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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 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 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