Orthopedic & Manual Therapy Blog
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In many cases, the patient's subjective history alone should be enough to diagnose the musculoskeletal issue. Whether it's the mechanism of injury, location of pain, and/or pattern of pain, we are often able to formulate our treatment plan from the patient's subjective report. That being said, there are cases where the subjective report doesn't match the typical presentation and is, therefore, insufficient in evaluating the patient. It is for this reason that we must be thorough with our examination.
Recently I had a patient that presented with a subjective history of Lumbar Extension Movement Impairment Syndrome (MIS). However, when I got to the objective examination, all the findings matched with a Lumbar Flexion Movement Impairment Syndrome. Cases like this can be challenging due to the conflicting presentation. This is where implementation of an asterisk sign or a system that utilizes asterisk signs can be useful.
The two systems I typically use are repeated motions and Sahrmann's Movement Impairment Syndromes. In both methods, first an asterisk sign is measured, followed by the assessment. The asterisk sign is then re-measured. With repeated motions, we want to see an improvement in pain, mobility, strength, reflexes, or other measurement with our asterisk sign after performing sets of 10-20 repetitions. The more repetitions, the more the asterisk sign should improve. With Movement Impairment Syndromes, the painful/abnormal movement pattern is observed, then corrected. If the corrected form eliminates or significantly improves the pain, that increases the likelihood of that direction of preference. Another way of thinking about it is stabilizing the region from excessive movement into a specific direction that it is susceptible to. In most cases, the subjective report and objective findings match a pattern or presentation. However, what do we do when the pattern doesn't match? What I recommend is to focus on the direction that the objective findings match with. Sometimes the patient doesn't give the most accurate subjective history and the objective examination is reproducible and can show immediate change. That being said, be prepared to re-examine the patient and switch directions following the first couple visits if the patient is not responding (or worsening). Check out the lecture below on how Examination of the Cervical Spine works utilizing Movement Impairment Syndromes! For more information like this, check out the FREE Mini Course: Management of the Cervical Spine
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The thoracic spine is an anatomical region that is often skimmed over in physical therapy school (especially during clinical and practical exams). Students are taught basic anatomy and some assessment/treatment techniques, but often fail to integrate this information into actual clinical scenarios. While these fundamentals are important, several important anatomical considerations and clinical connections are often overlooked. The thoracic spine links two of the most commonly injured body parts: cervical and lumbar spine. With the continued development of our understanding of regional interdependence, it is becoming increasingly important to use a whole-body examination for each of our patients. This post is an in-depth review of the thoracic spine.
Anatomy: When discussing thoracic spine anatomy, one of the first things to remember is that the thoracic spine is comprised of 12 vertebrae. These vertebrae have similar characteristics to the other vertebrae: a vertebral body (disk to vertebral body height ratio is 1:5), pedicles directed posterior from the body, lamina that connect to form a spinous process, and facets (Neumann, 2010). The transverse processes are directed posterolaterally and the spinous processes fall inferiorly (depending on the region). This orientation puts the transverse processes one segment below the corresponding spinous process. Clinically, this is an important consideration for palpation. T1-3 and T10-12 may actually have their spinous processes at the same level as the transverse processes (Egan et al, 2011). The spinous processes of T4-T6 fall half a level below the transverse processes, while T7-9 spinous processes fall a full level below the transverse processes (this is the “rule of 3’s” which has limited support at the time, so should be applied with caution). The pedicles actually sit directly posterior from the vertebral body, making the vertebral canal narrower here compared to other parts of the spine. T4-9 is known as the critical zone because the vertebral canal is narrowest here; it also has reduced blood supply (Egan et al, 2011). For this reasons, T6 is a tension point. At T6, motion of the spinal cord versus canal converge in different directions, meaning restriction in neural/spinal mobility can occur and may need to be addressed. The superior and inferior facets in the thoracic region are oriented about 60 degrees from the horizontal plane and 20 degrees from the frontal plane with the inferior facets facing anteriorly, inferiorly, and slightly medially; the superior facets face posteriorly, superiorly, and slightly lateral. Something to consider is that there is no immediate change between cervical to thoracic vertebrae and thoracic to lumbar vertebrae. The superior thoracic vertebrae bare qualities more similar to the cervical spine and the inferior thoracic vertebrae more so resemble the lumbar spine.
