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Red Flags for the Thoracic Spine and Ribcage Region Red Flag Red Flag Data obtained during Data obtained during Interview/History Physical Exam Chest Pain Pallor, sweating, dyspnea, nausea, palpitations Presence of risk factors: Previous history of: Symptoms lasting greater than 30 minutes and not coronary artery disease, hypertension, relieved with sublingual nitroglycerin smoking, diabetes, elevated blood serum cholesterol (>240 mg/dl) Men over age 40, women over age 50 Chest pain/pressure that occurs with predictable levels of exertion Symptoms are also predictably alleviated with rest or sublingual nitroglycerine Chest pain that occurs outside of a predictable Not responsive to nitroglycerine pattern Sharp/stabbing chest pain that may be referred to Increased pain with left side lying the lateral neck or either shoulder Relieved with forward lean while sitting (supporting arms on knees or a table) History of fall or motor vehicle crashHistory of Midline tenderness at level of fracture osteoporosisProlonged steroid useAge over Brusing 70Loss of function or mobility Lower extremity neurological deficitsEvidence of increased thoracic kyphosis Recent bout of coughing or strenuous exercise or Chest pain - intensified with inspiration trauma Difficult to ventilate/expand ribcage Hyperresonance upon percussion Decreased breath sounds Pleuritic pain - may be referred to shoulder Fever, chills, headaches, malaise, nausea Productive cough Severe, sharp “knife-like” pain with inspiration Dyspnea - deceased chest wall excursion History of a recent/co-existing respiratory disorder (e.g., infection, pneumonia, tumor, tuberculosis) Chest, shoulder, or upper abdominal pain Dyspnea Dyspnea Tachynea History of, or risk factors for developing a deep Tachycardia vein thrombosis Age under 40 Type “A” male or “neurotic” female High perceived level of vital exhaustion Recent uncontrollable and undesirable life events
Condition Myocardial Infarction1-3
Stable Angina Pectoris4
Unstable Angina Pectoris4 Pericarditis5 Spinal Fracture6
Chest Pain without cardiac disease8
References: 1. Berger JP, Buclin T, Haller E, et al. Right arm involvement and pain extension can help to differentiate coronary diseases from chest pain of other origin: a prospective emergency ward study of 278 consecutive patients admitted for chest pain. J Int Med. 1990;227:165-72. 2. Canto JG, Shlipak MG, Rogers WJ, Malmgren JA, et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA. 2000;283:3223-3229. 3. Culic V, Eterovic D, Miric D, Silic N. Symptom presentation of acute myocardial infarction: influence of sex, age, and risk factors. Am Heart J. 2002;144:1012-7. 4. Henderson JM. Ruling out danger: differential diagnosis of thoracic spine. Physician and Sportsmedicine. 1992;20:124-31. 5. Wiener SL. Differential Diagnosis of Acute Pain by Body Region. New York, McGraw-Hill, 1993 6. Hsu JM, Joseph T, Ellis AM. Thoracolumbar fracture in blunt trauma patients: guidelines for diagnosis and imaging. Injury. 2003;34:426-33. 7. Misthos P, Kakaris S, Sepsas E, et al.A prospective analysis of occult pneumothorax, delayed pneumothorax and delayed hemothorax after minor blunt thoracic trauma. Eur J of Cardio-thoracic Surg. 2004;25:859-864. 8. Roll M, Theorell T. Acute chest pain without obvious organic cause before age 40: personality and recent life events. Journal of Psychosomatic Research. 1987;31:215-221.
Joe Godges DPT, MA, OCS
KP So Cal Ortho PT Residency
THORAX AND RIBCAGE SCREENING QUESTIONNAIRE
NAME: __________________________________________ Medical Record #: _________________________ DATE: _____________
Yes 1. Do you have a history of heart problems? 2. Have you recently taken a nitroglycerine tablet? 3. Do you have diabetes? 4. Do you take medication for hypertension? 5. Have you been or are you now a smoker? 6. Does your pain ease when you rest in a comfortable position? 7. Have you recently had a major trauma, such as a vehicle accident or a fall from a height? 8. Have you ever had a medical practitioner tell you that you have osteoporosis? 9. Have you had a recent surgery? 10. Have you recently been bedridden? 11. Have you recently noticed that it is difficult for you to breathe, laugh, sneeze or cough? 12. Have you recently had a fever, infection or other illness? 13. In the past few weeks, have you notice that when you cough, you easily cough up sputum.
Joe Godges DPT, MA, OCS
KP So Cal Ortho PT Residency
Thoracic Spine Mobility Deficits ICD-9-CM: ICF codes: 847.1 thoracic sprain
Activities and Participation Domain code: d4105 Bending (Tilting the back downward or to the side, at the torso, such as in bowling or reaching down for an object) Body Structure code: s76001 Thoracic vertebral column Body Functions code: b7101 Mobility of several joints
Common Historical Findings: Symptoms precipitated by a trauma, strain, awkward movement, or prolonged static posture (bottom line - an identifiable mechanical stress) Pain is usually perceived inferior and lateral to the symptomatic segment Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: Pain increases at end range of the one particular motion Palpable asymmetry of adjacent transverse processes in either thoracic spine flexion or extension Unilateral posterior-to-anterior (PA) pressures on the involved segment reproduce the reported symptoms Physical Examination Procedures:
TP Symmetry in Flexion: Upper Thoracic Spine
TP Symmetry in Flexion: Mid and Lower Thoracic Spine
Joe Godges DPT, MA, OCS
KP So Cal Ortho PT Residency
TP Symmetry in Extension: Upper Thoracic Spine
TP Symmetry in Extension: Mid and Lower Thoracic Spine Performance Cues: Use neck flexion and extension when assessing segments above T4 Use trunk flexion and prone on elbows position for assessing segments around T4 and below Determine involved segment(s) by assessing: (1) Observable ROM limitations (2) Symmetry of transverse processes (3) Resistance to unilateral posterior to anterior (PA) pressures over transverse processes (segmental ROM restrictions) (4) Symptom response to PA pressures (5) Tenderness and hypertonicity of multifidi and rotatori myofascia of the involved segment(s)
Unilateral PA – using thumbs
Joe Godges DPT, MA, OCS
KP So Cal Ortho PT Residency
Unilateral PA: using a “spacer” thumb and pisiform Performance Cues: Determine amount of mobility, resistance to motion, and symptom response to PA pressure in order to determine the involved spinal segment
Thoracic Spine Mobility Deficits: Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with the vernacular term “Thoracic Facet Syndrome”
Description: This dysfunction is due to the inability of a thoracic spinal segment to move on a neighboring spinal segment. This decreased mobility is usually the result of the superior segments inability to slide up or down on the inferior segment during flexion, extension, rotation, side bending or any combination of thoracic spinal movement. The symptoms of “thoracic facet syndrome” are similar to the widely researched cervical and lumbar facet syndromes. Etiology: The suspected cause for the hypomobility of the involved thoracic zygapophyseal joint is due to molecular binding of the collagen fibers within the joint capsule. The cause of capsule disorders may be due to a displacement of fibro-fatty tissue within the outer borders of the facet capsule or from post-traumatic fibrosis of the facet capsule. The origin of this movement abnormality may be from a traumatic injury, awkward and/or unguarded movement such as a sudden twisting or bending motion, or from immobilization/prolonged static posture. The healing of the post-traumatic facet capsule may have an accompanying capsular contracture and shortening of the adjacent segmental myofascial. Thus, when the involved segment moves, it activates pain receptors resulting in perceived pain locally to or distal to the involved segment. The referral pain is no more than 2.5 segments inferiorly. The origin of chronic spinal pain may be from compressed or destroyed nerves from malignant or degenerative disorders or by musculoskeletal structures including, but not limited to facet joints. Facet joint pain is usually related to degenerative processes, collapse of vertebrae and/or continuous straining.
Joe Godges DPT, MA, OCS
KP So Cal Ortho PT Residency
Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7101. paravertebral tenderness in the same area Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7101. pain-limited inclinometer measurements / reduced ROM Pain is not worsened or lessened with repeated flexion or extension movements Symptoms can be replicated using unilateral posterior to anterior pressures over the involved segment(s) Restricted accessory movement of the involved segmental spine segment – with tenderness and hypomobility of the adjacent segmental myofascial. extension. pain at resistance A decrease in tenderness and motion restrictions of the involved segment commonly is associated with a reduction in symptoms Settled Stage / Mild Condition Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7101. side bending or rotation . OCS 4 KP So Cal Ortho PT Residency .3 SEVERE impairment of mobility of several joints • • • • • • • Pain is unilateral more often than bilateral and increases at end of ranges of flexion. nerve root tension Nondermatomal referred pain that is difficult to localize The patient experiences pain before resistance. without objective neurological signs.2 MODERATE impairment of mobility of several joints • • • As Above with the following differences Pain replication at end of range of one particular movement with or without overpressure.one direction is usually more symptomatic than the others. usually extension or rotation The paravertebral pain is in a distinct thoracic area of the back. MA.1 MILD impairment of mobility of several joints As above with the following differences • The patient’s unilateral symptoms are reproduced only with end range overpressures in either a combined extension and sidebending motion or a combined flexion and sidebending motion Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Decrease pain inflammation Restore normal segmental joint mobility Restore inclinometer measurements to within normal limits of spinal movements Joe Godges DPT.
