1
Q
What did Linton et al find for general prevalence of spinal pain? What percentage was thoracic pain?
A
- 66%
- 15% thoracic
2
Q
Where the inferior angle of the scapula (IAS) is typically thought to be in line with which vertebra? What is it most often in line with? What is the range?
A
- Conventionally thought of as T7.
- most often T8, but can range between T4-T11
3
Q
What is the “vertebral prominens”?
A
- thought of as C7, but can be T1
4
Q
What is the rule of 3s as it applies to the T-spine?
A
- T1-3: spinous px at the same level as the transverse pxs
- T4-6: spinous px a half level below the transverse pxs
- T7-9: spinous px a full level below the transverse pxs
- T10-12: spinous px at the same level
- in cadaver study, from T7-12, the spinous px is in general at the vertebral level of the next caudal level
5
Q
What is the rib angle?
A
- prominent area where the posterior rib angles laterally and anteriorly
- cited in literature as markers of dysfunction, but have not been validated as such
6
Q
What muscles attach at the rib angles?
A
- iliocostalis
7
Q
What is the orientation of the superior facet joints of the T-spine?
A
- planar joints
- angled 60* from the horizontal plane
- 20* from the frontal plane
8
Q
What are the ratios of vertebral disk height to vertebral disk body in the C-, T-, and L-spines?
A
- C-spine: 2:5
- T-spine: 1:5
- L-spine: 1:3
9
Q
What are the two categories that ribs can be classified as? What do they mean?
A
- true or false: whether or not they attach directly to the sternum
- typical or atypical: 2 facets for each attachment on the vertebral body (typical) vs one facet (atypical)
10
Q
Which are the true/false and typical/atypical ribs?
A
- true ribs: T1-7
- false ribs: T8-12 (costochondral or lack of attachment (T11-12))
- typical: T2-9
- atypical: T1, T10-12
11
Q
Which ribs attach to the transverse processes (and thus have a costotransverse joint)?
A
- T1-10
- T11-12 don’t
12
Q
From T1-T5 (or T6), the rib side of the joint is _____ and the transverse px side is _____. Lower, the costotransverse joints are ______.
A
- rib side is concave, and transverse px is convex
- in the lower T-spine the joint is planar
13
Q
Because of the difference in rib joint shapes, what are the differences in movement?
A
- in the upper T-spine, more likely to be able to have rotation/torsional movement
- in the lower T-spine, there is more planar movement
- with inspiration, allows flexion (sagittal plane) in the upper T-spine, and abduction (frontal plane) in the lower T-spine
14
Q
What are the medial attachment points for the trapezius?
What are it’s actions on the scapula?
A
- all T-spine spinous processes, C7 spinous px, ligamentum nuchae, external occipital protuberance
- part of the force couple that upwardly rotates and posteriorly tips the scapula during elevation
15
Q
What are the attachments for the iliocostalis thoracis muscles? Iliocostalis lumborum?
A
- from angle of the ribs 7-12 then spanning up to 1-6, as well as the transverse px of C7
- posterior sacrum and thoracolumbar fascia to the angles of ribs 6-12
16
Q
What changes of what muscles are thought to be associated with rib cage dysfunction?
A
- tissue texture and tenderness of the iliocostalis muscles
17
Q
Erector spinae weakness and decreased muscle density is associated with what poor outcomes?
A
- thoracic hyperkyphosis
- osteoporosis
- decreased quality of life
- increased risk of falls
18
Q
What are the attachments of the serratus anterior?
A
- From the outer surface/superior border of ribs 8-10 and the fascia of the external intercostal muscles
- to the anterior border of the vertebral side of the scapula
19
Q
What are the proximal attachments of the pec major?
A
- sternum
- clavicle
- ribs 1-6
20
Q
What are the actions of the pec major?
A
- adduction and IR
- clavicular portion can assist coracobrachialis and anterior delt with flexion
- in closed chain, will pull ribs anterior, superior, and lateral
21
Q
What are the attachments of the pec minor?
A
- anterior/superior surfaces of ribs 3-5
- to medial/superior coracoid px of the scapula
- when shorted or with hypertonicity, will lead to anterior tipping of hte scapula
22
Q
Which scalenes are attached to the first rib? To the second?
What is the general potential action on the ribs of the scalenes?
A
- First rib: anterior and middle
- Second rib: posterior
- with the C-spine fixed, can elevate the first or second ribs
23
Q
What are the 3 portions of the diaphragm and what are their attachments?
A
- sternal: back of the xiphoid px
- costal: internal surfaces of the costal cartilages and adjacent parts of the lower 6 ribs
- lumbar: first 2-3 lumbar vertebrae
24
Q
Each T-spine nerve exits _________ (above/below) it’s corresponding disk.