Ribs: Additionally, when assessing the thoracic spine, one must consider the ribcage. There are 12 ribs (usually) in the body, just as there are 12 thoracic vertebrae. Ribs 1-7 are true ribs in that they attach directly to the sternum in the front of the body (Neumann, 2010). Ribs 8-12 are false ribs. Ribs 8-10 join in cartilage before attaching to the cartilage of the 7th rib. Ribs 11 and 12 are floating ribs and have no ventral attachments. Ribs 3-9 have demifacets on the thoracic vertebrae for attachment that span 2 vertebrae. Ribs 1, 11, and 12 have one facet on the corresponding vertebrae. The 2nd rib attaches to both T1 and T2 vertebrae. Additionally, ribs 1-10 have facet attachments at the costotransverse joints, while ribs 11-12 lack these as "floating ribs." Above T7, the rib portion of the costotransverse joints are concave, allowing for more rotation compared to the planar joints of the below T7 (Egan et al, 2011). The sympathetic chain lies on the anterior side of the rib heads next to the costovertebral joints. Clinical Implications: As stated previously, the fact that the thoracic spine connects the cervical spine to the lumbar spine is reason alone that this anatomical area should be considered for treatment. Think about the impact of posture. In most patients that sit for prolonged periods with a forward head posture, the anterior shift of the center of gravity places an excessive flexion moment arm to the thoracic spine, furthering the already kyphotic nature of the thoracic spine. As with any tissue, prolonged stress and creep eventually leads to pain when the tensile stiffness is no longer sufficient and the patient experiences pain. Training postural muscles is key to encouraging a more neutral posture that does not stress the tissues excessively. This may include spinal stabilizers and scapular stabilizers and should be dosed appropriately (likely want some high repetition-based exercises to improve endurance). Consider facet restrictions: Limited joint mobility in one location often leads to hypermobility and pain in other regions, either nearby or distant. A joint dysfunction can often lead to hypertonic/painful muscle tissue near the joint as well. We can treat these restrictions with manual therapy and exercise. Two conditions less commonly discussed but seen relatively often include rib dysfunction and neural tension. Rib impairments are typically considered after a blow to the side or pain with breathing, but that is not always the case (making it harder to identify). A partially subluxed or restricted rib can be quite painful and present as thoracic paraspinal pain or even abdominal pain as the tip of a floating rib presses against the anterior tissue.  A potential location for pathology and treatment of neural tension is the thoracic spine. Remember that the thoracic spine contains the critical zone where the vertebral canal is narrowest. The spinal cord can easily become compressed here, leading to pain/neural tension along the path of a nerve. A nerve can become irritated anywhere in the body. Additionally, sometimes neural tension in the thoracic spine may be related to the cervical spine. With cervical radiculopathy or Cloward’s Area, thoracic/scapular pain can be coming from the cervical spine. When the patient presents with thoracic restrictions, a manipulation to the mid-thoracic spine often improves pain and neural tension by improving mobility. This doesn’t only apply to thoracic pain. There is research showing that patients with shoulder or neck pain may benefit from thoracic manipulation. In fact, there is a clinical prediction rule recommending thoracic manipulation for neck pain (non-validated):
For more information on topics like these, check out our FREE Cervical Spine Mini Course on how to treat Cervical Radiculopathy! References:
1. Cleland JA, Childs JD, Fritz JM, Whitman JM, Eberhart SL. "Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education." Phys Ther. 2007 Jan. 2. Egan W, Burns S, Flynn T, and Ojha H. The Thoracic Spine and Rib Cage: Physical Therapy Patient Management Utilizing Current Evidence. Current Concepts of Orthopaedic Physical Therapy, 3rd Ed. La Crosse, WI. 2011. 3. Neumann, Donald. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd edition. St. Louis, MO: Mosby Elsevier, 2010. 322-323. Print "How Long Will It Take to Get Better After My Surgery?"Patients often have unrealistic expectations regarding their rehabilitation prognosis and expected symptoms throughout each stage of the healing process. I like to use the graph below to help educate patients regarding how long it takes to feel 'normal' post-surgery. While 12 months can seem daunting for many patients, this timeframe is an honest and realistic approach to surgical tissue healing. Graph Overview PHYSICAL THERAPY PHASE (0-3 months) During the first 12 weeks following trauma or onset of symptoms, patients are generally improving. From a physiological perspective, collagen is maturing, remodeling, and getting stronger. In this stage patients are almost solely attending physical therapy and performing corrective exercises. At the end of 12 weeks, patients likely will feel 60-70% back to their prior level of function. Individuals who perform desk jobs should be back at full duty; more strenuous jobs are still on partial duty. COMBO GYM + CONTINUED PHYSICAL THERAPY REHAB (3-6 months) From 3-6 months the patient usually begins their normal gym routine (strength training and cardiovascular exercise) while performing rehabilitation concurrently. I generally think of this phase as someone attending PT 1x/week and performing their gym routine 3-4x/week. In this phase, the individual is starting to feel significantly better, but they have not reached full strength yet. They still have some discomfort (not necessarily pain), and transitional movements, such as getting out of bed and getting up from a chair are still not normal. Ultimately, they still need more work! FULL RETURN TO NORMAL ACTIVITY/SPORT (6-12 months) From 6-12 months, the patient has typically stopped their formal rehabilitation program. They are now performing their normal gym routine and daily activities. The individual continues to progress strength, mobility, flexibility, but now has all the tools needed to be independent. The occasional flare up may occur (especially if a novel training movement is incorporated), but is not anticipated. At the end of the 9-12 months, they should have reached life as usual. Closing Points Many patients do NOT realize how long post-surgery rehabilitation takes. In my active cash-based population, many of my patient's have self proclaimed high pain tolerances and feel better relatively quickly. Despite subjectively feeling strong, practitioners must remember that scar tissue continues to mature and remodel for 2+ years! Strengthening and retraining movement patterns will take months (even after the patient feels better). Reaching 100% pain free and 'normal' activity generally takes longer than someone will anticipate. Being honest and giving appropriate education early on can change a patient's outlook on their condition. Use this graph when educating your patients!
-Jim Heafner PT, DPT, OCS |
AboutDr. Jim Heafner & Dr. Chris Fox write about their treatment philosophy. 
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