Thoracic Spine Update
Thoracic Spine: Differential Dx
University of Delaware
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University of Delaware
Spinal Metastases
Infection
(Ozaki et al 2002; Deyo and Diehl 1988)
(Deyo et al 1988)
Uncommon cause of
thoracic pain (< .01%)
 Sign:

Most common form of Ca in thoracic
region (< 1 % of cases)
– Usually secondary to breast,
lung, or colon Ca
Prediction of Ca
– Hx of Ca (+ LH Ratio: 15.5)
– Age > 50 years (+ LH Ratio: 2.7)
– Unexplained Weight Loss (+ LH
Ratio: 2.5)
– Failure of Conservative
Treatment (+ LH Ratio: 2.6)
University of Delaware
– Fever
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Causes
– Osteomyelitis
– Diskitis
– Epidural infections
Metastasis of primary lung
cancer
3
Visceral Causes
University of Delaware
Vertebral Osteomyelitis
4
Visceral Referral Sites
Pain lacks mechanical presentation
 Referred pain
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– Theory: convergence of primary afferent neurons to
the same 2nd order neuron in the SC
University of Delaware
5
University of Delaware
6
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Signs/Sx
– Pain/pressure
– Clammy skin
– SOB
– Nausea/vomiting
Stable Angina
– Occurs with exertion
– Relieved with rest
Unstable Angina
– Random
– Unpredictable
– Not related to activity
– Risk factor of myocardial
infarction
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University of Delaware
Signs/Sx:
– Boring pain from epigastric
area to mid-thoracic region
– Upper abdominal pain that
causes awakening
– Provoked/Relieved by eating
– Feeling of fullness
– Mild nausea
– Bloody/dark tarry stool
– Fatigue
– Weight loss
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Signs/Sx
Male
Advanced age
Atherosclerosis
HTN
Blunt chest trauma
University of Delaware
10
Acute Pancreatitis
(Munoz and Katerndal 2000)
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Signs/Sx
– Left upper quadrant pain
» May radiate to thoracolumbar junction
– Pain worst after eating
– Abdominal distension
– Nausea/Vomiting
– Abdomen TTP
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Risk Factors
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Dehydration
Family/personal hx
Diuretic overuse
Diets high in Vit D
Urinary tract infections
University of Delaware
Risk Factors
– Females > males
– Advanced age
– Native American/Hispanic
descent
– Gallstones (90% cases)
Renal Colic
Risk Factors
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9
– Moderate-severe sharp pain in
back/side/groin
» “knife in side”
» front  back
» worse at night
– Sweating
– Pallor
– Nausea/vomiting
– Blood in urine
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Acute Cholecystitis
Signs/Sx:
– Pain in upper R quadrant/upper
middle abdomen
» May spread to back or below
right shoulder blade
» ↑ after eating greasy foods
– Clay-colored stool
– Fever
– Nausea/Vomiting
– Jaundice
Excessive alcohol intake
Regular use of aspirin/NSAIDs
Smoking/tobacco use
Radiation treatment
University of Delaware
• Risk factors:
8
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• Risk Factors
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Signs/Sx
– Sudden onset
– Unrelenting chest pain
» May radiate to back if
descending aorta is
involved
– Unrelieved with position
changes
– Fainting/Dizziness
– Heavy Sweating
– Nausea/Vomiting
– Pallor
– Rapid/Weak Pulse
– Low BP/Difference in BP
between limbs
– SOB/Swallowing Difficulty
University of Delaware
7
Peptic Ulcer Disease
•
Dissecting Aortic Aneursym
Myocardial Ischemia
11
Gallstones
Heavy alcohol intake
Infections
Trauma
Metabolic disorders
University of Delaware
12
Acute Pyelonephritis
(Shields and Maxwell 2010)
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Signs/Sx
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Rapid Onset (hours-days)
Flank/abdominal pain
Fever/chills
Fatigue
Frequent/painful urination
Cloudy/bloody urine
Thoracic Spine Special Tests
Risk Factors
– Females > males (< 65yr)
» Sexually active & pregnant
– Advanced age
– Diabetes
– Other renal diseases
University of Delaware
13
University of Delaware
Cervical Rotation Lateral Flexion
Test (CRLF)
(Lindgren et al 1989; Lindgren et al 1992)
for 1st rib hypomobility
– Use with brachial plexus sx
(i.e. TOS)
Seated
Passively & maximally rotate
away
– Flex as far as possible
Test
Beevor’s Sign
(Desai et al 2012)
 10th-12th
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Nerve Palsy
Supine
Raise head (or cough)
Umbilicus should
remain in straight line
Positive:
– Umbilicus moves
toward head
Reliability: excellent
» + if flexion ↓ (compare with
uninvolved side)
University of Delaware
University of Delaware
Superficial Abdominal Reflexes (SAR)
Adam’s Forward Bend Test
(Fujimori et al 2010)
(Cote et al 1998)
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Blunt pin
Lightly scratch skin from
outer abdomen toward
midline
Umbilicus should deviate
toward test side
Positive:
– Unilateral/Bilateral
absence
– Hyporeflexia
University of Delaware
VIDEO:
http://www.youtube.com/watch?
v=4oo1oDQSfPs
Abnormal SAR: Among those with scoliosis:
Predictor of non-idiopathic scoliosis:
Sensitivity: 38%
Specificity: 96%
+ Predictive Value: 90%
Predictor of scoliosis with syringomyelia:
Sensitivity: 89%
Specificity: 86%
+ Predictive Value: 80%
Scoliosis?
