Download 6 and 7- Thoracic Spine Thorax Functions: Shield (vessels, lymph

6 and 7- Thoracic Spine
Thorax
Functions: Shield (vessels, lymph, sympathetic chain, heart/lungs), respiration,pump for low pressure circ/lymph
Thoracic Vertebra
1. Medium sized body
2. Superior and inferior articular processes
3. Facet joint on transverse process to articulate with rib
4. Facets on body to articulate with ribs
5. Sloping spinous process
6. Vertically oriented articular facets (upper thoracic spine
7. Laterally oriented articular facets (9,10,11,12: more lumbar characteristics)
Due to the arrangement of rib heads, the circular thoracic cage and angulation of the spinous processes, the primary
motion in the thoracic spine is: ROTATION
Embryologically, the ribs begin posterior, just lateral to the neural tube forming from mesoderm and migrate ventrally,
pulling what will become intercostal a, v and ne with them. They are considered an extension of the thoracic vertebra.
SD in the thoracic spine will often lead to rib dysfunction and should typically be treated first.
This is what gives us anterior thoracic tender points
Physiologic considerations: Viscero-somatic reflexes/preganglion sympathetic
Viscerosomatic reflex patterns in paraspinal muscles
 Bronchus
T2-4
 Lung
T2-5
 Pleura of lung
T1-11, same level
 Heart
T2-5, left
 Stomach
T5-9, left
 Pancreas
T6-9, both
 Duodenum
T7-10, right
 Gallbladder
T9, right
 Liver
T5-9, right
 Kidney, ureters
T10-12 same side
 Adrenals
T10-11, same side
 Appendix
T11-12, ribs right
 Fallopian tubes
T11-12, L1
6 and 7- Thoracic Spine
Thoracic Sympathetic Innervations (where sympathetic cell bodies live) May contribute to spinal facilitation and TART
 Heart – T1-T5
 Lungs – T1-T6
 Stomach – T5-T9
 Liver and gall bladder – T6-T9
 Pancreas – T5-T11
 Small Intestine – T9-T11
 Colon and rectum T8-L2
 Kidney and ureters T10-L1
 Urinary bladder – T10-L1
 Ovary and fallopian tube – T9-T10
 Testicle and epididymus - T9-T10, L1-L2
 Uterus – T10-L1
Rule of 3’s
Rule of Threes – approximates the positions of the thoracic spinous processes (first column) in relation to the transverse
processes (after the arrow)
T1-3 equal
T4-6 ½ level up
T7-9 1 level up
Reverses each level from T10-12
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Fryette’s principles: motion mechanics
I. When the spine is in neutral position and sidebending is induced, rotation and sidebending will be in opposite
directions.
Found in neutral
Occur by convention only in thoracic and lumbar regions
Involves long curves (multiple segments)
Rotation and sidebending are opposite
Ex: If spinal segments are in a neutral position and rotation is left then somatic dysfunction is N SR RL
Neutral - sidebent to the right and rotated to the left
Treatment position is N SL RR
Neutral sidebent to the left and rotated to the right
6 and 7- Thoracic Spine
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II. When the spine is flexed or extended beyond the neutral position and sidebending is induced, rotation and
sidebending, of at least one segment, will be to the same side.
Found in flexion or extension (beyond neutral)
Occur in thoracic, lumbar, and cervical regions
Single segments (occasionally in small groups)
Rotation and sidebending are to the same side. (Rotation precedes sidebending)
Ex: If found in extension and rotated left, then somatic dysfunction is E RLSL and the treatment position
is F RRSR
III. Initiation of motion in any one plane will modify motion in the other two planes.
Thoracic spine disorders
Scoliosis: abnormal lateral curvature of spine (can have rotation component)
Named for the side of the convexity- protrusion (levo=sidebending curve pointing left; dextro= right)
Congenital, idiopathic, or neuromuscular
Kyphosis: accentuation of normal thoracic curve
Compression fractures are most often the cause of increased kyphosis especially in the elderly female
population. While compression fractures can occur from a traumatic incident, they may also be spontaneous in
those with weakened bone matrix – be it from osteoporosis or lytic lesions. Compression fractures are typically
treated with symptom management or in the acute setting, the patient my undergo kyphoplasty to decrease the
progression of disease.
