Knee range of motion consists of the flexion and extension arc of motion which totals 135 to 145 degrees. Are the shoulders abducted (protracted) or adducted (retracted)? For more information on flat back, see Tip 4. Some of the methods of assessment described in the tips in this chapter require you to locate specific bones. How does the cervicothoracic junction appear—any sign of a dowager’s hump (b)? Is the rib cage centered over the pelvis or is there evidence of thoracic rotation, lateral flexion, or lateral shift (a)? Tip 8 Assessing Thoracic Range of Movement If the scapulae “wing” away from the chest wall during the activity, this indicates serratus anterior is weak or nonfunctioning. Tip 7 A Trick for Identifying Spine Shape There are two types of scoliosis: functional and structural. Thoracic spine manipulation is a nonspecific intervention for neck pain where remote spinal segments are treated based on the concept of regional … Deviations from vertical are sometimes immediately apparent in this crude and quick assessment. With your client in this position, the tone in the muscles of spinal extension is decreased and it is easier to palpate through them, to the ribs. • The groin. Is the thorax elevated or depressed? Observe how the spinous process of a normal thoracic vertebra points downward. Over time, the lack of mobility in any one area due to the habitual extension posture can consequently lead to faulty positional and movement compensations elsewhere. Range of motion for the thoracic spine include 30 degrees of rotation and 50 degrees of kyphosis. Do any rib angles appear particularly prominent? If you slide your finger or thumb ever so slightly more laterally, you will feel the protrusion of the tip of the transverse process. Once you have identified C7, simply palpate inferior to this point to try to locate the spinous process of the first thoracic vertebra, T1, the beginning of the thoracic spine. You might do this if you wanted to know which movement provoked a particular symptom rather than how much motion was available. A rib “hump” is revealed on the side of their spine that is convex. Your thumb tips are pointing toward L4. Joint Motion AAOS AMA Cervical Flexion 45° 50° Cervical Extension 45° 60° Cervical Lateral Flexion 45° 45° Cervical Rotation 60° 80° Thoracic and Lumbar. The method illustrated here is a … In functional scoliosis, sometimes called flexible scoliosis, there are no structural changes to vertebrae or pathology affecting ligaments or muscles. The simplest way is to observe the movements your client can achieve. However, the traditional methods may not be easy to distinguish the hip from spinal motion and thoracic from lumbar motion. Ask your client to rest their hands against a wall and attempt to extend their elbows as if doing a push-up against the wall. Remember, however, as soon as your subject lowers their arm, the scapula position will change and become less prominent again. There are three positions in which you can do this. First, Maigne observed that if you apply gentle lateral pressure to the spinous processes (a), T12 to L2 will be uncomfortable when pressure is applied to the affected segment. True scapular winging is observed as a marked protrusion of the scapula from the posterior chest wall. It consists of 12 vertebrae that are distinct in shape and function from vertebrae found in other regions of the vertebral column. Many of you would have come across clients with pain in the upper part of their back, the thoracic spine. How do the ribs appear? Reduced range of motion can occur if damage occurs to the soft tissues of the spine or extremities, the lumbar discs, or if weak or tight muscles affect the posture of the individual. • Thoracic rotation is accompanied by lumbar lateral flexion to the opposite side. This is the spinal groove formed by the transverse process of that vertebra. Is there any evidence of either upward or downward rotation of the scapulae (g)? Look at this cross section of the back of the thorax. On many people the scapula is prominent and its outline readily visible. Although you may feel some soft tissue changes, T1 itself moves less than C7 with movement of the neck. Local hypomobility of a vertebral segment (although gross thoracic ROM appears normal. Question: Does it matter which movement the client performs first? total thoracic (T1-T12) RoM as compared with the upper thoracic spine (T1-T6) (p value < 0:001). Standing with cervical, thoracic, & lumbar spine in 0 0 of flexion, extension & rotation: Stabilize pelvis to prevent lateral tilting: Over posterior aspect of S1 spinous process Is the thorax centralized over the pelvis (a)? 