A
- below
25
A person had a thoracic disk injury and is feeling some paresthesias just above the level of T6. What nerve root is affected?
- T5
| - dermatomes are just inferior to corresponding vertebral level
26
What is the basic organization of the thoracic nerves?
- has anterior and posterior rami
- posterior rami are divided into medial and lateral branches.
- medial branch supports the spinal extensors and cutaneous sensation in the upper 6 segments
- lateral branch supports spinal extensors and cutaneous sensation in the lower 6 segments
- anterior rami wrap around in the intercostal spaces
- each nerve contributes preganglionic sympathetic fibers to the sympathetic chain
27
Where is the thoracic sympathetic chain located?
- just anterior to the rib head and lateral to the costovertebral joint
28
What muscles are innervated by the intercostal nerves (anterior thoracic)
- intercostals (internal and external), subcostal, posterior serratus, and abdominals
29
What levels of intercostals supply the abdominals?
- 7-11th
30
What anatomical design may allow for UE symptoms stemming from the upper thoracic spine?
- the intercostobrachial nerve (lateral cutaneous branch of the second intercostal nerve) supplies the floor of the axilla and joins the medial brachial cutaneous nerve to supply the medial side of the arm out to the elbow
31
What is the "critical zone" of the T-spine? What is it's significance?
- Between T4-9
- smaller diameter of the spinal canal and relatively reduced blood supply
- a large herniated disk has a larger potential to create cord compression
32
What is T4 syndrome?
What's it's origin?
What is appropriate intervention?
- mobility impairments in the "critical zone" between T4-9 that may be associated with upper or lower quarter neurogenic signs/symptoms such as bilateral paresthesias and sweating.
- origin is unknown, but likely a result of amplification of nociceptive input into the peripheral and CNS
- often improved with targeted mobilizations
33
What is the expectation for zygapophyseal pain referral?
- pain is most severe at one level inferior and slightly lateral to specific joint
- not expected to refer > a half a segment superiorly, but can refer inferiorly by 2.5 segments
- was found with a study that injected joints to provoke symptoms
- only looked at T3-11
34
What are the potential referral patterns for pain at the upper T-spine (C7-T3) and lower T-spine (T11-12) facet joints?
- a lot of overlap in the upper T-spine, with pain in the paravertebral region, as well as inferiorly toward the superior and inferior angles of the scapula
- in lower T-spine can have referral to the iliac crest
- typically only unilateral
- *** from a study with injections
35
What is the general expectation for pain localization/referral with the source at the costovertebral or costotransverse joints?
- pretty much localized to the affected joint, with the exception of the T2 costotransverse joint, which referred superiorly up to 2 levels above. Expectation for pain to be ipsilateral.
- pseudovisceral pain may be generated at the costovertebral joint due to potential degenerative changes encroaching on the sympathetic chain
36
What is an estimate for asymptomatic thoracic disk protrusion?
- 37%
37
What could be a t-spine origin for abdominal pain?
- a lower T-spine disk protrusion/hernation
| - pretty uncommon, but present in case report literature
38
What are the 3 functional sections of the T-spine from a mechanics perspective?
- upper T-spine functions more like the C-spine
- mid T-spine functions independently; significantly influenced by the rib cage
- lower T-spine functions more like the L-spine
39
Motion in the sagittal plane gradually (increases/decreases) from T1-2 through T11-12.
- increases; more potential flexion as you go lower
| - roughly 8-10* of flexion and extension (total range ~16-20*), based on a cadaver study with people ~70 yo
40
What is the hypothesized rib movement associated with T-spine flexion/extension?
- anterior rotation with flexion, posterior rotation with extension
- as the superior T-spine vertebra translates superiorly and anteriorly, the anterior translation pushes the superior demifacet of the rib head
41
What is the clinical significance for limited thoracic extension for the UE?
- thoracic extension and UE elevation are coupled movements, with lower thoracic extension contributing the most to elevation.
- may have limited shoulder elevation with limited thoracic extension
42
Sidebending in the T-spine gradually (increases/decreases) from T1-2 through T11-12.
- increases
43
What is the total lateral thoracic side bend potential per one study?
- ~23*
44
Does thoracic rotation couple contralaterally or ipsilaterally with sidebending?
- controversy!
- Seems to be some variability, especially in the upper C-spine
- ipsilaterally was more cited in the chapter, but it's kind of up in the air
45
What does the T-spine do during shoulder elevation?
- extends, rotates, and sidebends ipsilaterally, according to one study
46
What happens to the ribs during side bending?
- what you'd think. They approximate ipsilaterally, and separate contralaterally
47
T-spine rotation gradually (increases/decreases) from T1-2 through T11-12.
What is total T-spine rotation?
- decreases
- get the most rotation in the upper T-spine
- ~26* for total thoracic rotation
48
What happens to the superior vertebra during thoracic sidebending? Rotation?
