.4 Cervical and Thoracic P3

CCPT312: CLINICAL CORRELATION FOR PT (SEMINAR 2)
WEEK 3: Cervical and Thoracic Conditions

2ND SEMESTER І A.Y. 2021-2022 TRANSCRIBED BY: GUILBERT LASTRADO
LECTURER: Prof. Zarate
Cervical Spine Rehabilitation Ligaments of the Cervical Spine

1. Alar ligament
Applied Anatomy →Limits skull and atlas rot on axis
2. Accessory Atlantoaxial ligament
Function of the Cervical Spine →Assist Alar ligament
→Furnishes support and stability for the head 3. Apical Ligament
→Articulating vertebral facets allow for the head's ROM →Anterior foramen magnum to apex of dens
→Provides housing and transport for the spinal cord and 4. Transverse Ligament
vertebral artery →Holds the dens in place
5. Cruciform ligament
Cervical Spine →Transverse + Vertical ligament (Foramen magnum to
→Stability has been sacrificed for mobility body of dens)
→It sits between a heavy head and a stable thoracic spine
and ribs
→Cervicoencephalic for the upper cervical spine
- C0 to C2
→Cervicobrachial for the lower cervical spine.
Injury to the Cervicoencephalic Area:

→Headache,
→Fatigue
→Vertigo
→Poor concentration
→Hypertonia of sympathetic nervous system
→Irritability
→Cognitive dysfunction
→Cranial nerve dysfunction,
→Sympathetic system dysfunction
Atlanto-occipital joints
→C0 to C1 Ligaments of the Spine
→Ellipsoid and act in unison. I. Intersegmental ligaments
→Flexion-extension (15° to 20°), or nodding of the head 1. Anterior Longitudinal Ligament
→Side flexion is approximately 100, - Connect Ant. Vertebral body
→Rotation is negligible 2. Posterior Longitudinal Ligament
- Connect Post. Vertebral Body
3. Supraspinous ligament
- Connects the tip of spinous process (C7 to sacrum)
II. Intrasegmental ligaments
1. Ligamentum Flavum
- Connect adjacent laminae Yellow Ligament
2. Ligamentum Nuchae
- Connects tip of Spinous process C7 to occiput
Atlanto-axial joints 3. Interspinous Ligament
→C1 to C2 - Adjacent Spinous process
→Pivot (trochoidal) joint 4. Intertransverse Ligament
→Most mobile articulations of the spine - Adjacent transverse process
→Flexion-extension:10°
→Side flexion: 5°
→Rotation: 50
1
Symptoms related to the vertebral artery

→Vertigo,
→Nausea
→Tinnitus
→"drop attacks" (falling without fainting)
→Visual disturbances
→Stroke or death.
Lower cervical spine (C3 to C7)

→Cervicobrachial area
→Commonly referred into the upper extremity
- leads to neck pain alone, arm pain alone, or both
neck and arm pain.
→Neck and/ or arm pain, headaches, restricted range of
motion (ROM), paresthesia, altered myotomes and
dermatomes, and radicular signs.
Vertebral Artery
→Passes through the transverse processes of the cervical
vertebrae
→Starting at C6 but entering as high as C4-- supplies 20% of
the blood supply to the brain (primarily the hindbrain) ICA
80%
→Rotation and extension of as little as 20° have been
shown to significantly decrease vertebral artery blood flow.
Vertebral artery: Area of stress 14 facet (apophyseal) joints

1. Enters the transverse process of C6 →Synovial (diarthrodial) joints greatest flexion-extension of
2. Within the bony canals of the vertebral transverse the facet joints:
processes - C5 and C6 C4 to C5 and C6 to C7.
3. Between C1 and C2* →Degeneration is more likely to be seen at these levels.
4. Between C1 and the entry of the arteries into the Resting position: Midway between flexion and extension
skull* Close packed position: Full extension
Capsular pattern: Side flexion and rotation equally
limited extension
Recurrent meningeal nerve

→Sinuvertebral nerve
→Innervates the anterior dura sac, the posterior annulus
fibrosus, and the posterior longitudinal ligament
→Facet joints are innervated by the medial branch of the
dorsal primary rami
Innervated Structure of the Spine