painfree. ice (or heat) to provide pain relief and reduce muscle guarding Manual Therapy Soft tissue mobilization primarily to multifidus and rotatores of the involved segment Joint mobilization/manipulation using isometric mobilization and contract/relax procedures to the involved segment to reduce associated rotatores or multifi muscle guarding Passive stretching procedures to restore normal thoracic segmental mobility to the involved segment Therapeutic Exercise Instruct in exercise and functional movements to maintain the improvements in mobility gained with the soft tissue and joint manipulations Re-injury Prevention Instruction Instruct the patient in efficient. painfree responses to overpressures of combined extension and sidebending and/or combined flexion and sidebending • • Approaches / Strategies listed above Therapeutic Exercises Instruct in stretching exercises to address the patient’s specific muscle flexibility deficits Instruct in strengthening exercises to address the patient’s specific muscle strength deficits Joe Godges DPT. MA. motor performance of movements that are related by the patient to be the cause of the current episode of mid back pain • • • Sub Acute Stage / Moderate Condition Goal: Restore normal. OCS 5 KP So Cal Ortho PT Residency . painfree response to end of range motions or to overpressures at end ranges of rotation • Approaches / Strategies listed above – focusing on soft tissue mobilization and joint mobilization/manipulation to normalize segmental mobility followed by mobility exercises to maintain the improvements gained from the manual procedures Settled Stage / Mild Condition Goal: Restore normal.• Physical Agents Electrical stimulation.
pp 126 Dreyfuss P. The Saunders Group. Groen GJ. and Prevention of Musculoskeletal Disorders: Volume I Spine. pp 103-105. MA. Treatment. Wooden MJ: Orthopedic Physical Therapy. Jour of Manipulative and Physiological Therapeutics. 147-149. 122: 82-90 Joe Godges DPT. 1994 Flynn T. 3rd ed. 1994. Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure time activities • • Approaches / Strategies listed above Therapeutic Exercises Encourage participation in regular low stress aerobic activities as a means to improve fitness.If symptoms persists (>12 months). Churchill Livingston Inc. Acta Neurochir (Wien). then the patient may consider radiofrequency facet denervation. 1999 Saunders HD. when conservative measures fail. Schiller L. New York. Effectiveness of Spinal Manipulation Therapy in the Treatment of Mechanical Thoracic Spine Pain: A Pilot Randomized Clinical Trial. muscle strength and prevent recurrences Selected References Defranca G. Levine L: The T4 syndrome. Spine 19:807-811. Tibiletti C. Orthopedic Physical Therapy Clinics of North America 8-1:1-20. Minnesota. Vervest ACM. 18:34-37 Donatelli R. 24(6): 394-401 Stolker RJ. 1995. OCS 6 KP So Cal Ortho PT Residency . 2nd ed. J Manipulative Physiological Therapeutics. Thoracic Spine and Rib Cage Disorders. Dreyer SJ: Thoracic zygapophyseal joint pain patterns: A study in normal volunteers. Chaska. Percutaneous Facet Denervation in Chronic Thoracic Spinal Pain. 1993. July/Aug 2001. Saunders R: Evaluation.
Thoracic Spine Manual Examination and Treatment Procedures Upper Thoracic Mobility Assessment: Physiologic Forward Bending (sitting) Physiologic Rotation (sitting) Physiologic Sidebending (sitting) TP Positional Symmetry in Flexion (sitting) TP Positional Symmetry in Extension (sitting) Accessory Rotation (via transverse pressures on SPs) Accessory Rotation (via unilateral PA pressures on TPs) Palpation/Provocation of Segmental Myofascia Mid Thoracic Mobility Assessment: Physiologic Forward Bending (sitting) Physiologic Sidebending (sitting) TP Positional Symmetry in Flexion (sitting) TP Positional Symmetry in Extension (prone on elbows) Accessory Rotation (unilateral PA pressures in flexion) Accessory Rotation (unilateral PA pressures in extension) Accessory Rotation (unilateral PA pressures in neutral) Palpation/Provocation of Segmental Myofascia Upper Thoracic Treatment Procedures: Contract/Relax for restoring segmental Flexion/SB/ROT Contract/Relax for restoring segmental Extension/SB/ROT Soft Tissue Mobilization of involved segmental myofascia Joint Mobilization/Manipulation: Segmental Rotation (using pisaform/scaphoid on adjacent SPs) Rotation via TPs (using “spacer” thumb and pisaform) Rotation in Neutral (gaping – prone) Rotation/SB in Extension (closing – prone) Rotation/SB in Flexion (opening – supine or prone) Mid Thoracic Treatment Procedures: Contract/Relax for restoring segmental Flexion/SB/ROT Contract/Relax for restoring segmental Extension/SB/ROT Soft Tissue Mobilization of involved segmental myofascia Joint Mobilization/Manipulation: Flexion/SB/ROT (opening – supine) Extension/SB/ROT (closing – prone) Joe Godges DPT. OCS 7 KP So Cal Ortho PT Residency . MA.
MA.Upper Thoracic Segmental Myofascia Soft Tissue Mobilization Joe Godges DPT. OCS 8 KP So Cal Ortho PT Residency .
counter-translate the head to the right during the lateral translation) Upper thoracic forward bending localization is not as specific as mid thoracic – unless the forward bend is also taken up from below the involved segment (i. MA.e. PT: The Thoracic Spine and Ribcage: Musculoskeletal Evaluation and Treatment. 1996 Joe Godges DPT.e. p. OCS 9 KP So Cal Ortho PT Residency . then.. a localized slump) which is difficult to do in the upper thoracic area and still maintain the patient’s comfort The following reference provides additional information regarding this procedure: Timothy Flynn MS. 176-177. laterally translate the spine to the left so that the apex of the curve is localized to the involved segment Maintain the patient’s center of mass over his/her base of the support during the translation (i.Impairment: Limited Upper Thoracic Segmental Flex.. Right SBing and Right Rotation Upper Thoracic Contract/Relax (of segmental extensors and left sidebenders) Cues: Forward bend the cervical and thoracic spine to the midrange of the involved segment.
and Right Rotation Upper Thoracic Contract/Relax (of segmental flexors and left sidebenders) Cues: Note the following details in the photo: the patient’s position. elbow and little finger (cuing head flexion to maintain the upper cervical spine in neutral) The following reference provides additional information regarding this procedure: Timothy Flynn MS. 1996 Joe Godges DPT. palm. the therapist’s left forearm. PT: The Thoracic Spine and Ribcage: Musculoskeletal Evaluation and Treatment. the position of the therapist’s right fingers. and thumb (thumb is on the right side of the interspace of the impaired segment). OCS 10 KP So Cal Ortho PT Residency . MA.Impairment: Limited Upper Thoracic Segmental Ext. 181-182. p. Right SBing. the therapist’s position.
MA.Impairment: Limited Upper Thoracic Right Segmental Rotation Upper Thoracic Segmental Rotation (using adjacent spinus processes) Cues: Turn patient’s head in direction of rotation if possible Using the pisiform of your left hand apply a left lateral translatory force to the spinous process of the superior vertebrae of the involved segment Using the scaphoid of your right hand apply a right lateral stabilizing translatory force to the spinous process of the inferior vertebrae of the involved segment Joe Godges DPT. OCS 11 KP So Cal Ortho PT Residency .
MA. and. if possible. rotate the patient’s head into the direction of the desired rotation Caution: with all prone upper thoracic techniques – be tuned into the patient at all time assessing for signs of VBI Stand on side of pressure application Use your left thumb as the dummy thumb – catch the skin and myofascia about two segments above the involved segment’s transverse process Use your right pisaform to apply a unilateral posterior-to-anterior pressure through your dummy thumb to the left transverse process of the involved segment in a direction parallel to the plane of the facet Joe Godges DPT.Impairment: Limited Upper Thoracic Segmental Flexion. Right SBing and Right Rotation Upper Thoracic Unilateral PA (Segmental Superior/Anterior Glide) Cues: Position patient with pillow under thorax to reduce excessive cervical lordosis. OCS 12 KP So Cal Ortho PT Residency . arms at side to abduct the scapulae.
PT: The Thoracic Spine and Ribcage: Musculoskeletal Evaluation and Treatment. or 2) the right transverse process of the inferior vertebrae of the involved segment The mobilization or manipulation force is delivered through this stabilizing contact on the inferior vertebrae of the involved segment with slight counter pressure through the occiput (this force is through the occiput is mainly a long axis distraction counter force) The following reference provides additional information regarding this procedure: Timothy Flynn MS.right rotate down to the involved level Stabilize either 1) the left side of the spinous process of the inferior vertebrae of the involved segment. 188-189. 1996 Joe Godges DPT. forehead on table .don’t delay here as this is uncomfortable Left sidebend down to the involved segment Firmly block the inferior vertebrae of the involved segment Maintain the sidebend . p. OCS 13 KP So Cal Ortho PT Residency .Impairment: Limited Upper Thoracic Segmental Rotation Upper Thoracic Right Rotation in Neutral (“neutral gap”) Cues: Patient Prone. MA.
