding to mobilisation
3. Some thoracic areas become hypersensitive, too much local discomfort with mobilisation
   
   • Make sure to test out the segment prior to manip

Question 19

What are 10 contraindications to manipulation?

Answer 19

1. Non-musculoskeletal causes of pain
2. Systemic/inflammatory disease – e.g. RA, ankylosing spondylitis
3. Neoplasms, metastatic disease (Can exercise (challenging) but cannot manipulate)
4. Spinal cord, cauda equina compromise
5. Pregnancy
6. Osteoporosis, or treatment likely to cause eg long term steroids, anticoagulants
7. Severe nerve root pain
8. Fractures
9. Vertebral or internal carotid artery compromise
10. Usually not for older population

Question 20

What are 7 precautions to manipulation?

Answer 20

1. Pregnancy, post-partum period
2. Adolescents or children (Due to epiphyseal plates & psychological reasons)
3. Muscle spasm or pain positioning
4. Patient unable to understand
5. Patient not relaxed
6. Recent trauma
7. Older patients

Question 21

What is the grade 5 (manipulation) of a thoracic PA manipulation?

Answer 21

small amplitude of movement at the end of range performed with an impulse

Note: A manipulation is NOT performed with force, the key element is speed

Question 22

A manipulation is NOT performed with _____ , the key element is______

Answer 22

force; speed

Question 23

What is the indication of thoracic PA manipulation?

Answer 23

the presence of general hypomobility over several thoracic

segments

Ensure there are no contra-indications to manipulation

Question 24

What are 3 technical aspects of thoracic PA manipulation?

Answer 24

Example T5-6 ↓ ∞ lv

1. Refer prac notes for hand positions
2. Once joint/hands are in position, gently take segment to end of range
3. Apply a small impulse in the PA direction

Question 25

What are the 2 Thoracic mobilisation with assisted active movement (MWM)?

Answer 25

Effective techniques with added proprioceptive effects 1. Th → with active rotation 2. Th ↓ with active extension

Question 26

What are the 3 clinical pointers of Th →with active rotation as Thoracic mobilisation with assisted active movement (MWM)?

Answer 26

1. Technique is a transverse glide with an assisted active rotation (+ slight extension) 2. Performed in sitting, use soft area of hypothenar region - pisiform grip 3. Can be a progression of Transverse glides, or choose as an initial technique

Question 27

What are the 3 clinical pointers of Th ↓ with active extension as Thoracic mobilisation with assisted active movement (MWM)?

Answer 27

1. Technique is a ↓ caudad with an assisted active extension 2. Performed in sitting, use space between thenar and hypothenar on spinous process 3. Can be a progression of ↓, or choose as an initial technique PA-caudad glide

Question 28

What are 7 technical aspects of thoracic PA manipulation (eg. T5-6 ↓ lv)?

Answer 28

1. Always mark segment that aiming to manipulate 2. Ask patient to assist in flexing and rotating thorax to position posterior hand (Able to localise segment (when use hand) 3. Critical that hand supporting T6 is comfortable and the spinous process is supported between flexed fingers and thenar eminence (Base of thumb and PIP of index finger (can support fingers with tissue)) 4. Ask patient to assist in maintaining flexion as rolling back on hand 5. Gently lower patient onto thrusting hand and do not allow them to extend over hand (or rotate) as means therapist has lost the position 6. Place your hands on patient’s elbows for padding 7. Apply a small impulse through the elbows (Thrust back through line of the elbows)

Question 29

What are the 3 clinical pointers of T1-4 → with Rot as Thoracic mobilisation with assisted active movement?

Answer 29

1. effective technique for hypomobility, use in conjunction with → glides 2. reinforce with active mobilisation exercise 3. must use thumb pad as contact as thoracic spinous processes can be naturally tender

Question 30

What are the 3 clinical pointers of T1-4 ↓ with flexion as Thoracic mobilisation with assisted active movement?

Answer 30

1. technique can be performed at any level of the thoracic spine 2. use thumbs as contact point in upper thoracic region 3. use thumbs or space between thenar or hypothenar eminences for mid/low thoracic levels

Question 31

What are thoracic exercises?

Answer 31

Question 32

What are 4 characteristics of thoracic exercise to increase/maintain range?

Answer 32

1. Thoracic extension over roller 2. Yoga poses * Downward dog, cat/camel (4 point kneel --\> focuses on tsp) 3. Adding resistance with theraband, weights 4. Sport specific training

Question 33

What are characteristics of thoracic exercise to increase mobility; adding resistance?

Answer 33

Question 34

What are characteristics of thoracic exercise incorporating motor control exercise?

Answer 34

Incorporate axioscapular and lumbopelvic control into functional tasks