→Z-joint
→Joint Capsule
→Outer of annulus
→ALL
2
→PLL Conditions
→Interspinous ligaments →Osteoarthritis
→Erector Spinae →Discogenic disorders
→Multifudus →Trauma
→Periosteum of vertebral bone →Tumors
→Infection
→Cervical Radiculopathy
→Cervical Myelopathy
→Torticollis
→Whiplash
→Congenital deformities
→Myofascial pain syndrome
→Fibromyalgia
Cervical radiculopathy
Uncinate joints or joints of Luschka →Injury to the nerve roots in the cervical spine
→"saddle" form to the upper aspect of the cervical →Presents primarily with unilateral motor and sensory
vertebra symptoms into the upper limb
→Limiting side flexion →With muscle weakness (myotome)
→The portion of the vertebra above, which "articulates or →Sensory alteration (dermatome)
conforms to the uncus, is called the échancrure, or notch. →Reflex hypoactivity
→Found from C3 to T1
→Not seen until age 6 to 9 years and are not fully
developed until 18 years of age
→Result of degeneration of the intervertebral disc
Cervical myelopathy,
→Injury to the spinal cord itself
→More likely to present with spastic weakness,
Intervertebral discs paresthesia, and possible incoordination in one or both
→Approximately 25% of the height of the cervical spine lower limbs, proprioceptive and/or sphincter dysfunction
→No disc is found between CO to C1 and C1 to C2
→Gives the lordotic shape
→The nucleus pulposus functions as a buffer to axial
compression in distributing compressive forces,
→Annulus fibrosus acts to withstand tension within the
disc.
3
Whiplash Injury
Torticollis
→Congenital vs Acquired
→Sternocleidomastoid is the most targeted muscle.
→Sternocleidomastoid is to perform contralateral rotation,
ipsilateral inclination, and flexion of the head
Klippel-FeiI syndrome
→Congenital fusion of some cervical vertebra
→Usually, C3 to C5
→Shortened neck stature and low-lying hairline.
4
Myofascial Pain Syndromes

→Fascial system consists of solid (muscles, bone, cartilage,
and adipose tissue) and liquid (blood, lymph) components.
→Other components include the nervous, vascular, and
lymphatic system.
→"Regional pain syndrome characterized by muscle pain
caused by MTrPs."
Myofascial Trigger Points

→Minimum Criteria
- Taut band
- Trigger point in that taut band
Indications for Inactivation of Myofascial Trigger Points

→Unable to identify the underlying pathology of MTrP
Causes:
activation
→Constant microtrauma to the muscle system can increase
→Failure in treating the underlying pathologic lesion
oxidative metabolism and quickly depletes cellular energy
→Persistent pain or tightness resulting from MTrP even
reserves (ATP)
after complete elimination of the underlying pathology
→Presence of trigger points (TPs) may result from the
→Intolerable pain resulting from MTrP
alteration of the synaptic plate of muscle fibers
→Pain or discomfort interfering with functional activity
→The presence of a constantly altered mechano-metabolic
environment
→Hyaluronan (HA) is a component of glycosaminoglycan
polymer found in the extracellular matrix.
→Alteration of blood flow (an increase in systolic wave
velocity and a decrease in diastolic velocity due to
increased outflow resistance) may cause myofascial pain
Risk Factor
→Traumatic events
→Ergonomic factors (e.g., overuse activities, abnormal
posture)
→Structural factors (e.g., spondylosis, scoliosis, Prognosis:
osteoarthritis) →Acute vs Chronic
→Systemic factors (e.g., hypothyroidism, vitamin D - Acute MPS frequently resolves spontaneously or
deficiency, iron deficiency) after simple treatments
- Chronic MPS are usually worse in prognosis, and
Signs and Symptoms the symptoms can last for 6 months or longer.
Motor Aspects Sensory Aspect
- Disturbed motor - Referred pain Fibromyalgia
function - Local tenderness →"Chronic condition characterized by widespread pain that
- Muscle weakness - Peripheral and covers half the body (right or left half, upper or lower half)
- Stiffness central and has lasted for more than 3 months."
- LOM sensitization →Noninflammatory condition
- allodynia →Chronic pain disorder with unknown etiology.
- hyperalgesia →Condition characterized by chronic widespread
musculoskeletal pain
→Fatigue, cognitive disturbance, psychiatric and multiple
somatic symptoms often accompany the disorder
Primary Fribromyalgia
→"PURE" FMS having no association with any other
medical condition
Secondary Fribromyalgia
→Associated with another medical condition
- Example: RA, SLE, hypothyroidism
5
Co-Morbidities
→Depression
→Anxiety
→Insomnia
→Cognitive dysfunction
→Chronic fatigue
→Endocrinopathies
→Irritable bowel syndrome
→Dysfunction of the autonomic System
Clinical Signs & Symptoms