2017, in which he noted normal thoracic range of motion on examination. For example, on the erector spinae muscles, rhomboids, or trapezius? End with measurement at end of ROM with patient putting hand on buttocks & bending backwards : Lateral flexion. Is there evidence of shoulder elevation or depression or protraction or retraction based on your observation of the clavicles? This tip has been included near the start of the assessment section because it helps reinforce this point. Posterior View Of course, it is important to rule out other causes of this pain, but pain could be the result of the soft tissues and spinous processes being jammed together on movements involving spinal extension. Now glide gently to one side of this and you will feel a dip. For the compensable thoracic strain, Dr. Mukkamala found that Ms. Farnsworth had reached maximum medical improvement and required no further treatment. Sometimes, clients with flat back complain of pain on standing erect, and even greater pain on extension of their spine. . Your thumb tips are pointing toward L4. Normal ranges of motion for the cervical spine include 50 degrees of flexion, 60 degrees of extension, 45 degrees of lateral, or side bending, and 80 degrees of rotation. He assessed 0% impairment. Twenty six assessment tips provided here include simple identification of bony landmarks, palpation, and range of movement (ROM) tests that you may be familiar with, but also includes unique ways to test for thoracic stiffness, rib excursion, and some quick tests to help you assess muscle length. Is there evidence of scapular winging (h)? ROM of Lumbar Spine: Flexion: ~60 degrees (double inclinometer); 5-7 in (Modified-Schober) Extension: ~35 degrees (double inclinometer); 1-3 in (Modified-Schober) Lateral Flexion: 25-30 degrees (double inclinometer) Thoracolumbar Lateral Flexion: assess distance from middle finger tip to floor (compare side-to-side) Rotation: not assessed to due difficulty differentiating from T-spine However, some clients might feel anxious if you were to start by facing them. In complete contrast to the assessments for scoliosis in the previous tip, this trick is a crude and unorthodox method for quickly assessing the shape of the spine posteriorly. There are many different ways to do this. Many therapists are quick to spot kyphotic postures, and it is equally important to assess for a flat back. The upper extremity has multiple joints and the total range of motion is a combination of all of these joints working together. The Bureau of Labor Statistics reports that more than one million workers suffer back injuries each year. Could it be tension in soft tissues of the hamstrings and calf? Also, when standing, your subject will have a tendency to lean back toward you in order to maintain balance as you palpate and this will further increase the tone in their muscles. This movement occurs in the various areas of the body including the spine and extremities. Range of motion refers to the amount of movement that a particular joint or body part can move measured in degrees. The ranges of motion for the thoracic spine include 30 degrees of rotation and 50 degrees of kyphosis. Stretch Tests. The first position is with your subject standing. Is the thorax elevated or depressed? Instead of having to “count down” every single spinous process from the occiput until you reach the 12th thoracic vertebra, remember that T12 has a floating rib attached to it on each side. So let us begin with some tips to help you quickly locate these landmarks. You are likely to have some idea as to which movement this might be based on what your client has told you during your consultation. There is disagreement as to the best method of assessing ROM in the thoracic (and lumbar) spine. Symptoms range from feelings of stiffness to burning muscular pain, pain often associated with the retention of static postures. Normal range of motion of your back also includes lateral flexion in which you raise one shoulder while dropping the other, arching your spine towards the left or right of your hips. Range of motion refers to the amount of movement that a particular joint or body part can move measured in degrees. In standing or sitting positions, it can be located simply by flexing the head and the neck: the most prominent “bump” on the back of the neck is the spinous process of this vertebra. Palpate until you think you have found the lowest ribs. Ask him or her