T-Spine Manipulation- Cohen Flashcards
(49 cards)
1
Q
T/S Pain
A
- Viscera and T/S w/ shared innervation
- pts w/ primary c/o T/S pain should have ht’d awareness for non msk disorder
2
Q
Visceral referral pain to the T/S
A
see pics
- Cardiac Ischemia
- Dissecting thoracic aneurysm
- Peptic ulcer
- Cholecystitis
- Renal infection and kidney stones
3
Q
Serious Cond’s Causing T/S Pain
A
see pics
- Fx
- Neoplastic cond’s
- Inflammatory disorders
- Inflammatory or Systemic Dis’s
4
Q
Pot sources of mechanical t/s pain
3
A
- Thoracic facet jts
- Thoracic IVD
- Soft tissue
5
Q
Pot sources of mech. t/s pain
Thoracic facet jts
A
- pain local to jt
- may inc w/ closing
- EXT and ipsilat s/b
6
Q
Pot sources of mech. t/s pain
Thoracic IVD
A
- more common in lower t/s, can refer to abdominals and hip
- diffuse pain, may radiate ant.
- thoracic nerve root lesions uncommon
- possible directional preference of EXT
- Thoracic disc herniation in imging is common in those W/OUT pain
7
Q
Pot sources of Mech t/s pain
Soft tissue
A
trigger pts common in upper t/s and scapular region
8
Q
NOTE about t/s mechanical sources of pain
A
Probably not possible, nor necessary to ID the exact structural cause of t/s pain and all MSK pain as multi-factorial causes
9
Q
Mech sources of rib pain POSTERIORLY
2:
A
- Costovertebral jts
- Costotransverse jts
10
Q
Mech sources of rib pain ANTERIORLY
2:
A
- Costosternal jts
- Costochondral jts
11
Q
T/S pain referral patterns
A
- Pain mapping shows that thoracic facet and costotransverse jts refer pain locally OR @ most 1 lvl above or below
12
Q
Cervical referral patterns:
A
- Cervical facet jts and discs refer pain to the thoracic and periscapular area
- Cervical radiculopathy→ pts often report periscapular area pain
13
Q
Cervical radiculopathy
Pts often report pain referral to_______
A
Periscapular area
14
Q
Can mechanical t/s pain mimic visceral pain?
A
- shared innervation and convergence of primary afferent into the spinal cord
- Sympathetic division of ANS originates from T1-L2 (big region)
- Viscera below diaphragm receive sympathetic innervation from below T5
15
Q
Pseudo visceral pain
A
see pics
16
Q
Pseudoanginal pain
A
- T4-T7 segs freq’ly implicated in this phenomenon
- 6 reports of anginal pain relived by manipulation of mid t/s segs
17
Q
Mgmt of chest pain:
appraisal of most probable cause (“initial dx”)
A
- Ischemic heart dis→ 50%
- MSK pain→ 22%
- Psychiatric dis/anxiety→ 12%
- pulm dis→ 5%
- dyspepsia→ 5%
- GI dis→ 3%
- other (arrhythmia, HTN crisis)→ 3%
18
Q
Chest Wall Syndrome
A
- Most common cause of Ant. chest pain in pts presenting to primary care is benign
- Usually loc’d in ant chest wall and is MSK in nature
- 20-45%
19
Q
Abdominal pain of MSK origin
Responses to following questions predict that abdominal sx’s are likely of MSK origin:
A
-
YES to both:
- Does taking a deep breath aggravate your sx’s?
- Does twisting your back aggravate your sx’s?
-
NO to ALL 3:
- Has there been any change in B&B habit since onset of sx’s?
- Does eating foods aggravate your sx’s?
- Has there been any wt change since onset of sx’s?
20
Q
T4 Syndrome
RARE
Most hypOmobile segment
A
Clinical features:
see pics
21
Q
Assess of pt w/ T/S pain
A
- assess for red flags
- assess adj. regions
- c/s
- shoulder
- L/S
- ID t/s impairments
- mvmt impairs
- sensitivity to loading
22
Q
More assess of pt w/ T/S pain
A
- Hx→ trauma vs overuse
-
Area of sx:
- t/s vs ribs, c/s referred pain, visceral
-
Aggravating factors:
- sustained postures vs dynamic acts.
-
Special ?’s:
- night pain
- chest pain
- abdom. pain
- neuro sx’s
23
Q
T/S and Rib Composite Exam
A
- Observation/posture
- Screen C/S
- T/S AROM, AROM w/ overpressure
- palpation
- segmental mobility
- Thoracic central and U/L PA glides
- Rib PA’s and AP’s
- muscle length
- lats, pecs
- muscle strength
- mid/lower traps
- Serratus ant.