Standing
 Maximal flexion
 Positive test:
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– Rib hump on
convex side
Sensitivity: .92
Specificity: .60
University of Delaware
Traction Manipulation: CT Junction
(modified)
•
Thoracic Manipulations
May use if...
– Shoulder pathology or limited ROM
– Significant neural tension
PROCEDURE
-Pt sits at back edge
of table
-Adjust table height
-PT places their
hands over pt’s
-PT chest contacts
pt’s back
-staggered stance
-take up slack
-distract upward,
lifting with legs
University of Delaware
University of Delaware
Supine AP Manipulation:
Upper Ribs (T2-T4)
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Supine
Pt crosses arms & clasps
hands along base of neck
PT uses a “cupped hand” to
create a fulcrum over the
targeted rib
Bring pt over the fulcrum
PT uses body to press
through pt’s arms
Take up slack
Perform high velocity, low
amplitude thrust
Supine AP Manipulation: Mid
Ribs (T5-T8)
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•
University of Delaware
University of Delaware
Upper Rib: AP Manipulation
(Sitting)
Seated 1st Rib Manipulation
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Pt seated
PT behind pt with foot resting on table
Pt’s arm rests over the PT’s knee (uninvolved side)
PT uses “cobra” hand-arm placement on uninvolved side
PT places 2nd MCP over sup. 1st rib & introduces SB with
slight downward pressure
Upper hand
– Retracts the head
– Introduces slight SB toward the involved side
– Introduces slight rot. toward the uninvolved side
Thrust is inferior & slightly medial toward pt’s
contralateral hip (forearm aligned with vector)
University of Delaware
Same as previous
Target region lower so
requires > cervicothoracic
flexion
May need to have a 2nd person
hold the pt’s head so he/she
can relax
– Could use pillows to
elevate head if 2nd person
unavailable
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Pt seated with back at edge of table
Adjust table height
PT grabs pt’s thumbs & places them
at targeted rib level bilaterally
PT’s chest contacts pt’s back
Staggered stance (leg forward on
involved side)
Take up slack
Perform AP thrust while pressing
your chest into the pt’s back
.
University of Delaware
Upper Rib: AP Manipulation
(Standing)
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Pt standing
PT grabs pt’s thumbs & places them at targeted
rib level bilaterally
PT’s chest contacts pt’s back
Staggered stance (leg forward on involved
side)
Take up slack
Perform AP thrust while pressing your chest
into the pt’s back (creates thoracic extension)
University of Delaware
Lumbar Spine Update
University of Delaware
LBP: ICF 2012 Guidelines
University of Delaware
University of Delaware
University of Delaware
University of Delaware
Biopsychosocial Framework
Pain influenced by both tissue pathology &
psychological factors & social context in which pain
occurs
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The STarT Back Trial Study Protocol
Hay et al, 2008
University of Delaware
University of Delaware
Background
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STarT Back Tool
Psychosocial factors are useful for
predicting pts who will develop CLBP
LBP grouping tool for use in primary care
 3 categories for targeted treatment
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– In primary care, under-recognized
– Based on presence of…
Cognitive behavioral approaches help select
groups of pts with CLBP
 Need to sub-group heterogeneous pt
populations
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» Modifiable physical & psychological prognostic
indicators for persistent, disabling sx
– Categories
» Low risk
» Medium risk
» High risk
– “who will do best with which treatment”
University of Delaware
University of Delaware
STarT Back Tool
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Treatment: directed toward secondary
prevention of disabling LBP
Trial Objectives:
Participants
800+ patients
 8-10 general practices
 Inclusion Criteria:
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– 18 years or older
– LBP with/without radiculopathy
– Primary: Compare effectiveness of subgrouping for
targeted treatment with best current PT care
» Over 12 months
– Secondary:
» Investigate the change in prognostic indicators separately
for each sub-group as compared to the controls
» To evaluate cost-effectiveness of the proposed care
model
University of Delaware
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Exclusion Criteria:
– Serious pathology (i.e. non-mechanical LBP)
– Spinal surgery in past 6 months
– Pregnancy
– Current LBP treatment
University of Delaware
Study Protocol
Pts identified by GP, nurse, or PT
 “Pop-Up Screen” reminder
 Informed Consent Process
Study Protocol
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– Roland-Morris Disability Questionnaire
(RMDQ)
– Pain Catastrophising Scale (PCS)
– Nurse blinded to treatment group allocation
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Baseline questionnaires
Treatment allocation
– Targeted vs. best current care
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Interventions
Primary outcome measures
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Data Analysis
– Intention-to-treat
– Analyses for 4 & 12 month time-points
– Intervention auditing
– Clinical mentorship
University of Delaware
University of Delaware
Neural Irritation?