to abduct their arms a little and place your hands against the back of their rib cage. In 1974, Robert Maigne studied the phenomenon of pain referred from the T10–T11, T11–T12, and T12–L1 regions of the spine. This movement occurs in the various areas of the body including the spine and extremities. The disadvantage of this method is that you are palpating through the thoracolumbar fascia and active erector spinae muscles. Second, he said cellulalgia will be present. In some people, this bump is very obvious; in others, it is less so. Clavicles indicate the position of the scapulae which attach to these bones at the acromioclavicular joint. Performing the corresponding movements of rotation, flexion, extension, and lateral flexion in the thoracic spine is difficult to achieve in isolation as these movements are accompanied by movements in the lumbar spine too: • Lateral flexion of the thorax is accompanied by lumbar rotation to the opposite side. Tip 17 Identifying Thoracic Subluxations On the next few pages are some questions that serve as a reminder of some of the key aspects to consider when carrying out a postural assessment of the thoracic region. Any evidence of scapular tipping (e)? Once you have located L4, you can palpate superiorly to the spinous process of L3, L2, and L1, or inferiorly to L5. Many other tips refer to bony landmarks. This helps your subject relax and decreases tone in the spinal extensor muscles slightly, but again you will need to sit or kneel behind your subject. Although this section is about the thorax, as a therapist you know that body parts cannot be easily compartmentalized and that they impact on one another. So use the test to identify the scapula but not to record its resting position. Cellulalgia describes an area of thickened skin where skin rolling (b) elicits tenderness. They can be felt with the palm of your hand and seen when a person crosses their arms and flexes slightly at the waist. If it is nonfunctioning, then the scapulae will wing even if the subject is standing, without having to perform a push-up. However, this could make some subjects feel uncomfortable. True scapular winging is the result of nerve palsy, frequently affecting the serratus anterior muscle so that it cannot hold the scapula against the rib cage. It is unlike the mild protrusion of scapulae you sometimes see in a client with low body fat, or the slightly more prominent appearance of the scapulae in a client with a flat back. Is the rib cage centered over the pelvis or is there evidence of thoracic rotation, lateral flexion, or lateral shift (a)? Examples of useful bony landmarks you could use include the following: Note that this would only provide information about the change in relationship between body parts. A component of this decision is determining whether the patient is, in fact, appropriate for physical therapy management. Normal thorax (a) and thorax in scoliotic subject flexing to the right (b). Notice that the ribs are angled downward, so you will need to guestimate T12 as being slightly superior to the position in which you locate the lowest ribs. Notice that the ribs are angled downward, so you will need to guestimate T12 as being slightly superior to the position in which you locate the lowest ribs. One quick way to identify the scapula is simply to ask your subject to place their hand behind their back. Tip 18 Quick Tests for Pectoral Length With your client in this position, the tone in the muscles of spinal extension is decreased and it is easier to palpate through them, to the ribs. Copyright © Fairbank (2004) gives a nice account of a subject, Giddeon Mantell, whom Adams identified as having scoliosis. They can be very painful and can occur in the neck, mid or low back, affecting everything you do. Many of you would have come across clients with pain in the upper part of their back, the thoracic spine. He holds a Bachelor of Science in general science and a Doctor of Chiropractic from Palmer College of Chiropractic. He speculated that problems may arise in this particular segment of the spine because it is where a vertebra with the ability to rotate (the last thoracic vertebra, T12) joins a vertebra with almost no rotation (the first lumbar vertebra, L1). This tip has been included near the start of the assessment section because it helps reinforce this point. The 12th rib can be difficult to find, but the 11th rib is more easily palpated and rests approximately horizontal with the spinous process of T12. Question: How can I tell if my client has true scapular