→Widespread pain lasting more than 3 months
→Widespread local tenderness
Aggravating factors Relieved by
→Aches and pains
→Cold →Warmth or heat
→Stiffness
→Stress →Rest
→Swelling in soft tissue
→Excessive or no exercise →Exercise (gentle
→Tender points
→Physical activity stretching)
→Muscle spasms or nodules
(overstretching)
→Additional symptoms include 11 of 18 tender points at
specific sites throughout the body, nonrestorative sleep,
Clinical Signs & Symptoms
and morning stiffness
→Myalgia (generalized aching)
→A final common problem is fatigue with subsequent
→Fatigue (mental and physical)
diminished exercise tolerance.
→Sleep disturbances, nocturnal myoclonus, nocturnal
bruxism
→Tender points of palpation
→Chest wall pain mimicking angina pectoris
→Tendinitis, bursitis
→Temperature dysregulation
- Raynaud's phenomenon; cold-induces vasospasm
(hypersensitivity to cold)
- Hypothermia (mild decrease in core body
temperature)
→Dyspnea, dizziness, syncope
→Headache (throbbing occipital pain)
Tender Points Differentiating MPS from FMS

→Occiput MPS FMS
- at the suboccipital muscle insertions Trigger points Tender points
→Low cervical M=F F>M
- at the anterior aspects of the intertransverse 27 to 50 years 20 to 55 year
spaces at C5-C7 Localized musculoskeletal Systemic condition
→Trapezius condition
- at the midpoint of the upper border
No associated signs and Wide array of associated
→Supraspinatus
symptoms signs and symptoms
- at origins, above the scapula spine near the
Etiology: overuse, Etiology: neurohormonal
medial border
repetitive motions; imbalance; autonomic
→Second rib
reduced muscle activity nervous system
- upper lateral to the second costochondral
dysfunction
junction
→Lateral epicondyle
Clinical Assessment
- 2 cm distal to the epicondyles
→Gluteal
Symptoms
- in upper outer quadrants of buttocks in
→Pain
anterior fold of muscle
- May refer to the shoulders and arm
→Greater trochanter
→Stiffness
- Posterior to the trochanteric prominence
→Deformity
→Knee
- Wry neck or excessive flexion or extension
- At the medial fat pad proximal to the joint line
→Numbness, tingling & weakness
6
- Nerve root impingement

→Headache
→Tension
Signs
→No examination of the neck is complete without
examination of the upper trunk, both upper limbs, and
shoulder joints.
Chin Poking vs Military Posture

Observation
→Head and neck posture
→Shoulder levels
→Muscle Spasm or Any Asymmetry
→Facial Expression Boney and Soft-Tissue Contours
→Evidence of Ischemia in either upper limb
→Normal Sitting
Cervical Protraction vs Retraction
Feel
→Anterior Cervical Muscles
- Longus capitis and longus colli muscles
- Scaleneus anterior, medius, and posterior muscles
Upper crossed syndrome - Sternocleidomastoid muscles
→"poking chin" posture on the muscles. →Posterior Cervical Muscles
→The deep neck flexors are weak, as are the rhomboids, - Suboccipital muscles
serratus anterior, and often the lower trapezius. - Transversospinal muscles
→Opposite these weak muscles are tight pectoralis major - Erector Spinae Muscles
and minor, along with upper trapezius and levator scapulae
Palpation
Examination
→Active Movements
- Flexion Extension
- Side flexion left and right
- Rotation left and right
Look - Combined movements
→Search for deformities - repetitive movements
- Wryneck - sustained positions
- Stiffness →Passive Movements
7
Looking Down at Belt Buckle or Shoelaces

→At least 60° to 70° of neck flexion is necessary
- If this range is not available, the patient will flex
the back to complete the task
Shoulder Check
→At least 60° to 70° of cervical rotation is necessary
- If this range is not available, the patient will rotate
the trunk to accomplish this task
Tuck Chin In
→This action produces upper cervical flexion with lower
cervical extension
Poke Chin Out

