Physiotherapy Back Ax (The spine)

Click here for Lumbar spine Assessment.

 The Thoracic Spine

The thoracic spine  is vital in the diagnosis of upper limb/ rib and thoracic pain. It should include a full subjective and objective examination with use of special tests to aid differential diagnosis. The best way to learn good assessment skills is through hands on practice and watching experts. Try to spend a day with a consultant or extended scope practitioner to see how they perform an assessment. Visit the student room to  find preparation notes for work experience days.

Subjective

  • Patient history
  • -does coughing, sneezing, straining (ie increasing intrathecal and intradiscal pressure increase pain? Is there pain with breathing?)
  • Does any position aggravate symptoms? (radicular symptoms/dermatomal/sclerotomal pattern)
  • Social history
  • Insidious onset?
  • Trauma
  • Region – identify possible structures being affected.
  • Are symptoms felt within a dermatomal pattern?
  • Review of systems (cardiovascular,gastrointestinal, pulmonary)

What does this tell you?

The region of pain indicates which structures could be involved. If pain is localised and palpation of a structure reproduces pain this is usually the source of the symptoms. If tenderness can not be found it the area the patient reports pain and the pain lies in a dermatomal pattern (ie pain into the ribs in the T4 dermatome) then it may suggest that the symptoms are coming from a dysfunction of the T4 facet joint. If the pain lies across the 7th rib and there is a history of trauma and tenderness ++ of palpation this may suggest a rib fracture and if the patient is also experiencing shortness of breath A and E referral is needed to rule out a pnuemothorax. In this situation it may also be wise to take obs (O2 sats, HR and BP) and auscultate so this can be monitored for deterioration.This may be more appropriate to those looking after sports teams.
If symptoms are insidious onset again look for cause- Is there prolonged postures, computer work or repetitive twisting that could be causing the symptoms? Pins and needles or paraesthesia often represents a neural component so also consider where the symptoms may be coming from.

Differential Diagnosis

Scheurmann’s Disease (Juvenile kyphosis)

  • 12-18 yrs
  • Affects males more commonly than females
  • Localised pain
  • Insidious onset
  • Diagnosed with Radiographs
  • May see tight hamstrings

 

Costovertebral joint dysfunction

  • Onset can be sudden/insidious ( if sudden rule out rib fracture)
  • Unilateral symptoms over costoverterbral joint
  • Good posture
  • Aggravated by deep breath
  • PA glides over suspected costoverterbral may reproduce symptoms.

Facet dysfunction

  • Onset sudden/insidious
  • Unilaterally symptoms over facet. symptoms may refer away from spine
  • Thoracic rotation or extension may aggravate
  • PA glides over suspected facet may reproduce symptoms.

 

Postural dysfunction

  • Insidious onset
  • Occupation: Computing/sedentary/prolonged poor posture with work.
  • Patient demonstrates poor posture
  • Localised tenderness on palpation

 

Compression Fracture

  • Flexion increases symptoms
  • Osteoporotic individual
  • Sharp pain with/without signs of neural compression.
  • Diagnosed with radiographs

 

Objective

Clinical reasoning – the thoracic spine can be the referral site of pain from pathology in the cervical spine, shoulder or lumbar spine therefore these must all be cleared. Non musculoskeletal abnormalities such as renal, pulmonary, cardiovascular and gastrointestinal  tumours must also be considered and ruled out.

 

STANDING

  • Observation –
  • Posture (Scoliosis, Dowagers hump, Kyphosis), Bony deformity, Muscle atrophy, gait.
  • AROM (Note quality of movement or pain). These can be recorded by fingertip to floor, down side of leg or using an inclinometer.
  • Thoracic flex, thoracic ext, thoracic sidebending.
  • Myotomes – Ankle plantar flexion(S1-S2); single heel raise.

 

SITTING

  • Observation- (As with standing) + Function – Repeated flexion and extension in sitting/standing. Breathing pattern.
  • AROM – usual measured using an inclinometer and estimation ie % of range.
  • (Quality of movement and pain should be noted)
  • Thoracic flexion, extension, rotation and side bending.
  • Myotomes.
  • Muscle stretch reflexes- Knee jerk (L3-4), Hamstring (L5), Ankle Jerk (S1)
  • Pathologic reflexes (Babinski/Clonus)
  • Dermatomes (UL).
  • Special Tests – Dural/meningeal irritation, nerve root involvement, slump.

 

Supine

  • Myotomal Screen
  • Dermatomes

 

Sidelying

  • Can perform myotomal screening is this position.
  • Palpate PPIVMs for gapping during flex,ext.

 

Prone

Palpation (click here for palpation list)

  1. Soft tissue  2.Bony landmarks  3.Pain apprehension, guarding, spasm.

Joint feel.

1.PACVP

2. PAUVP

3. Transverse pressure.

4. Costovertebral joints (rib springing)

Special Tests

Slump Test- Detects increased tension in the dura/meninges. Patient sits in slumped position with thoracic and lumbar flexion. Patient then flexes cervical spine and gently extends knee. Positive sign – Reproduction of symptoms and/or radicuar pain.

Brudzinski sign – Detects dural/meningeal irritation or nerve root involvement. Patient lies supine. Clinician passively flexes cervical spine by pulling head to chest. Positive Sign – Reproduction of symptoms. Patient may involuntarily flex knees/hips to relieve back pain.

 Check your anatomy and improve skills by reading X-Rays and completing a self directed image interpretation course, brought to you by Heidi Nunn DCR (D) Pgcert.

 

References

Maitland GD: The slump test: Examinationa nd treatment. Aust J Physiother 31:215,1985

Brudzinski J: A new sign of the lower extremities in meningitis of children (neck sign). Arch Neurol 21:217-218,1969.

Flynn TW. Whitman J, Magel J: Orthopaedic Manual Physical Therapy mangement of teh Cervical-Thoracic Spine & Ribcage. CD-ROM. manipulations, Inc, 200.

 

 

 

 

 

 

 

 

 

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