winging? Locating T12: The 12th Thoracic Vertebra This may be due to a congenital abnormality or may be the result of injury to the long thoracic nerve. A systematic approach to assessment is encouraged, but you do not need to use all of these assessments with each client. You may wish to examine whether your intervention has had an impact on functional changes, such as improvements to respiratory capacity or a person’s ability to perform daily activities, for example. Is there evidence of kyphosis or flat back (c)? Excessive flexion in the lumbar spine can result in damage to the intervertebral disks, increasing the risk of a herniated disk. Normal lumbar flexion ROM (degrees) 20-35. Ask your subject to bend forward as far as they are able as you observe their rib cage. A flattened thoracic curve can contribute to localized pain. The pain and range of motion (ROM) changes in the cervical spine could be a result of intervention on the thoracic spine [4, 5]. If the thoracolumbar junction is involved, you would expect a thickening of skin in the iliac crest/superior buttock region. Third, you would be able to reproduce symptoms when a point that is 7–8 cm (2.7–3.1 in) from the midline on the iliac crest (c) is rubbed, as this is where the associated cutaneous T11, T12, or L1 nerve crosses the ilium. Loss of the thoracic curve means that these processes come closer together. Tip 12 How Can I Tell What Is a Normal Thoracic ROM? Tip 5 Scapular Winging A rib “hump” is revealed on the side of their spine that is convex. In flexion, measure from floor to fingertips. How does the muscle tone on pectorals (b) and abdomen (c) appear? Tip 10 How to Improve Your Thoracic ROM Tape Measuring Techniques Tip 23 Assessing Vertebral Restrictions – Subjective The thoracic column is joined to the neck at C7/T1, where the first thoracic vertebra (T1) joins the seventh thoracic vertebra (C7). Ankle range of motion includes 50 degrees of plantar-flexion, or toes pointing toward the ground, and 20 degrees of dorsi-flexion with the toes pointing toward head. True scapular winging is observed as a marked protrusion of the scapula from the posterior chest wall. Many therapists are quick to spot kyphotic postures, and it is equally important to assess for a flat back. Although this section is about the thorax, as a therapist you know that body parts cannot be easily compartmentalized and that they impact on one another. Is the person slouched or standing with a military posture (d)? The human body is capable of a wide range of movement. Palpate until you think you have found the lowest ribs. In many sports medicine clinics, range of motion in the upper and lower extremities are also tested. Similarly, you would not wish to “rock” individual vertebrae to assess their mobility in a subject with osteoporosis or rheumatoid arthritis. Tip 22 Assessing Ribs Press your hands downward and when you hit bony resistance on either side, that is the iliac crest. These are commonsense contraindications, about which you are likely to be aware of. At the lower portion of the neck, the spine curves backwards (kyphosis) and becomes the thoracic spine. However, there are limited studies that compared the effect of CT junction mobilization against an effective intervention in neck pain. However, as a practicing therapist you will no doubt be able to determine for yourself their appropriateness. In very general terms, functional scoliosis disappears on the Adam’s test (forward flexion) and on lying supine, and may be corrected by the subject. Then bring your hands inward, trying to differentiate between soft tissue and bone. Assessment of the region which links the cervical and lumbar spines is crucial and yet overlooked by many therapists. 8-4 through 8-7 ). When checking cervical range of motion, the examiner tests the movement of the head, or skull, and neck in flexion, extension, lateral bending and rotation. Tip 2: Thoracolumbar Junction Syndrome (Maigne Syndrome) The thoracic spine lies between the superior cervical spine and the inferior lumbar spine. Upper extremity parasthesias (glove-like distribution) Differential Diagnosis: Must rule out: - Carpal Tunnel syndrome - Special tests to rule out: Tinels Phalens - Thoracic outlet syndrome Special tests to rule in/out: - See TOS - Cervical disk disease William Adams (1820–1900) devised the forward bending test, which carries his name. Normal TMJ ROM, mouth opening in mm. ROM Using a Goniometer (Geelhoed et al, 2006):Flexion: 20-45 degrees Extension: 25-45 degrees Lateral Flexion: 20-40 degrees Rotation: not