- side bend: small ipsilateral translation
| - rotation: slight contralateral translation
49
What happens to the ribs during rotation?
- ipsilateral posterior rotation, contralateral anterior rotation
50
Describe the difference between the "pump handle" and "bucket handle" movements associated with the ribs during inspiration.
- pump handle: ribs move anteriorly/superiorly through their axes at the costovertebral/-transverse joints as the sternum rises; anterior/superior motion more associated with upper ribs
- bucket handle: ribs move laterally and superiorly as the transverse diameter of the thorax expands. Lateral/superior motion more assocaited with the lower ribs
51
While the pump/bucket handles are thought to be associated with specific regions, what was found in an in vivo study?
- found that rib cage motion is pretty similar on all levels
| - At ribs 11-12, found a more caliper like action than a handle action
52
Theoretically, the thoracic sympathetic chain is elongated during which motions/positions?
- flexion, contralateral sidebending, and contralateral rotation
- furthered with cervical flexion in long-sitting, with thoracic flexion and contralateral sidebending
53
What are the theoretical implications of what puts the sympathetic chain on tension?
- potential for injury with whiplash type event
54
What could be the clinical picture for a thoracic sympathetic chain injury?
- burning, itching, pareshtesias
| - slump test in long-sitting that's positive for provocation
55
Which T-spine level is thought to be a tension point for neural tissue?
- T6; area where motion of the spinal cord relative to the spinal canal converges in different directions
56
Is mid-T spine manip appropriate for neural tension symptoms?
- Yes, but rationale for effectiveness is speculative. It makes sense based on our current understanding; but multiple potential mechanisms
57
What are common signs of T4 syndrome?
- headaches
- neck pain
- UE pain
- B "stocking glove" paresthesia
- potential for sweating/sympathetic symptoms
58
Is manipulation/mobilization appropriate for management of T4 syndrome?
- yes
- studies have found a decrease in symptoms after thrust manipulation for people with complex UE regional pain syndrome
- Grade 3 mobs have a sympathetic excitatory response in the hands at T4
- the etiology of effect of mobs on sympathetic nervous symptoms is still not clear though
59
T or F;
There are no studies tha tlook at the motion of T-spine and costal cage in pts with primary or secondary T-spine disorders.
- T
| - most advice is based on expert opinion, biomechanics, and clinical models
60
Most of the motion impairment models/assumptions refer to which articulations?
- the facet joints
61
Are thoracic spine mobility impairments common in individuals that don't have symptoms?
- yes
- the link between pain, impairment, and funcitonal limitation with mobility impairments is not well established
- i.e., manual therapy and/or exercise may create improvements in symptoms without an improvement in mobility
62
What segments most often have impaired flexion mobility?
- upper to mid T-spine
- specifically, T3-4 through T6-7
- presents as reduced kyphosis
63
What movements might demonstrate a unilateral thoracic flexion impairment?
- combined flexion, contralateral rotation, and contralateral sidebend limitation
64
What segments most often have impaired extension mobility?
- upper T-spine to cervicothoracic junction, as well as the lower T-spine
- C7-T2
- presents as hyperkyphosis
65
What movements might demonstrate a unilateral thoracic extension impairment?
- combined extension, ipsilateral rotation, and ipsilateral sidebend
66
What negative outcomes are associated with thoracic mobility deficits?
- decreased quality of life
| - increased risk of falls
67
What impairments/changes are associated with increased kyphosis?
- vertebral compression fx
- spinal extensor muscle weakness
- degenerative changes of the T-spine
68
What is a hypothetical upper rib dysfunction that can occur?
- first rib elevation
- potentially with trauma or repetitive overuse
- may be associated with TOS due to nerve entrapment between the first rib and the clavicle
69
What is the validity of middle/lower rib dysfunction?
- probably exists, but the capacity to dx reliably has not be established in the literature
OCS prep
flashcards
Decks in class (25)
# Cards
-
Osteoarthritis142
-
Foot and Ankle112
-
Knee meniscal issues36
-
Lateral and anterior knee pain55
-
Knee ligamentous issues132
-
Knee ligament CPG42
-
Knee pain and mobility impairments CPG46
-
Pelvis and SIJ (APTA)85
-
Lumbar spine (APTA)104
-
Shoulder APTA (1)172
-
Shoulder APTA (2)163
-
Shoulder APTA (3)78
-
C-spine APTA109
-
C-spine APTA (2)67
-
Hip APTA104
-
Hip APTA (2)139
-
T-spine APTA69
-
T-spine APTA (2)73
-
Elbow APTA96
-
Elbow APTA (2)114
-
Elbow APTA (3)78
-
Misc Trivia83
-
Wrist and hand (OCS-A summary)53
-
TMJ (OCS-A summary)55
-
Misc Trivia 283