→This action produces upper cervical extension with lower
cervical flexion
Cervical Myotomes
→Neck flexion: C1 to C2 Neck Strength
→Neck side flexion: C3 and cranial nerve XI →In athletes, neck strength should be approximately 30%
→Shoulder elevation: C4 and cranial nerve XI of body weight to decrease chance of injury
→Shoulder abduction/shoulder lateral rotation: C5
→Elbow flexion and/or wrist extension: C6 Paresthesia
→Elbow extension and/or wrist flexion: C7 →Referred to the hands, may make cooking and handling
→Thumb extension and/or ulnar deviation: C8 utensils particularly difficult or even dangerous
→Abduction and/or adduction of hand intrinsic: T1
Starting Action Functional Test
Functional Assessment of the Cervical Spine Position
→Breathing Supine lying Lift head 6 to 8 repetitions: Functional
- Normal, unlabored breathing should be seen with keeping chin 3 to 5 repetitions: Functionally
tucked in (neck fair
the mouth closed
flexion) 1 to 2 repetitions: Functionally
- no gulping or gasping
poor
→Swallowing 0 repetitions: Nonfunction
- A complex movement involving muscles of the lips, Prone lying Lift head Hold 20 to 25 seconds:
tongue, jaw soft palate, pharynx, and larynx as backward (neck Functional
well as the suprahyoid and infrahyoid muscles extension) Hold 10 to 19 seconds:
Functionally fair
Is the patient a mouth breather? Hold 1 to 9 seconds: Functionally
→Mouth breathing encourages forward head posture and poor
increases activity of accessory respiratory muscles Hold 0 seconds: Nonfunctional
Side lying Lift head Hold 20 to 25 seconds:
(pillows sideways away Functional
under head from pillow Hold 10 to 19 seconds:
so head is (neck side Functionally fair
not side flexion) (must Hold 1 to 9 seconds: Functionally
flexed) be repeated for poor
other side) Hold 0 seconds: Nonfunctional
Supine lying Lift head off Hold 20 to 25 seconds:
bed and rotate Functional
to one side Hold 10 to 19 seconds:
keeping head Functionally fair
off bed or Hold 1 to 9 seconds: Functionally
pillow (neck poor
rotation) (must Hold 0 seconds: Nonfunctional
be repeated
Looking Up at the Ceiling both ways)
→At least 40° to 50° of neck extension is usually necessary
for everyday activities
- if this range is not available, the patient will bend
the back or the knees, or both, to obtain the
desired range
8
Outcome Measures Special Test

→Neck Disability Index (NDI) →Foraminal Compression (Spurling's) Test
- capture perceived disability in patients with neck →Upper Limb Tension Test (ULTT)
pain →Jackson Compression Test
→Patient-Specific Functional Scale (PSFS) →Distraction Test
- alternative or supplement to generic condition- →Shoulder Abduction Relief Test
specific measures →Valsalva Test
→Tinel's for Brachial Plexus
Cervical Active Range of Motion →Romberg's Test
→The amount of active neck flexion, extension, rotation, →Tinel's for Brachial Plexus
and side bending motion measured using an inclinometer →Romberg's Test
→Lhermitte's Sign
→Vertebral Artery (Cervical Quadrant) Test
→Hautant's Test
→Naffziger's Test
→Sharp-Purser Test
→Transverse Ligament Stress Test
Physical Therapy Intervention

Cervical and Thoracic Segmental Mobility →Cervical Manipulation/Mobilization
→With the patient in prone, cervical and thoracic pine - SHOULD be performed as an adjunct t exercise
segmental movement and pain response are assessed →Thoracic Mobilization/Manipulation
→Assess the mobility of each joint using the thumb →Stretching
(cervical) and hypothenar (thoracic) to check each joint - Anterior, medial, posterior scalene; upper
trapezius; lector scapulae; pectoralis minor; and
Cranial Cervical Flexion Test pectoralis major
→Using pressure biofeedback inflated to 20mmHg →Coordination, Strengthening, and Endurance Exercises
→Give pressure (22, 24, 26, 28 and 30mmHg) →Voluntary contraction and release methods
→Should maintain 10 secs each stage - Muscle energy technique
→Abnormal response: - Reciprocal inhibition
- is unable to generate an increase in pressure of at - Post-isometric relaxation
least 6 mmHg →Upper Quarter and Neck Mobilization
- is unable to hold the generated pressure for 10 →Traction
secs
- Uses superficial neck muscles to accomplish the
cervical flexion
- uses a sudden mov't of the chin or pushing the
neck forcefully against the pressure device
Neck Flexor Muscle Endurance Test