24
Q
T/S Assessment
Mechanical T/S pain
*NOTE: usually rotation affected→ Facets, T/S
A
- painful + restricted t/s ROM and t/s seg. mobility
- AND/OR
- pain w/ sustained t/s loading
25
T/S Assessment
**Mechanical Rib Pain**
**\*NOTE:** usually S/B→ rib issue, CV or CT jts
* painful + restricted t/s ROM +/- **painful breathing**
* painful + restricted rib seg. mobility
26
T/S pain evidence for mgmt:
* NO high qual evidence for mgmt of primary t/s or ribcage pain
* 1 low qual RCT suggests benefit of man tx + ex for pts w/ primary t/s pain
* Regional interdependence
* mod evidence for t/s manipulation in mgmt of indiv's w/ neck pain
* conflicting evidence for shoulder disorders
27
T/S and C/S Connection
* Mvmt of **C/S** associated w/ mvmt of **T/S**
* T1, T6, T12 segs **all move during C/S mvmts\*\*\***
* excursion from **full c/s protraction to retraction** involves 30% and 10% contributions from lvls **C4-T4** and **T5-T12 respectively**
28
Evidence for T/S Manipulation in **Neck Pain**
* **T/S manip usually included as part of multi-modal tx package**
* diff to separate out effects
* **Cond's studied:**
* mech. neck pain
* C/S radiculopathy
* WAD
* **Majority studies show + effects compared to:**
* competing intervents
* sham manip→ just putting them into pos.
* controls
29
T/S Manipulation for **Neck Pain _Rationale_\*\*\***
* Potentially **safer** than C/S manip
* tx neck pain w/out tx neck
* Can be used when neck is irritable
* **acute c/s radiculopathy**
* **Acute** WAD or neck pain
30
T/S Manipulation
Huisman 2013
10 studies (677 pts)
* 8/10 studies showed **sig reduction in pain and disability for pts w/ mech. neck pain**
31
T/S Manipulation for **C/S Radiculopathy**
## Footnote
**Young et al and Cleland**
* Included @ least one manual tx tech targeting **upper and mid t/s in multimodal tx package for pts w/ c/s radiculopathy**
32
Does the technique matter?
* All studies done on pts w/ neck pain
* TS manips may have greater **short term effect** compared to mobs
* TS manip + CS manip/mobs may have **greater short-term effect** compared to **CS manip/mobs alone**
* **Choice OR direction of tech. _does not affect_ immediate outcomes**
* seated, supine, prone
33
**Regional Interdependence:**
**Thoracic spine and Shoulder**
* **Upper t/s Ext and ipsilateral s/b REQUIRED for _end-range shoulder Flex_**
* Restricted t/s mobility→ subAC patho
* Restricted upper rib mobility→ **s/s consistent w/ subAC impingement or TOS\*\*\***
34
T/S and **Shoulder Girdle**
* **Incd T/S kyphosis** leads to **reduced shoulder elevation ROM**
* assoc'd w/ pain?
* Full B/L shoulder elevation assoc'd w/ on avg **12 degs of t/s Ext (lower\>upper)**
* close to total amt of t/s Ext available\*\*\*
35
T/S Kyphosis and Shoulder Elevation
* **Taping** to **reduce t/s kyphosis** lead to inc in **shoulder flex and scap plane ABD** in some people w/ and w/out shoulder pain
* Pain was unchanged in people w/ sx's
* Deg of elevation where they reported pain was higher
36
T/S Manip and Shoulder Pain
* Part of multimodal program in pts w/ shoulder pain
* Pilot studies found immediate effects of TSM on shoulder pain and/or ROM
* No diff in indiv's w/ SubAC impinge
37
Shoulder Pain and the **Upper Ribs**
see pics
38
T/S and Tennis Elbow
* 70% indiv's w/ tennis elbow reported c/s or t/s pain compared to age match controls
* **Local pain in elbow** was elicited w/ **TS spring testing** in almost half pts w/ tennis elbow
39
T/S Neurodynamics \*\*
* Phys health and mobility of TS may effect **spinal neurodynamics**
* Consider assess of TS in pts w/ **sx's brought on by neurodynamic testing**
* Ex. **Slump Test**
40
Mech. Effects of TSM
see pics
41
Neurophysiological Effects of TSM
see pics
42
T/S Summary
* Primary T/S or Rib pain **should alert clinician to _possible Red Flags_**
* SCREEN!
* **Lower c/s** _frequently refers to_ **Upper t/s**
* Mgmt of MSK t/s disorders→ **focus on impairs w/ _mobility deficits_**
* Regional interdependence of **T/S** and **neck pain** and **shoulder pain**
43
T/S PA's
Spring Testing
see pics for instructions
Used for **assessment and mobilization**
44
T/S Manipulation
## Footnote
**INDICATIONS (DO)**
* Neck pain
* c/s radiculopathy
* c/s HAs
* WAD
* t/s pain
* shoulder pain
* Lat elbow pain
* stiffness w/ t/s testing
* restricted CS and TS ROM
45
TS Manips
## Footnote
**CONTRAINDICATIONS (DO NOT DO)**
* Osteoporosis (known or @ risk for)
* Hx of OR active neoplasm
* Fx of TS
* Spinal infection
46
Manual Therapy Clinical Decision Making
* Functional test/pain score/location of sx's→ basic manual exam→ manual intervent→ **_reassess_ functional tests/pain score/loc of sx's**
* \*Consider:
* safety
* irritability
* pt comfort
* pt expects
* clinician skills
* Baseline outcome measures→ reassess @ follow-ups
* PSFS
* NDI
* NPRS
47
Seated Mid-TS Thrust Manip
see pics
48
Prone TS Manip w/ Thrust
see pics
49
CTJ Distraction Manipulation w/ Thrust
\*Full Nelson one
see pics