Scapular dysfunction:
Erbs Palsy: retraction of the scapula
Elevation of the scapula characteristic of overuse
-Traumatic –MVA or Fall, birth trauma with associated fractures, nerve palsy
- Blunt force with spinal or rib frx
- Somatic dysfunction
- Non traumatic: overuse syndrome, postural changes, scoliosis, rotator cuff tendonitis
-Compression frx, postural, referred pain (visceral) infection, tumor
Scapular motion:
Elevation – levator scapula, trapezius
Depression – lower trapezius and rhomboids
Protraction (lateral) –serratus ant
Retraction (medial) – rhomboids, trapezius
Rotatory (clockwise or counterclockwise) – combination of these muscles
Landmarks:
Spine of scapula= T3
Tip of scapula=T7
Palpatory Evaluation and Diagnosis Objectives
Diagnosing thoracic and scapular dysfunction
 Thoracic somatic dysfunction
 Type
 Type I, Neutral
 Type II, Non-neutral/segmental
 Bilaterally extended
 Bilaterally flexed
 Thoracic inlet
 Location
 T1-12
 Scapular somatic dysfunction
Stacked motion preference (cephalad/caudad, medial/lateral, clockwise/counterclockwise)
6 and 7- Thoracic Spine
Somatic Dysfunction: Impaired or altered function of related components of the somatic system (body framework):
skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements.
 Identified through palpation to determine the presence of Tissue texture changes, Asymmetry,
Restricted motion (barrier) and Tenderness
Thoracic Examination
Observation: Posture and Breathing
Palpation: Global ROM
Directed soft tissue screen: Paraspinal red reflex; Paraspinal hypertonic changes
Screen
Run fingers along paraspinal mm assessing for TART
Palpate along spinous processes assessing for midline orientation and proximity
Spring at costo-transverse junction or midline on spinous processes
Segmental screen: Springing
With pt either prone or seated, anteriorly compress the right transverse process (inducing a left
rotation) & then do the same for the left, inducing right rotation
Repeat in flexion and extension and compare
If changes found, diagnose specific area.
If segmental dysfunction, make segmental dx.
If soft tissue changes, make soft tissue diagnosis.
Chronic changes…
locally increased SNS
vasoconstriction (cool skin, pale skin)
decreased muscle tone (boggy, fibrotic, ropy texture)
dull ache
longer term history, may not recall injury
Documentation
 Segment involved
 N, F, E
 Direction of Sidebending and Rotation
 ****Remember: if b/l flexed or extended, then no Sb or Rot involved.
Example:
 Objective findings
 TP prominent on right at T4
 PROM improves in flexion
 PROM to left worsens in extension – TP becomes more prominent, or segment feels stiffer in extension
 Some restriction to PROM of left rotation in neutral
 Spinous process has a wider gap between T4 and T5.
Diagnosis: T4 F R/Sb Right
 Objective findings
 TP prominent on left at T3, T4, T5, T6
 Restriction to PROM of right rotation in neutral
 PROM worsens in flexion - TP becomes more prominent, or segment feels stiffer in extension
 PROM worsens in extension – TP becomes more prominent, or segment feels stiffer in extension
Diagnosis: T3-6 N Sb Right R Left
Name Scapular SD by motion of preference
6 and 7- Thoracic Spine
Indications for OMT- Thorax
 Improve spinal mechanics & motion
 Improve rib cage mechanics & motion
 Balance myofascial tension
 Balance sympathetic tone in a thoracically-influenced tissue, organ or system
Contraindications for OMT-Thorax
 ↓ sympathetic or ↑ parasympathetic tone would be harmful
 Manipulation of the involved structure would be harmful (acutely postop or post-injury)
 Vascular supply tenuous
 Patient tolerance / Other common-sense situations
Jones Strain-CounterStrain Tenderpoints for Thoracic Spine
Jones’ tender point
Small, hypersensitive points in the myofascial tissues of the body used as diagnostic criteria and treatment
monitors
Strain-counterstrain
Indirect treatment utilizing a myofascial tenderpoint reflective of musculoskeletal dysfunction elsewhere in the
body
Tenderpoint and associated somatic dysfunction is relieved by placing the patient into a position of ease.
Contraindications
Absolute: No SD present, lack of pt consent/cooperation
Relative: Pt who cannot voluntarily relax, Severely ill, vertebral a. disease, severe osteoporosis
Procedure
 Structural exam
 Find tenderpoint
 Establish the pain scale for the patient, “THIS IS A 10 ON A SCALE OF 0-10 WITH 0 BEING NO PAIN.”
 Passively position the patient into a position of ease, where the relative tenderness ilicited by palpation of the
same point decreases by 70%
 Hold the patient in this position for 90 seconds while continuously monitoring the point.
 Slowly, passively, return the patient to the original starting position.
 Retest the point.
Trigger point
 Characteristic pain pattern
 Located in muscle
 Locally tender
 Elicits jump sign when pressed
 Elicits a radiating pain pattern when pressed
 Present within a taut band of tissue
 Elicits twitch response with snapping palpation
 Dermagraphia of skin over point
Tenderpoint
 Typically no characteristic pain pattern
 Located in muscle, tendons, ligaments
 Locally tender
 Elicits jump sign when pressed
 No radiating pattern when pressed
 Taut band not present
 Twitch response not present
 Dermographia not present
6 and 7- Thoracic Spine
Levator scapula TP
Rhomboid major TP