Impairment: Limited Upper Thoracic Segmental Extension. 1996 Joe Godges DPT. Right SBing. At the end of the patient’s exhalation. OCS 14 KP So Cal Ortho PT Residency . guide the sidebending with your right hand under the patient’s forehead 3.stabilize the spinous process of the inferior vertebrae of this segment with your left thumb. Sidebend head. apply a posterior-to-anterior mobilization or manipulative force to the right transverse process of the inferior vertebrae of the impaired segment with your left hand – your right hand is on the back of the patient’s occiput maintaining the sidebending and rotation “barrier” The following reference provides additional information regarding this procedure: Timothy Flynn MS. neck. 183-184. PT: The Thoracic Spine and Ribcage: Musculoskeletal Evaluation and Treatment.the “barrier” or end feel should now be even firmer 4. 1. and Right Rotation Upper Thoracic Rotation/Sidebending in Extension Cues: Here are the steps.“forehead on table” 2. and upper thoracic spine also to the impaired level . MA. rotate the head. Maintain the sidebending “barrier”. Position patient prone with head and neck in neutral . neck. and upper thoracic spine down to the impaired level . p.
177-178. 1996 Joe Godges DPT.take up the slack in both end ranges . p.relax . Left SBing.elicit contraction of the lengthened myofascia .Impairments: Limited Mid Thoracic Segmental Flexion. They can be used in the other thoracic regions but often require modifications in body positioning and manual contacts Position patient at end range of posterior translation and right lateral translation at the involved segment . OCS 15 KP So Cal Ortho PT Residency .repeat contraction The following reference provides additional information regarding this procedure: Timothy Flynn MS. and Left Rotation Mid Thoracic Contract/Relax (of segmental extensors and right sidebenders) Cues: Mid thoracic techniques work most effectively in the T4 . PT: The Thoracic Spine and Ribcage: Musculoskeletal Evaluation and Treatment.T9 area. MA.
PT: The Thoracic Spine and Ribcage: Musculoskeletal Evaluation and Treatment. 2. 4. grasp the patient’s right shoulder and roll the patient toward you exposing the involved segment. Reach around with your left arm and “twist” the skin to take out the skin slack so the pressure is firm over the right (thenar eminence .Impairments: Limited Mid Thoracic Segmental Flexion. 1996 Joe Godges DPT. 7. a rolled-up towel may help spread the pressure. 179-181.for left rotation stand on left side. 6.scaphoid) and left (“padded” DIP of the 2nd or 3rd finger) transverse processes of the inferior vertebrae of the involved segment. deliver the mobilizing or manipulating force by via trunk flexion from your body weight (upper rectus abdominus over the patient’s elbows) The following reference provides additional information regarding this procedure: Timothy Flynn MS. sidebend and rotate the thorax to the left . OCS 16 KP So Cal Ortho PT Residency . 3. Roll the patient back into your left scaphoid and DIP. Stand on side that you want to rotate toward .fine tune these combined movements to create a “crisp. p.hand away from you underneath (in armpit). if patient has proportionally long humerii. MA.right hand in upper t-spine area. 5. Left SBing. and Left Rotation Mid Thoracic Segmental Rotation/Sidebending in Flexion Cues: Here are the steps: 1. Support the patient’s head with your right forearm .” firm barrier at the involved segment with trunk flexion through the elbows. With your right hand. Position elbows over involved segment . Flex.
MA. OCS 17 KP So Cal Ortho PT Residency . 1996 Joe Godges DPT.e. extending) the segment The following reference provides additional information regarding this procedure: Philip Greenman DO. FAAO: Principles of Manual Medicine.. 217.Impairment: Limited Mid Thoracic Segmental Right Rotation Mid Thoracic Contract/Relax (of segmental sidebenders) Cues: Right rotation in neutral is coupled with left sidebending Create left sidebending with depression of the left scapula . p.using left hand Create the apex of the sidebending to the involved segment by guiding the movement with the right fingers (on the spine) and the left hand (on the superior part of the shoulder Use this procedure to “gap” a joint prior to “closing” (i.
repeat 3 to 5 times The following reference provides additional information regarding this procedure: Timothy Flynn MS. Right SBing and Right Rotation Mid Thoracic Contract/Relax (of segmental flexors and left sidebenders) Cues: To create right sidebending have right hand on the superior aspect of the right shoulder Position the patient at end range of anterior translation (using manual and verbal cuing “move your chest forward right here”) and left lateral translation of the involved segment – elicit contraction of the lengthened myofascia .repeat contraction .relax . p. OCS 18 KP So Cal Ortho PT Residency .take up slack .take up the slack in both translatory barriers . MA. PT: The Thoracic Spine and Ribcage: Musculoskeletal Evaluation and Treatment.Impairment: Limited Mid Thoracic Segmental Ext. 184-185. 1996 Joe Godges DPT.
extension) The following reference provides additional information regarding this procedure: Timothy Flynn MS. 1996 Joe Godges DPT.Impairment: Limited Mid Thoracic Segmental Extension. p. superior-to-inferior pressure to the right transverse process provides right sidebending Preload the rotation and sidebending motions – then – anterior mobilization or manipulative pressure evenly applied on both transverse processes provides the anterior translation (i. PT: The Thoracic Spine and Ribcage: Musculoskeletal Evaluation and Treatment.. Right Sidebending and Right Rotation Mid Thoracic Rotation/Sidebending in Extension Cues: Stand on right side of patient (who is prone) Position patient close to edge of table – arms at side At the involved segment (same vertebrae) contact the left transverse process with your left pisiform and contact the right transverse process with the right pisiform Use a “Texas Twist” to eliminate the skin and myofascial slack over the transverse process. (The right pisiform will need to catch the skin about two segments above the involved level and take up the slack with its inferior pressure) Posterior-to-anterior pressure to the left transverse process provides right rotation. 185-186.e. MA. OCS 19 KP So Cal Ortho PT Residency .
anterior/posterior or superior/inferior Limited and painful rib mobility with either anterior-to-posterior (AP) glides or posteriorto-anterior (PA) glides of the involved rib Tender iliocostalis insertion. OCS 1 KP So Cal Ortho PT Residency .6 costochondritis (Tietze's Disease) Activities and Participation Domain code: d498 Mobility.Related to the Reported Activity Limitation or Participation Restrictions: Asymmetrical position of rib . other specified (Expansion of the ribcage during forceful respiratory movements such as deep breathing. coughing.especially a deep breath or cough Blunt trauma to thorax Common Impairment Findings .Thoracic Cage Respiratory Mobility Deficits ICD-9-CM: ICF codes: 733. sneezing or laughing) Body Structure code: s4302 Thoracic cage Body Functions code: b4402 Depth of respiration (Functions related to the volume of expansion of the lungs during breathing) Common Historical Findings: Lateral or anterior chest wall pain Pain worsens with respiratory movements . and/or intercostal myofascia Physical Examination Procedures: Rib Positional Assessment (Anterior Rib Asymmetry) Rib Positional Assessment (Superior Rib Asymmetry) Joe Godges DPT. MA.
stand at side of patient. restriction to movement. MA. thumb down . use gentle pressure.ok to use "dummy thumb" under hypothenar eminence in scapular area Assess mobility. use hypothenar eminence. and symptom response to pressures Joe Godges DPT. OCS 2 KP So Cal Ortho PT Residency . keep fingers in area of xiphoid and clavicular areas For PA pressures .Performance Cues: For anterior-posterior symmetry assessment palpate near costochondral junction anteriorly and rib angle posteriorly For superior-inferior symmetry assessment palpate width of intercostal spaces Palpate for tenderness and symptom reproduction/provocation in conjunction with palpating for asymmetries Rib AP Pressures Rib PA Pressures Performance Cues: For AP pressures .stand on opposite side of the rib to be assessed.
and painful swelling of an upper costochondral area. MA. the patient may experience inability to perform functional activities. Deficits may be noted in body mechanics and work site positions. arthritis or infection. Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b4402. poor postural alignment. subluxation. dislocation. without any evidence of overlying disease. Patient may be experiencing moderate headaches. With a Stage II dysfunction. ninth or tenth ribs. impinging on the intercostals nerves. the patient’s symptoms are reproduced with activity or work. More attention needs to be focused on the atraumatic diagnoses examination to rule out ones that need to be referred back to the physician. Etiology: The cause of rib dysfunction is most commonly due to a significant trauma to the chest or sternum from a fall. severely impaired depth of respiration) • • • Pain with cough. sprain.g. The primary goal is to improve tolerance to perform occupational or recreational tasks. visceral complaints. A change in the position or alignment of a rib can put pressure on the soft tissues around where the rib attaches or along edges of the rib where muscles of the thorax attach (sternum) in front or along the side of the spine in back. upper limb pain or symptoms suggestive of thoracic outlet syndrome and vague. With a Stage I disability. localized. Yet non-traumatic causes may be serious diagnoses such as Hodgkins lymphoma and viral/bacterial/yeast infection seen in drug abusers. Slipping rib syndrome is an infrequent cause of thoracic and upper abdominal pain and is thought to arise from the inadequacy or rupture of the interchondral fibrous attachments of the anterior ribs. the patient reports less severe symptoms or primary postural-related symptoms. or contact sport related injury. most non-traumatic chest pain is usually diagnosed as costochondritis or Tietze’s syndrome.3 SEVERE impairment of respiratory mobility. costochondral injury. OCS 3 KP So Cal Ortho PT Residency . deep breathing. costochondritis or inflammation. After serious cardiac disease and gastrointestinal problems are ruled out. cartilage (costochondral joints). In most cases it is attributed to luxation of the costal cartilage at the eight. and Intervention Strategies The below description is consistent with descriptions of clinical patterns associated with the vernacular term “Rib Dysfunction” Description: Rib dysfunctions involve the ribs and their associated articulations to the vertebral bodies (costovertebral joints). This disruption allows the costal cartilage tips to sublux.Thoracic Cage Respiratory Mobility Deficits: Description. and/or trunk movements Pain with rectus abdominus contraction (slipping rib syndrome) Pain noted during respiration at the extremes of inhalation and exhalation Joe Godges DPT.. With a Stage III dysfunction. Etiology. changes in breathing patterns secondary to pain. surgery. transverse processes of the vertebra (costotransverse joints) or sternum (sternocostal joints). Stages. sneeze. such as overhead work and computer keyboard activity/operation. This may cause pain with abnormal mobility of the ribs and their joints. (e. Tietze’s syndrome is characterized by benign.