→In supine, the ability to lift the head and neck against
gravity for an extended period
→Supine, hook-lying position
→With the chin maximally retracted and maintained
isometrically
→Pt. lifts head and neck until head is ~1 inch above plinth
keeping chin retracted to the chest
9
Thoracic Spine Rehabilitation Transverse Processes

→Directed laterally from the junction of laminae & pedicles
Related Anatomy
Spinal Segments
→Anterior
- Hydraulic, WB, shock absorption
→Posterior
- Gliding mech for movt Spinal Canal
- Muscle attachment: cause & control movt
- Spinal stability
Facet Joints
→Zygapophyseal jts
→Synovial
→Between inf. & sup. Articular
Vertebral Body
→Its anterior portion: weakest; potential site of collapse
Typical Cervical Vertebrae
Pedicles
→Cylindrical sides of the vertebral arch
Atypical Cervical Vertebrae
Lamina
→Flattened, post. arch
Thoracic Vertebrae
Spinous Process
→Directed posteriorly from the junction of laminae &
pedicles
10
Lumbar Vertebrae
Facet Joints
→Kyphosis
- Primary curve
- Thoracic
→Lordosis
- Cervical: Lifts head up; sits IV joint
- Lumbar: Stands and walks
Spine Movement: Factors

1. Facets
2. Ligaments
3. Thoracolumbar fascia
4. Spinous process
5. IVD thickness: VB height
1. Orientation of the Facets

→CS
- FP; oblique in TP
- Flexion/ext/rot
→TS
- Upper: FP
- Lower: SP
- Rot/side/forward bending
→LS
- SP
- (-) rotation
Costovertebral Joints
→Synovial plane joints located between the ribs and the
vertebral bodies
→Radiate ligament: joins the anterior aspect of the head of
the rib radiating to the sides of the vertebral bodies and
disc in between
11
2. Ligaments Rotation
Posture
3. Thoracolumbar Fascia
4. Spinous process
→Limits extension
5. IVD thickness- VB Height Ratio
Poor Posture
→CS- 2:5 (most mobile)
→TS- 1:5 (least mobile)
→LS- 1:3
Facets Joints in Motion
Flexion/ Extension
12
Conditions: Postural Deviations
Kyphosis
→AKA "posterior curvature"
→most prevalent in the thoracic spine
→Hyperkyphosis is a kyphotic angle of greater than 40°
commonly measured by the Cobb method (T4 and T12)
→After age 40, the thoracic kyphosis tends to increase.
Structural Kyphosis
a. Congenital Kyphosis
→Defect of segmentation
→Failure of formation of anterior element of the spine
Scheuermann’s Disease
→most common structural kyphosis in adolescents but can
occur in adults.
→Its etiology is unknown
→Anterior vertebral wedging of at least 5 degrees of 3
consecutive vertebra
→Structural kyphosis
b. Osteoporosis
Primary Secondary
Type I Type II Type III
→Post- →Senile →At any age
menopausal →CAUSES:
Loss of →Secondary - Nutritional
estrogen to deficiency
→ (helps in degeneration - Endocrine
reabsorption and disorder Hump back
of Ca++) aging - Drug: →AKA "gibbus"
→Ca++ is Corticosteriod →Anterior wedging or collapse of the body of one or two
malabsorbed - Immobility thoracic vertebrae.
- Nephropathy →Pt with Pott's disease, fracture, tumor, or bone disease
→Pelvic inclination is usually normal (30°).
Types of Kyphosis →Structural kyphosis
→Round back
→Scheuermann's disease
→Humpback
→Flat back
→Dowager's hump
Round back*
→Decreased pelvic inclination (20°)
→Thoracolumbar or thoracic kyphosis
→Kyphosis compensate and maintain the body's center of
gravity
→Both structural or postural/Functional
- Structural kyphosis, by a growth disturbance result
or usually caused by tight soft tissues from
prolonged postural change Flat back
→Decreased pelvic inclination (20°) with a mobile spine.
→Similar to round back, except that the thoracic spine
remains mobile and is able to compensate throughout its
length for the altered center of gravity caused by the
decreased pelvic inclination.
→It does not have the appearance of an excessive kyphotic
curve
13
Dowager's hump
Heuter Volkmann Law
→Postmenopausal osteoporosis.
→Growth is retarded by increased
→Because of the osteoporosis, anterior wedge fractures
→Mechanical compression, accelerated by reduced loading
occur to several vertebrae
in comparison with normal values.
→Usually in the upper to middle thoracic spine
→Causing a structural scoliosis that also contributes to a
decrease in height
Structural Non-structural
→Non-functional/ →Functional/ postural/
irreversible reversible
Scoliosis →Causes: → (+) lateral bending test
→"Hunchback of Notre Dame" - Neuromuscular
→Deformity in which there are one or more lateral - Osteopathic →Causes:
curvatures of the lumbar or thoracic spine (Congenital)
→Cervical spine: torticollis - Idiopathic* - Muscle guarding/
→Thoracic spine alone, thoracolumbar area, or lumbar - Genetic spasm
spine alone →Structural change in the - Habitual
→A lateral deviation of the normal vertical lines of the bone & normal flexibility asymmetrical
spine >10° or an in-potency, 3-dimensional—form deviation of the spine is lost posture
from the spine, which is accompanied by lateral curvature - LLD
of the spine with or without a change in the sagittal and
axial surfaces Structural
→Early Onset Scoliosis (EOS) refers to spine deformity that
is present before 10 years of age
14
Non-structural
Epidemiology
→80%: IDIOPHATIC | 20% Pathologic