assessed to due difficulty differentiating from L-spine ROM Using a Tape Measure (Geelhoed et al, 2006): Flexion: >2.7 cm Extension: >2.5 cm Thoracolumbar Lateral Flexion: assess distance from middle finger tip to floor (compare side-to-side) Although their study was specific to the assessment of musicians, Struyf et al (2009) provide a nice overview of the assessment of scapula position. Tip 21 The Rhomboid Myth Then, using the table showing normal ROMs (see p. 170), decide whether you think your subject has an increased or decreased ROM in their thoracic spine. They are all weight-bearing and generally increase in size from superiorly to inferiorly with an increase in the amount of weight that needs to be support… Range of motion allows the body to move in many ways. Question: Does it matter where I start my assessment—anterior, lateral, or posterior? For a good overview, see Martin and Fish (2008). For a brief and interesting overview of patients treated surgically for scapular winging, see Iceton and Harris (1987). If you glide even more laterally, you can feel the costotransverse groove, a useful point to be able to locate when trying to determine whether ribs are correctly aligned. For example, in Tip 2, it will be useful to be able to identify the T12/L1 junction as well as the iliac crest; in Tip 3, you will need to identify the medial border and the inferior angle of the scapula; in Tip 15, you will have to locate the 10th thoracic vertebra (T10). No. Although the thoracic spine is known to have a limited range of motion (ROM) owing to the robust rib cage, the sagittal posture of the thoracic spine and the thoracic mobility have a correlation with neck pain severity and disability [7-9]. Cervical Your cervical region has the greatest range of motion as compared to your thoracic or lumbar regions, according to the Mayfield Clinic for Brain and Spine. , William Adams (1820–1900) devised the forward bending test, which carries his name. For a good overview, see Martin and Fish (2008). Resting supine is often possible but may be uncomfortable as scoliosis remains, Can be corrected independently by the subject. Tip 11 Measuring Thoracic ROM Using a Goniometer After a treatment series, range of motion is tested again for functional improvement in the care plan. The lumbar spine has five vertebrae and connects the spine to the pelvis. Loss of the thoracic curve means that these processes come closer together. However, unlike the cervical region of the spine, it can be difficult to accurately assess range of movement (ROM) in the thorax. The disadvantage of this method is that you are palpating through the thoracolumbar fascia and active erector spinae muscles. TIP: You are working through contracted muscles if you palpate while your subject is seated or standing, and through relaxed muscles if you palpate with your subject prone. Bending forward or rounding your lower back is called flexion. Structural scoliosis does not disappear on the Adam’s test—if anything, this test highlights the scoliosis; the scoliosis does not disappear when the subject rests supine and the curve cannot be corrected by the subject without assistance. Lateral View Tip 6 Adam’s Test for Scoliosis For a good article describing how to use more detailed measurements to assess scoliosis, please see Petias et al (2010). LIVESTRONG is a registered trademark of the LIVESTRONG Foundation. These are safe assessments for most people with thoracic symptoms. These compensations occur The spinous process is the most central bony protrusion. Tip 9 Measuring Thoracic ROM Using a Tape Measure This is sometimes present in the thorax alone, but is often accompanied by symptoms in the neck or lumbar spine. Tip 24 Assessing Soft Tissue Restrictions with Palpation Weakness in trapezius and rhomboids can also contribute to scapular instability. 2020 Press your hands downward and when you hit bony resistance on either side, that is the iliac crest. All areas of the body have specific ranges of motion. Nevertheless, where special caution is needed, this is noted in the text. Locating the Iliac Crest These are commonsense contraindications, about which you are likely to be aware of. Ranges of motion in the elbow and forearm include 90 degrees of supination and pronation, or rotating the forearm. You would not wish someone with problems in their lumbar spine to do this, nor someone who experiences dizziness in such a position. Although you may feel some soft tissue changes, T1 itself moves less than C7 with movement of the neck. How do the ribs appear? For