OCS 4 KP So Cal Ortho PT Residency . mildly impaired depth of respiration) • • As above with the following differences The patient’s unilateral symptoms are reproduced only with end range overpressures in either a combined extension and sidebending motion or a combined flexion and sidebending motion Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Decrease pain and inflammation Restore normal rib movement Restore rib alignment and symmetry • Physical Agents Cold application.g. MA. moderately impaired depth of respiration) • • • As above with the following differences Pain replication at end of range of one particular movement with or without overpressure. combined with ice Ultrasound Joe Godges DPT..1 MILD impairment of respiratory mobility (e.g.palpation may reproduce the reported pain with its referral pattern along the costal border.• • • • • • • Limited and painful rib mobility with either anterior-to-posterior or posterior-toanterior glides to the involved rib(s). Painful hypermobility of a rib may be present following some types of traumas or surgical procedures Muscle guarding.2 MODERATE impairment of respiratory mobility (e. ice or ice pack Electrical stimulation. pain at resistance A decrease in tenderness and motion restrictions of the involved segment commonly is associated with a reduction in symptoms Settled Stage / Mild Condition Physical Examinations Findings (Key Impairments) ICF Body Functions code: b4402. tenderness of the intercostal muscles associated with the involved ribs .. Tenderness at the costochondral junction of the involve rib Tender iliocostalis insertion and/or intercostals myofascia Palpable asymmetrical position of a rib – anterior/posterior or superior/inferior Localized tender spot that corresponds to the site of injury Pain limited mobility of the thorax and shoulder girdle may be present Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b4402.
the athlete may return to sports participation in 710 days with lower chest strapping • Joe Godges DPT. strength. and body mechanics • • • Approaches / Strategies listed above – focus on promoting/maintaining rib symmetry. coordination. typically ~ 6-8 weeks Manual Therapy Soft tissue mobilization to restricted intercostal myofascia Joint mobilization to restricted rib movement to restore normal symmetry and mobility – including isometric mobilizations Joint mobilization to thoracic spine segmental motions associated with rib dysfunction(s) Therapeutic Exercises Segmental breathing exercises maintain and enhance gain in mobility from soft tissue and joint mobility Thorax extension and flexion and rotation exercises Shoulder girdle and upper extremity mobility exercises Normal breathing pattern retraining with Pursed Lip Breathing. which takes less excursion and same amount of oxygen than closed mouth breathing.• External Devices (Taping/Splinting/Orthotics) Consider taping procedures for hypermobile rib (placing tape along the rib attachment to temporarly keep it from moving. OCS 5 KP So Cal Ortho PT Residency . and normal trunk mobility Physical Agents Heat application alternating with cold Manual Therapy Passive treatments should be used cautiously and only to rapidly facilitate a patient into an active rehabilitation program External Devices (Taping/Splinting/Orthotics) If the symptoms have resolved. helps to hold the rib still while giving the soft tissue around the rib a chance to heal) May use a direct pressure pad over costochondral joint. Union of acute costochondral separation occurs slowly. MA. normal respiration. Re-Injury Prevention Instruction Limit contact sports for 3-4 weeks • • • Sub Acute Stage / Moderate Condition Goal: Reduce deficits in posture. flexibility. A rib belt or strapping may be used to hold the pad in place.
• Therapeutic Exercises Add progressive resistive exercises. prevention. and exercises Therapeutic Exercises Maintain and increase general fitness through low-stress aerobic and general conditioning exercises Ergonomic Instruction Perform work site evaluation and intervention if indicated Re-injury Prevention Instruction Teach bracing techniques to athletes • • Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupation or leisure time activities • • Approaches / Strategies listed above – focus on long-term strategies for good posture. muscle strength and prevent recurrences Incorporate a regulated program to allow the athlete to return to their sport without re-injury Joe Godges DPT. These should be designed to improve the movement restriction and re-educate or stretch the appropriate muscle groups that assist in normal movement in postural alignment Settled Stage / Mild Condition Goal: Improve tolerance to perform occupational or recreational tasks. stabilization and postural exercise. prevention. and exercises Therapeutic Exercises Encourage participation in regular low stress aerobic activities as a means to improve fitness. ergonomics. OCS 6 KP So Cal Ortho PT Residency . ergonomics. • • Approaches / Strategies listed above – focus on long-term strategies for good posture. MA.
. PT OCS. 3(3): 143-50. March 1999: 1-20. Fioravanti A. Ann Ital Med Int. Paediatric Anasthesia. Jones GE. Evans PA. J Fam Pract. 1996. et al. Biofeedback Self Regul. Saunders Co.18: 790-795. Zachazewski J.38:345-52. Quillen W. 2001. Treatment of Tietze’s syndrome pain through paced respiration. Episodes of care for chest pain: a preliminary report from MIRNET (Michigan Research Network).. et al. The slipping rib syndrome in children.14:118-23. Lymphomas presenting as Tietze’s syndrome: a report of 4 clinical cases. Tietze’s syndrome in children and infants. MA. 11:740-743 Klinkman MS. 1990 Jul-Sep.com/Spine/rib_rehab. Gorenflo DW. Mukamel M. Stevens D. Benhamou C. Kornreich L. 131: 774-775. OCS 7 KP So Cal Ortho PT Residency . http://www.htm A Patient’s Guide to Rehabilitation for Rib Dysfunction. 498-500. Pseudovisceral pain referred from costovertebral arthropathies. Saltzman DA. Cocco R. Roux C. Athletic Injuries and Rehabilitation. PhD.chehalempt. Galieni P. 1997. Pennsylvania: W. Joe Godges DPT. An exploratory report of chest pain in primary care: a report from ASPN. Pediatrics. Bellan C. Spine. 1994. J Am Board Fam Pract.Selected References Flynn T. 1993. et al. Orthopaedic Physical Therapy Clinics of North America Upper Quadrant: Evidence-Based Description of Clinical Practice.B. 1999.5:295-303. 1980. Magee D.
MA. OCS 8 KP So Cal Ortho PT Residency . Exhalation: Lateral/Medial Motion Anterior/Posterior Motion Superior/Inferior Motion AP Glides (supine) PA Glides (prone) Lateral Glides (sidelying) Inferior Glide of 1st Rib Rib Angle/Iliocostalis Intercostal Myofascia Costocondral Articulation Passive Movements: Palpation: RIB MANUAL TREATMENT Patient Problem: Limited 1st Rib Inferior Glide ST MOB: JNT MOB: Scalene Myofascia Inferior Glide (sitting and supine) Inferior Glide combined with contralateral scalene contraction Ipsilateral scapular posterior depression RE-ED: Patient Problem: Limited Rib Posterior Glide ST MOB: JNT MOB: Intercostal Myofascia Posterior Glide (supine) Posterior Glide combined with ipsilateral serratus anterior contraction Lateral Expansion RE-ED: Patient Problem: Limited Rib Anterior Glide ST MOB: JNT MOB: Intercostal Myofascia Anterior Glide (prone) Anterior Glide combined with ipsilateral pectoralis major contraction Anterior-Posterior Expansion RE-ED: Joe Godges DPT.RIB PHYSICAL EXAMINATION Structure: Symmetry of Rib Contours: Anterior/Posterior Superior/Inferior Intercostal Spaces Active Movements: Inhalation.
e.. MA. contact only the posterior surface) Joe Godges DPT. OCS 9 KP So Cal Ortho PT Residency .Impairments: Positional Rib Asymmetry Limited Rib Posterior Translation Rib Posterior Glide with Isometric Mobilization Cues: Passively glide the involved rib and its costal cartilage posteriorly Elicit serratus anterior contraction to provide additional posterior glide mobilization Be precise with your manual resistance to ensure that pectoralis major is not facilitated (i.