Lumbar Spine Special Tests
University of Delaware
Bowstring Test
(Cramm Maneuver, Popliteal
Pressure Sign)
Sciatic Nerve
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Supine
SLR placed on examiner’s
shoulder
Maintain thigh position & flex
knee 20° to reduce sx
Apply pressure to popliteal fossa
Positive:
– Pressure results in sx return
(i.e. tingling in hip/buttock)
University of Delaware
University of Delaware
Kernig’s Sign
SC/Root Involvement
 Supine
 Hips and knees flexed
 Extend knee to resistance
(should be > 135°)
 May place head in hands; Flex
head to chest (to further
stretch)
 Positive:
– Pain or resistance
University of Delaware
Active SLR
(Mens et al 2003: Roussel et al 2007; Mens et al 2012)
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Need for Stabilization Program?
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University of Delaware
Supine
“Try to raise your legs
(~20 cm), one after the
other, above the table
without bending your
knee (hold for 5 sec).”
Pt scores effort:
– 0=not difficult
– 5=unable
– Add R & L
Reliability: good-to-excellent
Posterior Pelvic Pain in Pregnancy:
-Sensitivity: 54% (0-1 cut-off)
-Specificity: 100% (3-4 cut-off)
University of Delaware
1. Resistive SLR
(Kumar et al 2012)
Supine
Passively flex hip
while maintaining
knee in extension
 Positive:
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Secondary Gain Motives (SGM)?
– Pt actively exerts
downward resistance
during SLR
University of Delaware
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Sensitivity: .74
Specificity: .94
University of Delaware
2. Resistive Forward Bend Test
3. Heel Compression Test
(Kumar et al 2012)
(Kumar et al 2012)
Guide the pt as you ask them
to bend forward to touch their
toes
Positive:
– Complete inability to bend
forward/ or “great
difficulty”
– Pt actively exerts resistance
on examiner’s hand
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“This test may/may not cause or
exacerbate your LBP.”
Apply axial compression
through heel.
Positive:
– Pt c/o onset or exacerbation
of LBP
Sensitivity: .87
Specificity: .79
Sensitivity: .82
Specificity: .61
University of Delaware
University of Delaware
Composite (1-3)
Hoover’s Sign
(Kumar et al 2012)
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In predicting SGMs:
 2 positives
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– Sensitivity: .91
– Specificity: .79
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3 positives
– Sensitivity: .57
– Specificity: .97
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University of Delaware
Examiner places a hand
under each heel
Ask patient to perform
SLR
If unable to lift leg but
no downward pressure
on opposite limb
? SGM
University of Delaware
Waddell’s Signs
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Tenderness:
– Superficial: tender to touch over wide area, not associated with specific pattern
– Non-anatomic: deep, not localized, may extend to pelvic/thoracic regions
Simulation Tests:
– Axial Loading: press lightly down on pt’s head
– Simulated Rotation: turn pt as one segment
Distraction Tests:
– Test & Retest; pain disappears with distraction (or different position)
» i.e. SLR vs. Slump Testing
Regional Disturbances:
– Weakness: “giving way” of many muscle groups; cannot be neurologically
explained
– Sensory: diminished sensation to light touch, pinprick, or other neurological testing
in “stocking” rather than dermatomal pattern
Overreaction: disproportional verbal or non-verbal communication
University of Delaware
Trunk Muscle Endurance
University of Delaware
Video Discussion: http://www.youtube.com/watch?v=mWxaa_yEs7w
Endurance: Ito Test
(Ito 1996; Moreau 2001; Muller 2010)
Biering-Sorensen Endurance Test
(1984; Demoulin 2006)
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Good reliability
Predominant muscles tested: multifidi & iliocostalis
Instructions: “maintain cervical flexion while contracting your
buttock muscles, holding your chest off the table”
Criteria for Stopping the
Test:
•5 minutes
•Pt fatigues
•Pain
University of Delaware
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Assess isometric trunk extensor endurance
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↓ in individuals with back pain
Predominant muscles tested: multifidi & semitendonosis
Starting Position: pt performs a concentric contraction to place the spine in
horizontal
Documenting Horizontal: visually assessed by the clinician; may use inclinometer
over T12
Criteria for Stopping the Test:
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Unable to maintain position
Pt becomes too fatigued to continue
Pt experiences pain
Pt exceeds 240 seconds
University of Delaware
Sorensen Test: Adapted
Modified BieringSorensen Endurance
Test
Lumbar Spine ICF Treatment
Guidelines, 2012
University of Delaware
University of Delaware
University of Delaware
University of Delaware
University of Delaware
University of Delaware
University of Delaware