→AIS >10%: 0.93 to 12%
→Progression of AIS: MC in female
- 10-20 (1.3:1)
- 20-30: (5.4.1)
- >30% (7:1)
- Critical threshold: 30-50
→2% -4% among 10-16 y/o (AIS)
→Ratio:
- 10° curvature: equal
- >30° curvature: 10 G:18
→10%: medical intervention
→More than 90%: observation
Classification
A. Site
1. Cervical
2. Thoracic
3. Lumbar
B. Etiology and onset
1. Degenerative
2. Neuromuscular
3. Congenital
4. Secondary
5. Idiopathic
James Classification (Chronological)

Ponseti Classification (Topographical)
15
Evaluation →The ribs on the concave side move anteriorly, causing a

"hollow" and a widening of the thoracic cage on the
History concave side
→FHx: scoliosis
→Menstrual onset
→Presence of pain & neurologic changes, including bowel
& bladder dysfunction
→Atypical: presence of severe pain or neurologic Sxs
Physical Examination
→GI: height (sitting & standing) & weight
→Postural Ax: Plumb line test
- Asymmetric shoulder level
- Rib hump/bump Convex Concave
- Protrusion of hip on one side →High shoulder →High pelvis
- Pelvic obliquity → (+) post rib hump → (+) ant rib bump
- ↑ lumbar lordosis → (+) prominent scapula →Spinous process on this
- Uneven waist crease →VB rotation on this side side
*This is applicable for a C curve scoliosis
Postural Ax: TRACE
Nash-Moe Grading of Vertebral Rotation
0- Normal
1-Mild rotation. (R) pedicle only partly visible
2- Moderate rotation (R) pedicle disappeared
3-Severe rotation: (L) pedicle in midline
4-Marked rotation; (L) pedicle on the (R) side
Razorback Spine
→Mild rib hump to a severe rotation of the vertebrae,
causing a rib deformity
→The vertebral bodies rotate to the convexity of the curve
and become distorted.
→If the thoracic spine is involved, this rotation causes the
ribs on the convex side of the curve to push posteriorly,
causing a rib "hump"
→Narrowing the thoracic cage on the convex side.
→The spinous process deviates toward the concave side.
16
→Adam's Test: curve flexibility

→Muscle strength: stretch & tight weakness esp. hamstring
tightness
→Anthropometric Meas: LLM, CEM
→Scoliometer: degree of curvature
→Neuroeval:
- Motor & sensory
- Reflexes: DTRs & Pathologic reflexes
Adam Forward Bending vs Lateral Bending Test
→Physical Capacity Evaluation