Impairments: Positional Rib Asymmetry Limited Rib Anterior Translation Rib Anterior Glide with Isometric Mobilization Cues: Passively Glide the involved rib anteriorly Elicit pectoralis major contraction to provide additional anterior glide mobilization The anterior passive force is countered with the pectoralis major resistance force (This keeps the patient balanced on his/her ischial tuberosities). MA. Joe Godges DPT. OCS 10 KP So Cal Ortho PT Residency .
p. 1993 Joe Godges DPT.Impairment: Positional Asymmetry of the lst Rib Limited Left lst Rib Inferior Glide lst Rib Inferior Glide Cues: Sidebend head slightly to the left to lessen tension on the left upper trapezius and scalene myofascia Contacting the1st Rib with the index finger metacarpal head using a “flat palm” (slightly supinated and extended wrist) is usually the most comfortable for the patient Swinging your stool a bit to the right may help line up your forearm to allow a more “connected” weight shift Elicit a sustained contraction of the right scalenes to reciprocally inhibit the left scalenes during the mobilization Consider using a sitting 1st rib inferior glide if a stronger mobilizing force is indicated lst Rib Inferior Glide (sitting) The following reference provides additional information regarding these procedures: Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques. OCS 11 KP So Cal Ortho PT Residency . 266. MA.
nausea following prolonged neck flexion activities.g. sitting in bath tub) Diffuse and multiple areas of symptoms (e.g.4 Thoracic or Lumbosacral neuritis or radiculitis. headaches.g.Related to the Reported Activity Limitation or Participation Restrictions: Symptom reproduction with slump testing Less than normal range of motion with nerve tension tests Physical Examination Procedures: Slump Test Neck Flexion and Ankle Dorsiflexion Joe Godges DPT. MA. such as driving in a car or sitting in a bathtub) Body Structure code: s76000 Cervical vertebral column s76001 Thoracic vertebral column s76002 Lumbar vertebral column Body Functions code: b28013 Pain in back Common Historical Findings: Pain or paresthesia associated with prolonged long sitting or flexed positions (e. entire spine..Thoracic Region Pain ICD-9-CM: ICF codes: 724.. associated with sustaining a long sitting or flexed position. excessive sweating while in a slump sitting position) Common Impairment Findings . unspecified Activities and Participation Domain code: d4108 Changing basic body position. intolerance to cold. often with related diffuse extremity pain.. other specified (specified as diffuse back pain. driving in car. extremities) May report autonomic nervous system symptomatology (e. OCS 1 KP So Cal Ortho PT Residency .
arms behind back Note changes in symptoms with each maneuver: Trunk Flexion Neck Flexion Knee Extension Ankle Dorsiflexion Bilateral Knee Extension Bilateral Ankle Dorsiflexion Determine symptom alteration with neck flexion and extension. which explains the fact that no pain is elicited on piercing of this area in such procedures as lumbar puncture. thoracic and/or lumbar spine. working at computer. spinal stenosis. diffuse sweating with prolonged slump sitting). MA. Pain or paresthesia is associated with prolonged long sitting or flexed positions (i.. Dural pain is described as funicular pain. driving in car. knee flexion and extension. cold intolerance. Theories state that dural adhesions can be caused by disc degeneration. The sinuvertebral nerve is primarily a sympathetic nerve and courses in a cephalic direction up to 4 segments and a caudal direction for up to 4 segments. It is not radicular in distribution but rather involves unilateral or bilateral limbs. In addition. trauma and intramedullary mass lesions among others. or entire body. trunk. Decreased tolerance with prolonged long sitting or flexed positions at the spine and/or hip is the main characteristic of this disorder Etiology: The cause is of this disorder is largely unknown. which gives evidence as to why diffuse pain is noted with dural adhesions. Patients with dural disorders may also report autonomic nervous system symptomatology (i. If there is pressure on the nerve trunk. Headaches may also occur. These disorders can cause inflammation of the spine. sitting in bathtub). while the posterior region of the dura is sparsely innervated. but is also innervated by the nerve plexus of the posterior longitudinal ligament and the nerve plexus of radicular branches of segmental arteries.passive overpressures are required to reproduce/alleviate symptoms Thoracic Region Pain: Description. paresthesia or an abnormal sensation such as a “pins and needles” feeling or tingling may be present.e. intradural arachnoid cysts. poorly localized. Etiology.Performance Cues: Establish baseline: Neutral sitting on edge of table. burning sensation or abrupt stabbing pain. there is no innervation in the medial part of the posterior region. OCS 2 KP So Cal Ortho PT Residency . The anterior region of the dura mater is densely innervated. This results in considerable overlap of innervations between adjacent segments and count for the multiple pain sites of the dural adhesion.active movements will reproduce/alleviate symptoms With low level of symptoms . Joe Godges DPT.e. ankle dorsiflexion and plantar flexion With high level of symptoms . Dural symptoms can also be triggered by spinal cord compression from cervical spondylosis or neoplasm of the cervical. nausea. diffuse. and Intervention Strategies The below description is consistent with descriptions of clinical patterns associated with the vernacular term “Dural Adhesion” Description: The dura mater is innervated primarily by the sinuvertebral nerve also known as recurrent meningeal nerve. Stages.
which may limit normal mobility of the mixed spinal nerve and the adajacent dura producing decreased mobility and quality of range of motion (i. Research studies also suggest possible etiologies of trauma at more distal sites. such as repetitive hamstring strain or ankle inversion sprain. slump) related symptoms Alleviate pain with normal (non end range) activities • Manual Therapy Soft tissue mobilization to restricted segmental myofascial of the thoracic region or site of peripheral nerve entrapments related to the patient’s complaints Joint mobilization/manipulation is usually restricted spinal segments Joe Godges DPT. Myofascial and soft tissue restrictions in the muscles of the back may inhibit the mobility of the posterior primary rami nerve through its normal pathway.3 SEVERE pain in back • • • • • Symptoms are produced or aggravated with slump test positions Postural adaptation to pain-free position may be observed – such as diminished thoracic kyphosis Limb nerve tension tests (e.which in turn may cause irritation and fibrosic adhesion in the dura to form. Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b28013..2 MODERATE pain in back • • • • As above – except less severe symptoms are exhibited Pain takes longer to present itself while in slumped position Pain perception during the slump test is strongly correlated with passive tissue resistance felt by the examiner A decrease in tenderness and a reduction mobility deficits of the involved segments during the slump test is commonly is associated with a reduction in symptoms Settled Stage / Mild Condition Physical Examinations Findings (Key Impairments) ICF Body Functions code: b28013.. MA.. SLR test) commonly exhibit limited range of motion Soft tissue restrictions in the posterior segmental spinal myofascial Autonomic nervous system signs (such as excessive perspiration) may be present Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b28013.2 MILD pain in back • • As above with the following differences: Passive overpressure while in slump position may be required to reproduce symptoms Intervention Approaches / Strategies Acute Stage / Severe Condition Goal: Reduce dural (i. a positive slump test).e.g.e. OCS 3 KP So Cal Ortho PT Residency .
MA. OCS 4 KP So Cal Ortho PT Residency .• Therapeutic Exercises Slump and peripheral nerve mobility exercises in painfree ranges Sub Acute Stage / Moderate Condition Goals: As above Increased flexibility of the dural elements (as measured by ability to assume the slump positions without symptoms) • • Approaches / Strategies listed above Therapeutic Exercises Slump and peripheral nerve mobility exercises in creating mild stretch sensation at end ranges that do not worsen the symptoms with repeated exercises Settled Stage / Mild Condition Goals: As above Increased flexibility of spinal flexion Increased flexibility of upper and lower extremities • • Approaches / Strategies listed above Therapeutic Exercises Slump and peripheral nerve mobility exercises in creating a strong stretch sensation at end ranges that do not worsen the symptoms with repeated exercises Re-injury Prevention Instruction: Promote cardiovascular and flexibility and strengthening programs in order to maintain neural mobility and decrease the probability of future dural adhesions • Intervention for High Performance / High Demand Functioning in Workers or Athletes Goals: Return to desired occupational or recreational activities • • Approaches / Strategies listed above Therapeutic Exercises Provide specific stretches to enhance the ability to perform desired activity General stretching/conditioning programs. such as yoga or Pilates type programs may be helpful interventions to promote high performance/high demand functioning Joe Godges DPT.
75:622-636. Maitland GD: The slump test: examination and treatment. Neurology 1961.31:215-219.10:800-809. Perrin. Surg Radiol Anat. 1997. Hamel O. Le Borgne J. Salem. Pathor S. 1997. MA. Drukker J. Physiotherapy. Raoul S. George SZ. DH: Comparison of nonballistic active knee extension in neural slump position and static stretch techniques on hamstring flexibility. OCS 5 KP So Cal Ortho PT Residency . Lew P: The effect of stretching neural structure on grade one hamstring injuries. Melbourne: Churchill Livingstone. Toppenberg R.92:39-46. 1983. Post Grad Med. Manual Therapy 1996. 2002. George P: Adverse neural tension: A factor in repetitive hamstring strain? J Orthop Sports Phys Ther.24:366-371. The innervation of the spinal dura mater: anatomy and clinical implications.27:16-21. 1991 Butler DS: The concept of adverse mechanical tension in the nervous system. Faure A. An investigation of neural tissue involvement in ankle inversion sprains. 1989.1:192-197.Selected References Briggs CA. Characteristics of patients with lower extremity symptoms treated with slump stretching: a case series.A. Relationship between the cervical component of the slump test and change in hamstring muscle tension. J Orthop Sports Phys Ther.26:310-317. Baljet B. Role of the sinuvertebral nerve in low back pain and anatomical basis of therapeutic implications. Chiarello CM. Manual Therapy. 1985. Kornberg C. Kimmel D: Innervation of the spinal dura mater and dura mater of the posterior cranial fossa.32:391-398. Simon DG. Robert R. 1990.2:98-105. Cuillere P. Randolph BJ. F. Webright WG. Byrne T: Spinal Cord Compression. Joe Godges DPT. Butler DS: Mobilization of the Nervous System. J Orthop Sports Phys Ther. 1998. Travell JG: Myofascial origins of low back pain. 1997.13:418-487. 1998. Turl S. Aust J Phys. Davis Co. Johnson EK: The slump test: the effects of head and lower extremity position on knee extension. Groen GJ.26:7-13.73:66 –108. Lew PC. J Orthop Sports Phys Ther. Acta Neurochir 1988. 2002. Rogez JM. J Orthop Sports Phys Ther.
