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.
- 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?
- Region – identify possible structures being affected.
- Are symptoms felt within a dermatomal pattern?
- Review of systems (cardiovascular,gastrointestinal, pulmonary)
What does this tell you?
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.
- 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.
- Insidious onset
- Occupation: Computing/sedentary/prolonged poor posture with work.
- Patient demonstrates poor posture
- Localised tenderness on palpation
- Flexion increases symptoms
- Osteoporotic individual
- Sharp pain with/without signs of neural compression.
- Diagnosed with radiographs
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.
- 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.
- 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.
- 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.
- Myotomal Screen
- Can perform myotomal screening is this position.
- Palpate PPIVMs for gapping during flex,ext.
Palpation (click here for palpation list)
- Soft tissue 2.Bony landmarks 3.Pain apprehension, guarding, spasm.
3. Transverse pressure.
4. Costovertebral joints (rib springing)
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.
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.