- FEV1, FVC, FEVS/FVC
→Joint Laxity
- Beighton score
- ≥4 out of 9 points for boys and ≥5 for girls
→HRQoL
- SRS 22
Prognostic Factors
1. Gender
→G: 10x risk of curve progression
2. Growth potential/Skeletal maturity
a. Chronological age (G-14; B-16)
b. Onset of menstruation (2 yrs after menarche)
3. Curve magnitude
Growth Potential/ Skeletal Maturity

Methods:
1. Tanner Staging
2. Risser Staging
- Lower grade greater risk of progression
Curve Magnitude
1. Cobb angle
Lateral Bending Test

→Structural
- Asymmetrical posture past 0° from side bending
(curve's apex)
- Does not disappear on forward bending
17
2. Risser-Fergusson Lenke Classification of Curve Types
→<30°
- no progression if skeletally mature
→30°-50°
- 10°-15° lifetime progression
→>50°
- progress 1°-2° per year Management
Risk of Curve Progression Treatment Algorithm
King-Moe Curve Classification
CONSERVATIVE: Goals of Tx
1. To stop curve progression at puberty (or possibly even
reduce it)
2. To prevent or treat respiratory dysfunction
3. To prevent or treat spinal pain syndromes
4. To improve aesthetics via postural correction
18
1. Fusion Surgery
A. Posterior B. Anterior
1. Harrington →Choice of treatment for
(standard) the thoracolumbar and
- distraction lumbar scoliosis
2. Cotrel and →Shorter fusion levels,
Dubousset less post-op pain & scar
- rotation formation (video-assisted
3. Suk (segmental thoracoscopic surgery)
pedicle screw)
Posterior Spinal Fusion
Surgical Management
Anterior Spinal Fusion
2. Fusionless Surgery
→Indications
1. to control growth
- Epiphysiodesis on the convex side of the deformity
2. to avoid fusion for skeletally immature patients
with SCI or myelodysplasia
- Vertebral Wedge Ostetomies
General Indication: curves exceeding 45 or 50 degrees by 3. to delay the timing of the definitive fusion surgery
the Cobb's method - provide correction and maintain it during the
1. Curves larger than 50 degrees progress even after growing years while allowing spinal growth for
skeletal maturity early onset scoliosis
2. Curves of greater magnitude cause loss of pulmonary 4. to increase the volume of the thorax
function, and much larger curves cause respiratory failure - to treat thoracic insufficiency syndrome associated
3. Larger the curve progress, more difficult to treat with with fused ribs and congenital scoliosis
surgery - vertical expandable prosthetic titanium ribs
(VEPTR)
19

.4 Cervical and Thoracic P3

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CCPT312: CLINICAL CORRELATION FOR PT (SEMINAR 2)

WEEK 3: Cervical and Thoracic Conditions

Cervical Spine Rehabilitation Ligaments of the Cervical Spine

Injury to the Cervicoencephalic Area:

Symptoms related to the vertebral artery

Lower cervical spine (C3 to C7)

Vertebral artery: Area of stress 14 facet (apophyseal) joints

Recurrent meningeal nerve

Innervated Structure of the Spine

Myofascial Pain Syndromes

Myofascial Trigger Points

Indications for Inactivation of Myofascial Trigger Points

Clinical Signs & Symptoms

Tender Points Differentiating MPS from FMS

- Nerve root impingement

Chin Poking vs Military Posture

Cervical Protraction vs Retraction

Looking Down at Belt Buckle or Shoelaces

Poke Chin Out

Outcome Measures Special Test

Physical Therapy Intervention

Neck Flexor Muscle Endurance Test

Thoracic Spine Rehabilitation Transverse Processes

Typical Cervical Vertebrae

Atypical Cervical Vertebrae

Spine Movement: Factors

1. Orientation of the Facets

Facets Joints in Motion

Conditions: Postural Deviations

→80%: IDIOPHATIC | 20% Pathologic

James Classification (Chronological)

Evaluation →The ribs on the concave side move anteriorly, causing a

→Adam's Test: curve flexibility

Adam Forward Bending vs Lateral Bending Test

→Physical Capacity Evaluation

Growth Potential/ Skeletal Maturity

Lateral Bending Test

2. Risser-Fergusson Lenke Classification of Curve Types

Risk of Curve Progression Treatment Algorithm

King-Moe Curve Classification

Posterior Spinal Fusion

Anterior Spinal Fusion

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