Coughing.Thoracic Spine and Rib Cage Algorithms Mid/Lower Thoracic Single Plane Active Mobility Exam No Pain with Respiration. OCS . or Sneezing? Yes Transverse Plane Mobility Loss Sagittal Plane Mobility Loss Coronal Plane Mobility Loss Go To Rib Cage Clinical Pathways Contralateral Pain End of Range Ipsilateral Pain End of Range Contralateral Pain End of Range Ipsilateral Pain End of Range Contralateral Pain End of Range Mid/Lower Thoracic Spine Segmental /Soft Tissue Mobility Exam Ipsilateral Pain End of Range Mid/Lower Thoracic Spine Segmental/Soft Tissue Mobility Exam Mid/Lower Thoracic Spine Segmental /Soft Tissue Mobility Exam Transverse Plane Flexion Dysfunction Pattern Transverse Plane Extension Dysfunction Pattern Coronal Plane Flexion Dysfunction Pattern Sagittal Plane Flexion Dysfunction Pattern KP So Cal Ortho PT Residency Sagittal Plane Extension Dysfunction Pattern Coronal Plane Extension Dysfunction Pattern Skulpan Asavasopon MPT.
OCS KP So Cal Ortho PT Residency .Thoracic Spine Examination Algorithm End of Range Pain Contralateral Side Thoracic Spine Active Mobility Exam (with over pressure if indicated) End of Range Pain Ipsilateral side Pain Limited Positive Asymmetry in Flexion on Painful Side Active Mobility Positive Asymmetry in Extension on Painful Side Transverse Process Symmetry Palpation Structural Asymmetry Soft Tissue Mobility Restriction/Provocation on Painful Side Soft Tissue Mobility/Provocation Exam Soft Tissue Mobility Restriction/Provocation on Painful Side Pain Limited Soft Tissue Mobility Resistance Limited Accessory Motions with Symptom Provocation Mobility Examination of Thoracic Spine Accessory Motions Resistance Limited Accessory Motions with Symptom Provocation Pain Limited Accessory Motions Flexion Mobilization Pattern Stabilization Or Modalities Pattern Extension Mobilization Pattern Skulpan Asavasopon MPT.
OCS KP So Cal Ortho PT Residency .Rib Cage Algorithm Suspect Underlying Stress Fracture? Palpation/Provocation of: • Costovertebral Joints • Costochondral Junction Consult With Referring Healthcare Practitioner Costovertebral Joint Pain Costrochondral Junction Pain Observe Rib Cage: • Excursion with Inhalation/Exhalation Palpation for Symmetry Costovertebral Joint Mobilization Pattern Anterior Rib Mobilization Pattern Posterior Rib Mobilization Pattern Skulpan Asavasopon MPT.
or STM Intercostal Muscles Intercostal Muscle Skulpan Asavasopon MPT. Sternocostal Joint.Rib Cage Clinical Pathways Inhalation Breathing Exercises Pain with Inhalation Respiratory Pattern Recognition Exhalation Breathing Exercises Pain with Exhalation Anterior with Internal Rotation Anterior with External Rotation Rib Positional Testing Posterior with Internal Rotation Posterior with External Rotation Posterior Rib Mobilization with STM to facilitate Internal or External Rib Anterior Rib Mobilization with STM to facilitate Internal or External Rib Costovertebral Joint Provocation Testing Sternocostal Joint Mobilization of Costovertebral. OCS KP So Cal Ortho PT Residency .
strain.1 onov = 4 or less mnov = 12 SR with contraction of involved myofascia End range stretch to the involved myofascia and joints Provocation of the involved myofascia and joints onov = optimal number of visits mnov = maximal number of visits SR = Symptom Reproduction Joe Godges.C. or prolonged static posture) Lateral or anterior chest wall pain Often precipitated by blunt trauma to the thorax – or – coughing/sneezing Pain worsens w/respiratory movements (e. MA.2 onov = 4 or less mnov = 12 STM.E. deep breath or cough) Diffuse and multiple areas of symptoms Pain and paresthesias associated with pro-longed long sitting or flexed positions May report ANS symptomatology Chest wall/thorax pain Blunt trauma or fall onto chest wall PHYSICAL EXAM Pain increases at end range of one particular movement Palpable asymmetry of adjacent TP’s in T-spine flexion or extension SR with unilateral PA pressures on the involved segment Palpable asymmetrical position of rib SR with AP or PA glides of the involved rib Palpation/provocation of the intercostal myofascia and/or iliocostalis insertion at rib angle SR with slump testing Nerve mobility deficits with LLTTs or ULTTs PT MANAGEMENT Segmental STM and C/R Joint mob/manip Ther Ex’s “Thoracic Facet Syndrome” 847.g.g.SUMMARY OF THORACIC SPINE AND RIBS DIAGNOSTIC CRITERIA AND PT MANAGEMENT STRATEGIES DISORDER HISTORY Mid back pain – usually perceived inferior and lateral to the involved segment Sx’s precipitated by an identifiable mechanical stress (e.I..1 onov = 4 or less mnov = 12 “Rib Dysfunction” 733.6 onov = 4 or less mnov = 12 Segmental STM and C/R Joint mob/manip Ther Ex’s “Dural Adhesion” 724. awkward movement. OCS KP So Cal Ortho PT Residency . Ther Ex to areas of potential spinal and peripheral nerve entrapments Slump/nerve mobility ex’s If acute: P. DPT.R. Joint mob/manip.. trauma. instructions Ther Ex’s (including breathing ex’s) STM/Joint mob if needed to restore normal motion when subacute Chest Wall Contusion 922.
Epidemiology: The number of osteoporotic vertebral compression fractures (700. sleep disorders. The most common pathology behind these fractures is osteoporosis. patients with increasing numbers of VCF demonstrate decreased functional status as recorded in physical function tests. including impaired body image and self esteem. The percentage of women with clinical depression increases with number of spinal fracture deformities. and anxiety. Mortality increases with the number of fractures and the degree of kyphosis. After the first compression fracture. Pathogenesis: Spinal compression fractures are caused by axial loading on a flexed spine. with osteoporotic spinal compression fractures. whether painful or not. Patients report a fear of falling. thoracic hyperkyphosis compresses the lungs and results in a reduction of forced vital capacity (FVC) and forced expiratory volume (FEV1). Additionally these patients may suffer from chronic pain. Compression of the abdominal viscera by the rib cage or loss of lumber spine height leads to decreased appetite.1 Spinal Compression Fracture Repair and Rehabilitation Surgical Indications and Considerations Anatomical Considerations: Compression fractures are characterized by anterior compression of the vertebral body. Osteoporotic vertebral compression fractures are associated with debilitating psychological effects. further fracture and a loss of independence. clinical depression. Similarly. The increased mortality is primarily related to pulmonary complications. Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs Joe Godges DPT. The five-year survival rate for a patient with a vertebral body compression fracture is lower than an individual with a hip fracture. has significant impact on the longevity and quality of life of VCF patients. Diagnosis: • • • A spinal compression fracture can be readily diagnosed on plain radiographs and with computed tomography The pain associated with the fracture is typically localized at the apex of the fracture MRI may be used to assist in differentiation between acute and chronic fractures Nonoperative Versus Operative Management: Open surgical intervention in this frail population. MA. bed rest and bracing has been historically recommended for the vast majority of patients. is fraught with morbidity and implant failure. Compression fractures are a major contributor to both the substantial morbidity and the cost associated with osteoporosis. The spinal deformity caused by vertebral compression fractures (VCFs). Traditionally surgery has been limited to those who have neurologic complications.000) per year easily outnumbers fractures of the hip and ankle combined. Patients with VCF have a 23% increased risk of mortality compared to aged matched controls without VCF. Additionally. nonoperative management including narcotic pain medication. Therefore. the risk of additional vertebral fractures increases 5 to 25 times above baseline. early satiety and weight loss. OCS . Posterior elements of the vertebral body my also be involved but the posterior body remains intact.
as necessary. Surgical Procedure: The noninvasive surgical techniques of percutaneous vertebroplasty and balloon kyphoplasty both internally stabilize the fractured vertebral body through injection of polymethylmethacrylate (PMMA) and are typically performed within three months of the fracture. Kyphoplasty is distinctly different from vertebroplasty by its ability to reduce the fracture using an inflatable balloon tamp to create a void within the vertebral body that allows for injection of PMMA in a thick. Neurological deficits often develop months after the index fracture. large numbers of patients report intractable pain and an inability to return to their prior level of function. Preoperative Rehabilitation • Pain management with narcotics • Bracing and instruction on body mechanics • Appropriate treatment for the underlying osteoporosis POSTOPERATIVE REHABILITATION Treatment Goals: The goals of nonoperative and operative management of vertebral compression fractures are the same and include the restoration of a painless. two new noninvasive techniques (first used in the United States in 1993) offer rapid pain relief and return to routine activities through percutaneous bone augmentation: vertebroplasty and balloon kyphoplasty. kyphoplasty should have longterm benefits beyond those of pain relief provided by vertebroplasty by avoiding the pulmonary and gastrointestinal complications through improved spinal alignment. Some practitioners request a physical therapy consult for patients on the day of surgery to assist in early mobilization. OCS . Both procedures are performed with imaging guidance in the radiology suite or operating room and can be done under local anesthesia with conscious sedation. as the spinal cord drapes over the apex of the deformity. Observation in the hospital for 1 to 2 hours post procedure is typical. Theoretically. MA. bending and twisting. thereby reducing the risk of emboli and extrusion outside the vertebral body. or with general anesthetic. at which time most patients will be able to stand and walk with minimal or no pain. coupled with posterior instrumentation and fusion. open surgical intervention is usually an anterior decompression and fusion. which exacerbates the disease process and increases the risk of additional fractures. When neurologic complications occur. doughy state under low pressure. and for the instruction of body mechanics to avoid heavy lifting. The recommended and frequently self imposed bed rest leads to accelerated bone mineral loss and diminishing muscle mass. Following a vertebroplasty or kyphoplasty the patient is instructed to remain supine for 1 hour to allow the cement to harden. Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs Joe Godges DPT. stable spinal column with optimal neurologic function and minimal treatment morbidity. balanced.2 Unfortunately. However. Early return to daily activities is encouraged.
