T Spine

What is the orientation of the thoracic facet joint?

60 degrees off horizontal plane, 20 degrees off frontal plane

What is the coupling pattern of the thoracic spine?

There are no consistent coupling patterns in the thoracic spine

What is the impact of cervical protraction/retraction on the thoracic spine?

All thoracic levels move during this motion

Which patient populations are more commonly affected by T spine pain?

Females and adolescents (esp. older adolescents)

What is the threshold for diagnosis of scoliosis?

Cobb angle greater than 10 degrees

What is the hand dominance pattern?

Dominant side typically has lower shoulder and higher hip

What is the threshold for kyphosis?

Greater than 50 degrees with dual inclinometers

Does increased thoracic kyphosis predict extension mobility loss?

Not in younger populations; frequently in older populations

What is the normal active range for flexion/extension of the thoracic spine as measured via dual inclinometers?

20-45 degrees

What are the anatomical barriers to flexion?

PLL, ligamentum flavum, facet capsule

What are the anatomical barriers to extension?

ALL, abdominals, spinous process approximation

What is the normal active range for thoracic rotation?

35-50 degrees

What are the anatomical barriers to rotation?

Rib cage, ossification of costal cartilage with age

What is the normal active range for sidebending of the thoracic spine?

25-45 degrees

What are the anatomical barriers to thoracic sidebending?

Rib cage, facet joints

If a patient presents with ipsilateral paraspinal contracture/bowstringing with sidebending, what diagnosis should you be suspicious of?

Ankylosing spondylitis // axial spondyloarthritis

What is the typical endfeel of thoracic PIVMs?

Elastic to firm

If a PIVM results in a hard endfeel, what diagnosis should the therapist be suspicious of?

Osteoporosis or ankylosing spondylitis // axial spondyloarthritis

What are common symptoms associated with thoracic spine pain with instability?

Episodic pain, catching, crepitus, and fatigue

What are common aggravating factors for thoracic pain with instability?

Acute pain with sudden movements and spinal positional changes, sustained spinal loading

What are common alleviating factors associated with thoracic spine pain with instability?

Manipulation (short term), spinal unloading, external support during position changes

What impairments are associated with thoracic spine pain with instability?

Aberrant movements, painful arcs, hinge points, decreased resistance, rotation, weakness of interscapular muscles, weakness of erector spinae (esp. longissimus), weakness of thoracic multifidi, lumbar motion/motor control issues, deep cervical flexor weakness, systemic hypermobility

What are recommended treatment methods for thoracic spine pain with instability?

Treatment of adjacent hypomobility, tonic holds (segmental isometrics of multifidi), integrated tonic holds (prone lying progression - longissimus holds —> with isometric trunk rotation —> with scapular activation —> with upper extremity progressive resistance)

What symptoms are commonly associated with thoracic spine pain with mobility deficits?

Stiffness, pain, facet referral pattern, costotransverse referral pattern, potential difficulty with respiration

What factors commonly aggravate thoracic spine pain with mobility deficits?

Sustained postures, repetitive movements, concurrent cervical or lumbar pathology

What impairments are typically associated with thoracic spine pain with mobility deficits?

Limited thoracic active range of motion with concurrent PIVM deficits, capsular pattern (sidebending and rotation have equal limitation, greater extension loss than flexion), resistance noted before pain, firm endfeel, myofascial tightness (pec minor and lats), rib motion limited during respiration, reduced cervical rotation and lateral flexion

Does scoliosis bracing have long term impacts on quality of life?

No

What is the purpose of scoliosis bracing?

To prevent further curve progression

What is the appropriate approach for scoliosis and posterior musculature?

Strengthen convex side, stretch concave side

What is the most common age of onset for thoracic spine pain with neurological involvement (radiating pain)

The fourth and fifth decades (30s and 40s)

What symptoms are commonly associated with thoracic spine pain with neurological involvement (radiating pain)?

Axial pain to mid/lower thoracic region, T10 most commonly reported level of pain distribution (regardless of disc level involved), increased pain with coughing, sneezing, and straining, radiating pain from the spine to around the ribs, possible sensory complaints in the trunk or lower extremities

What impairments are commonly associated with thoracic spine pain with neurological involvement (radiating pain)?

Symptom distribution changes with repeated movements, cervical movements, traction, and compression, noncapsular restriction with spasm endfeel, radiating symptoms with stress tests, possible sensory deficits

What medical history may be associated with thoracic spine pain with neurologic involvement (with myelopathy)?

PLL and ligamentum flavum ossification, spinal/spinal cord tumor, trauma, infection, thoracic disk disease, spinal cord herniation

What symptoms are commonly associated with thoracic spine pain with neurologic involvement (with myelopathy)?

Similar to that of radiating pain with added possibility of limb pain, weakness, low back pain, bowel and bladder changes

What impairments are associated with thoracic spine pain with neurologic involvement (with myelopathy)?

Positive upper motor neuron tests, distal bilateral neurologic signs and symptoms, gait disturbances

What is the appropriate course of action with thoracic spine pain with neurologic involvement (with myelopathy)?

Immediate referral to emergency care

What are possible diagnoses associated with anterior chest wall pain?

Costochondritis, Tietze’s, and slipping rib

What patient populations are most at risk for costochondritis?

Patients over 40 years old

What patient populations are most at risk for Tietze’s?

Rare condition, but more often seen in patients under 40 years old

What patient populations are most at risk for slipping rib?

Females (70.4% female predominance)

What symptoms are associated with Tietze’s?

Localized, unilateral, single articulation paint at 2nd and 3rd ribs, localized sternocostal swelling

What symptoms are associated with costochondritis?

Multiple unilateral articulations at 2nd through 5th ribs involved, pain with exertion, deep breathing, and upper body movements

What symptoms are associated with slipping rib?

Ribs 8-10, 11-12, can have posterior pain also, bending, twisting, and deep breathing with sharp stabbing pain followed by dull ache (rib slip)

What patient demographics most often experience thoracic outlet syndrome?

Females and patients age 20-50 years old

What symptoms are commonly associated with thoracic outlet syndrome?

Heavy, achy pain with fatigue, worsened with upper extremity elevation and sustained positions, night and early morning paresthesia, vague location of paresthesia, temperature change complaints, cervical spine pain, occipital headache, chest pain, arm pain, scapular pain

What other diagnoses may need to be ruled out when considering thoracic outlet syndrome as a differential diagnosis?

Pancoast tumor, brachial plexopathy, Parsonage turner syndrome, cervical HNP, peripheral neuropathy, carpal tunnel, upper extremity DVT, angina, T4 syndrome

What impairments are associated with thoracic outlet syndrome?

Cervical spine AROM not provocative unless scalenes are on stretch, C8/T1 sensation altered, but often not in a dermatomal pattern

What symptoms are associated with thoracic/thoracolumbar/rib fractures?

Vague, ill-defined ache that worsens to sharp stabbing pain, increased pain with cough and sneezing, generally posterolateral to anterior pain

What type of treatment plan is best for thoracic/thoracolumbar/rib fractures?

Extension-based exercises