Truumees E. American Family Physician. Acute versus chronic vertebral compression fractures treated with kyphoplasty: early results. Clinical Imaging. Kim DH. Percutaneous balloon kyphoplasty for the correction of spinal deformity in painful vertebral body compression fractures. Percutaneous vertebroplasty: a therapeutic option for pain associated with vertebral compression fracture. Spine Journal. Itoi E. Percutaneous vertebral augmentation. Garfin SR. Dai L. Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow-up of postmenopausal women. Percutaneous vertebroplasty: new treatment for vertebral compression fractures. Spine Journal. Spine Journal. Reilley MA. If the compression fracture is secondary to a fall. 2003:85-A:2455-2470. J Bone Joint Surg. Vaccaro AR. Diagnosis and management of thoracolumbar spine fractures. Theodorou SJ. J of Back and Musculoskeletal Rehabilitation. et al. Selected References: Sinaki M. et al. et al. Theodorou DJ. 2002:2:76-80. Predey TA. Harrington KD. Medical management can include medications to increase bone mineral density and physical therapy can assist in establishing an appropriate strengthening and weight bearing exercise program to stimulate an increase in bone density. Injury. MA. Bone. 2002:30:836-841. Eckel TS. Slaughter D. 2001:83-A:1070-1073. J Bone Joint Surg. Crandall D. et al. 2004:4:218-229. the patient’s balance systems also need to be addressed. OCS . Mathis JM. 2004:4:418-424. et al. Minimally invasive treatment of osteoporotic vertebral body compression fractures. Hilibrand A. 2002:33:579-582. Sewall LE. Major neurological complications following percutaneous vertebroplasty with polymethylmethacrylate. Low lumbar spinal fractures: management options. et al. 2002:26:15.3 All osteoporotic patients with VCFs should have an appropriate evaluation and treatment of their underlying osteoporosis. Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs Joe Godges DPT. et al. 1999:13:1117. 2002:66:611-616.
Physical limitations: a. Common tests to determine the extent of the PE limitation include physical. 1. sometimes referred to as a "pigeon breast" deformity. 17 Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs Joe Godges DPT. OCS . physiologic and psychological tests: 1. 10-13 PE is far more common than PC deformities. Epidemiology: Pectus deformities are the most common congenital chestwall deformities.1 Pectus Excavatum Repair and Rehabilitation Surgical Indications and Considerations Anatomical Considerations: Pectus deformities refer to abnormal growth and alignment of the costal cartilages (ribs) and their attachment to the sternum. 9 Children with a genetic predisposition to PE who also have an imbalance in their primary respiratory muscles will see an exacerbation of their sternal deformity. Pathogenesis: Pectus excavatum deformities can be congenital. Pectus carinatum (PC): an outward displacement of the cartilage causing an anterior protrusion of the sternum. 15 Diagnosis: The diagnosis of a PE is made visually by observing the shape of the anterior chestwall. 3. 2. If the intercostal muscles are overpowered by the diaphragm. Pectus excavatum is more prevalent in males than females. Radiographs or CT of chest and spine on coronal and sagittal planes to determine PE severity and other possible musculoskeletal restrictions such as scoliosis and kyphosis 16 b. the pectus excavatum.000. with reports of incidences varying from 3 to10 times more often. 14. sometimes referred to as a "cavus" or "funnel" chest. acquired or both. 2. Haller Index rating of CT scan to rate the severity of the PE 16.1 There are two primary deformities of which this Practice Guideline will focus on the more common of the two. PE occurs congenitally if the cartilage is overgrown.2-4 PE can also be acquired due to a dynamic muscle imbalance of the primary respiratory muscles: diaphragm. Pectus excavatum (PE): an inward displacement of the cartilage causing a posterior (inward) deformity at the lower portion of the sternum. 3.8. the sternum will be pulled inward resulting in a PE. MA. The rate of occurrence varies among published reports from 1/300 live births to 1/1. PE is generally reported as occurring in approximately 85% of the pectus deformities. intercostals and abdominals.2. deformed or weak allowing the sternum to be pulled inward due to the negative pressure created during inhalation in the thorax.5-7 This is a fairly common secondary development for infants and children with increased respiratory workloads secondary to pulmonary disorders and/or neuromuscular disorders.
fed under the anterior chest wall. The sternum is then elevated to the proper position and a strut is inserted to maintain the alignment for around 6 months. The patient is hospitalized for 2. 2 The Ravitch procedure repairs only the damaged cartilage on the anterior chest wall. 23. Survey outcomes to determine the effect of the PE on the child's self image and willingness to participate in peer related activities 21.2 2. yet only 2 articles suggest physical therapy for the patients with PE and no article suggested PT as a regular screening test for PE. Pulmonary limitations: a. and finishes on the opposite lateral wall. the shape of the entire anterior chest wall and the relationship of the ribcage to the thoracic spine is changed. The literature notes musculoskeletal problems frequently occur with or because of the PE. Quality of Life limitations: a. The Nuss procedure uses a Lorenz pectus bar. The bar is then "flipped" to mechanically reverse the PE deformity by lifting the anterior chestwall. It is also called the "Open Repair" technique and is championed by Dr. 24 Currently. 22 Non-operative versus Operative Management: Typically. there are 2 options presented to the patient: have surgery or do nothing. Ravitch in 1949. The bar remains in place for 2 – 4 years to support normal growth of the ribs and cartilage around its support. 20 b. more joints are affected and • Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs Joe Godges DPT. Cardiac limitations: a. Eric Fonkalsrud at UCLA who has extensive experience performing this technique and reporting on outcomes for the past several decades. Echocardiogram to determine the extent of the cardiac compression and to rule out other vessel abnormalities associated with connective tissue disorders that commonly present with PE 19. The strut removal is done as an outpatient. however I will share my nonsurgical experience with this population later in the guideline. Pulmonary Function Tests to determine the amount of lung restriction and lung growth retardation 14. Because of this. Surgical Procedure: Two different surgical procedures are commonly performed to reduce the PE deformity: the modified Ravitch 25or the Nuss procedure. once the bar is flipped. OCS . ECG to determine any electric abnormalities 19. The Nuss procedure was introduced by Dr. 26 His technique is also called "minimally invasive repair of pectus excavatum (MIRPE)".5 days for the initial surgery. Donald Nuss at the Children's Hospital of the King's Daughters in Norfolk. 2 The open repair surgically corrects and or resects the damaged cartilage (usually up to 4 rib cartilages). VA in 1998. which is a thin long metal sheet that resembles the shape of old fashioned bicycle handle bars. there is no literature to suggest that PE can be influenced by physical therapy. 20 4. It does not affect the relationship of the entire rib with the thoracic spine. 27 Although the Nuss procedure is less invasive from a surgical perspective. The bar is inserted laterally through a small incision. Exercise Stress Tests to determine the extent of exercise intolerance due to the compression of the lungs and heart 17 3. MA. 18 b. 26 • The modified Ravitch procedure is based on the technique described by Dr.
Fonkalsrud and Dr. surgeons do not require any pre-operative preparation other than to complete medical tests. 13 Fonkalsrud reported the outcomes of the modified Ravitch and Nuss procedures that were performed at 2 large hospitals during 1996 – 2000 and is presented below. OCS . 28 Recent research shows that with continual modifications of both procedures improving the overall outcomes.9 (2-5) 0 3 3 1. Gale Tiemann.5 (5.7 (1-3) 0 0 0 0 12 (8-18) 107 19 (15-31) 6 (5. Both procedures have good outcomes. said they do not routinely use physical therapy. Tina Gustin. I also directly contacted the offices of the 2 primary PE surgeons: Dr.2 (3.9 (3. Nuss' office.5) The overall the morbidity and mortality rates related to either procedure are very low. Both program coordinators indicated that they do not use PT for regular pre-op or post-op screening or intervention. 29 TABLE Patient Parameters Compared Parameter Number of patients Average age (yr) Mean pectus severity index Previous pectus repair Operating time (min) Blood loss (mL) Length of hospitalization (d) Epidural used Pneumothorax Transient pericarditis Intravenous analgesics (average d) Patients placed in ICU Bar displacement (flipped) Reoperations Rehospitalizations for pain Return to school/work (average d) Number sternal bars removed electively Bar removal operating time (average min) Time to bar removal (avg mo) NOTE: Values in parentheses are ranges. She stated that the patients are given a simple pre-op exercise form-sheet from the doctor and encouraged to "improve their posture and strengthen their back muscles" before and after surgery on their own. 28.5) 0 75 (45-130) 90 (10-120) 6.8) 66 7 0 5 (3-7) 2 6 7 2 18 (14-26) 18 25 (17-40) 24 (23-26) Modified Ravitch Repair 139 17.2-9. Nuss Repair 68 12 (5-19) 4. Nuss.1-9. Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs Joe Godges DPT. decisions about which surgical technique to use should depend on the patient and the surgeon's particular situations. 10. There is no report of pre-op physical therapy (PT) evaluations in any of the literature that I used for this assignment. but each has its own followers. indicated that the PTs are involved in general bed mobilization education following surgery. Fonkalsrud's assistant.3 (3-53) 4.8) 9 212 (110-260 90 (15-400) 2. Dr. 30-36 Reported complications of both procedures include: • failure of the strut or bar to hold the corrected deformity • cardiac complications • pulmonary complications Pre-operative Rehabilitation: Generally.5-6. program coordinator at Dr.3 the patients generally report more pain than with the Ravitch procedure. MA.
Nuss' office was contacted directly for this information. Patients are instructed to sleep supine. Steen Boas) and a pediatric thoracic surgeon (Dr. so Dr. avoid "heavy lifting". the patient can re-engage in any sporting activity. For 3 – 4 months.4 POSTOPERATIVE REHABILITATION Procedure 1: Nuss or minimally invasive repair of pectus excavatum (MIRPE): There were no detailed post-op protocols lists published in the articles or on the Nuss website. After 6 weeks. etc. Marleta Reynolds who uses a modified Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs Joe Godges DPT. MA. the results should be permanently maintained by the patient's own musculoskeletal system. • • • Inpatient hospitalization is around 2 – 5 days. Fonkalsrud's office was contacted directly for this information. Procedure 3: Alternative Interventions to surgery: I work with a pediatric pulmonologist (Dr. • • • • • • Inpatient hospitalization is around 5 . joints and cartilage to reshape themselves along the improved chest alignment until the results are permanently maintained by the patient's own musculoskeletal system. wrestling. Goals: Maintain the position of the chest bar during the 6-month post-op period until the cartilage and sternal junction is healed. the patients can re-engage with all physical activities except those with a high risk for full body contact such as football. the patients can engage in swimming and other low risk activities that will not cause a sudden jerking motion of the chest or cause a blow to the chest or spine. the patients are instructed to avoid lifting over 10 pounds. No sports or no gym classes are allowed during this time After the strut bar is removed at 6 months. OCS . Interventions: PT is rarely utilized beyond initial inpatient mobilization period. At 12 weeks. contact martial arts. After 2-3 years when the chest bar is removed. After 8 weeks. Procedure 2: Modified Ravitch or open repair technique: No published post-op protocols were available for the modified Ravitch either. They are also told to avoid lifting their arms above 90 degrees suddenly or to twist their bodies suddenly. Goals: To maintain the position of the chest bar during the 2-3 year post-op period to allow the bones. These limitations are in place for 4 weeks. the patients can begin slowly begin a weight lifting program. PT is utilized for general bed and ambulation mobilization. Once it is healed. and avoid twisting their spine. Intervention: PT is rarely utilized beyond initial inpatient mobilization period. walking is the only allowed "exercise". so Dr.8 days. the patients can re-engage in full activities including contact sports. PT is utilized for general bed and ambulation mobilization. For the first 6 weeks.
spine. The goal of the pre-op evaluation is: • • • • to determine the physiologic restrictions (cardiac.) if any. Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs Joe Godges DPT. neck. OCS . • • Intervention: In our multidiscipline assessment. etc. PT is regularly utilized to screen the patients for chest wall mobility. In particular. surgery is put off for 6 – 12 months to see if physical rehabilitation can reduce the cosmetic and physiologic restrictions adequately enough to decide that surgery is no longer necessary. integumentary restrictions. postural abnormalities. pulmonary. If a patient is deemed a PT candidate. Cardiopulmonary interventions to teach more efficient breathing patterns and coordination with movement. teach the patients how to use their own bodies to minimize the deformity and related physical and physiologic restrictions to the best of their own ability and to help determine whether surgery is necessary to attain a better result with all aspects considered. retraining focuses on imbalance as they relate to breathing. etc. respiratory and trunk muscle imbalance. on the child as a result of the PE to assess the child's potential for physical rehabilitation as a means of reducing the PE and related postural abnormalities to determine the need for surgery to determine the best sequence of intervention strategies PT Goals: Through the use of specific intervention strategies including those listed below. swallowing/aspiration problems. The outcomes of our team interventions are currently being collected and will hopefully be analyzed and published at a later date. connective tissue.5 Ravitch procedure) as a team to evaluate the best intervention strategy for children with PE. MA. shoulders. postural control and trunk stabilization. Implement related pulmonary programs as necessary such as airway clearance (patients often have true pulmonary disorders such as asthma and broncho-pulmonary dysplasia). development delays of effective movement strategies. and pelvis Neuromuscular re-education from a developmental perspective to teach these patients how to correct muscle imbalances that have been present their entire lives. most commonly the chest. Integumentary techniques to reorganize the underlying connective tissue structures that limit full erect posture and normal UE positioning. • • Musculoskeletal techniques to improve mobility of all affected joints.
nih. Molik KA. Engum SA. Evolving management of pectus excavatum based on a single institutional experience of 664 patients. Available at: http://www. 1991. Rescorla FJ.6 References 1. Accessed 7-26-04.org/health/info/chest/diagnose/pectusexcavatum.htm. Grosfeld JL. Dunn JC. Kramer SS.3(1):3-8. Welch K. Massery MP. 1987. 17. Chest wall and spinal deformities in adults with congenital diaphragmatic defects. Louhimo I. Repair of pectus excavatum deformities: 30 years of experience with 375 patients.edu/asp/Clinical. Jr. discussion 262254.gov/medlineplus/ency/imagepages/2927.231(3):443-448.asp?Clinical_Service=Pectus%20Excavatum. 1989. Rintala R.medsch. Medicine & Science in Sports & Exercise.9(5):551-556. Kinematic analysis of patients with spinal muscular atrophy during spontaneous breathing and mechanical ventilation. Mitchell J. Pectus Excavatum. Kharasch V. 2003. Croitoru DP. 11. 1998. Jr. Pediatric Physical Therapy. Swoveland B. Wilson JM.36(2):324-328. 2004. 1999. 10/6/03. Fonkalsrud EW. Peltonen J.nih. Prevention of pectus excavatum for children with spinal muscular atrophy type 1. Lund DP. discussion 582-573. 1996. Pectus excavatum repair: experience with standard and minimal invasive techniques. Bach JR. Medline plus Health Information.surgery.34(12):1787-1790.209(5):578-582. Lawson ML. Shamberger R. Goretsky MJ.cincinnatichildrens. Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients. Bianchi C. Congenital diaphragmatic hernia: the hidden morbidity. Available at: http://www. 2003. Cincinnati Children's Hospital M. Quigley S. 2002. Journal of Pediatric Surgery. Wen-Ying L. Cardiorespiratory outcome after corrective surgery for pectus excavatum: a case study. Annals of Surgery.% 20Pectus%20Carinatum%20and%20Pectus. Colombani PM. Pulmonary function for pectus excavatum at longterm follow-up. Crabbe DC.4(3):237-242. Lietman SA.nlm. Accessed 10/10/03. Fonkalsrud EW. Lindahl H.22(10):904-906. 16. Paediatric Respiratory Reviews. 9.36(2):183-190. 2001. Medline Plus E. Journal of Pediatric Surgery. Fonkalsrud EW. 10.. Kelly RE. American Journal of Physical Medicine & Rehabilitation. Nuss D. 15. OCS . Journal of Pediatric Surgery. 2004. Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs Joe Godges DPT. Malek MH. Tzeng AC. 7. Scherer LR. Jr. 13.htm [Internet website].. Haller JA. Waters P. 1989. Lissoni A.nlm. Pectus Excavatum [internet website]. Xiao-Ping J. Hall JE.37(3):437-445.htm?&MSHiC=28591&L=10&W=pectus+&Pre=%3CFONT+STYLE%3D%22color %3A+%23000000%3B+background%2Dcolor%3A+%23FFFF00%22%3E&Post=%3C%2FFON T%3E. Journal of Pediatric Orthopedics.82(10):815-819. 2004. Journal of Pediatric Surgery. Journal of Pediatric Surgery. http://www.77(3):188-192. Turner CS.31(6):851-854. Micheli LJ. Atkinson JB. Haller JA. Pectus deformities of the anterior chest wall. Chest development as a component of normal motor development: implications for pediatric physical therapists. 2000. American Journal of Physical Medicine & Rehabilitation. 1994. et al.ucla. 14. Vanamo K. Use of CT scans in selection of patients for pectus excavatum surgery: a preliminary report. 4. Ting-Ze H. Annals of Surgery. Available at: http://www. 6. Pectus Excavatum at Medline plus. 2004. Williams AM.gov/medlineplus/ency/imagepages/2927. Pectus Carinatum and Pectus [internet website].29(2):258-262. 3. 2004. West KW. Bach JR.. Scherer LR. Aliverti A. Jaaskelainen J. Scoliosis in children with pectus excavatum and pectus carinatum. Kuehn M. MA. Journal of Pediatric Surgery. 5. Accessed 7-26-04. 12. 8. 2.
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