more information, see Tip 5 (p. 162). Are they symmetrical (i)? Tip 3: Postural Assessment of the Thoracic Region – A Reminder The LIVESTRONG Foundation and LIVESTRONG.COM do not endorse Tip 6: Adam’s Test for Scoliosis This is sometimes present in the thorax alone, but is often accompanied by symptoms in the neck or lumbar spine. Tip 1 Identifying Key Bony Landmarks Do any rib angles appear particularly prominent? Similarly, you would not wish to “rock” individual vertebrae to assess their mobility in a subject with osteoporosis or rheumatoid arthritis. On the next few pages are some questions that serve as a reminder of some of the key aspects to consider when carrying out a postural assessment of the thoracic region. Locating C7 Tip 16 Assessing Thoracic “Stiffness” Now glide gently to one side of this and you will feel a dip. In doing so, the medial border and inferior angle of this bone become more prominent. With your hands on the iliac crest, extend your thumbs and try to get your thumb tips to touch. Also, when standing, your subject will have a tendency to lean back toward you in order to maintain balance as you palpate and this will further increase the tone in their muscles. What is the position of the clavicles (d)? Once you have identified C7, simply palpate inferior to this point to try to locate the spinous process of the first thoracic vertebra, T1, the beginning of the thoracic spine. The inferior angle rests approximately level with the spinous process of T8, the spine of the scapula approximately level with T3, and it has been suggested that the medial borders should be approximately 5 cm (2 in) lateral to the spinous processes of the spine. The 12th rib can be difficult to find, but the 11th rib is more easily palpated and rests approximately horizontal with the spinous process of T12. The upright T1-T12 Cobb angle ranged from 28 to 45 (38:7 , SD 6:1 ) and fell also within the lower normal range of the reported data in the literature (Figure 4). Terms of Use loss of cervical lordosis . Then stand back and observe the tracks you have made. Tip 12 How Can I Tell What Is a Normal Thoracic ROM? If the scapulae “wing” away from the chest wall during the activity, this indicates serratus anterior is weak or nonfunctioning. Clavicles indicate the position of the scapulae which attach to these bones at the acromioclavicular joint. Flexion in the lumbar spine is primarily limited by compression of the intervertebral disks and tension in the ligaments that run along the back of the spine. Normal extension ROM is 45 degrees. With your hands on the iliac crest, extend your thumbs and try to get your thumb tips to touch. For example, in Tip 2, it will be useful to be able to identify the T12/L1 junction as well as the iliac crest; in Tip 3, you will need to identify the medial border and the inferior angle of the scapula; in Tip 15, you will have to locate the 10th thoracic vertebra (T10). For a full description of how to perform postural assessment, including what your findings might mean, please see Johnson (2012). Of course, it is important to rule out other causes of this pain, but pain could be the result of the soft tissues and spinous processes being jammed together on movements involving spinal extension. According to the text "Orthopedic Physical Assessment," during an examination two types of range of motion tests are commonly performed. 1. Look at this cross section of the back of the thorax. Tip 15 Assessing Thoracic Excursion Using a Tape Measure These measure active and passive range of motion. Remember, however, as soon as your subject lowers their arm, the scapula position will change and become less prominent again. 209–210). Therefore, if you locate the 12th rib, it will be relatively easy to locate T12. Mid-spinal (thoracic) pain (less common) ... Stiffness in your lower back area that restricts range of motion. Moreover, we do not select every advertiser or advertisement that appears on the web site-many of the 209–210). (Kyphosis is just a name for the outward curve of the thoracic … Using the Adam’s Test Range of motion can be assessed as a visual estimation, by handheld instrument or by a computer-controlled inclinometer. Chapter 4 Thoracic Assessment How does the cervicothoracic junction appear—any sign of a dowager’s hump (b)? Is there evidence of scapular winging (h)? Rib angles are the most prominent parts of the ribs. On many people the scapula is prominent and its outline readily visible. Injuries to muscle, ligaments or bone can impair range of motion, which is commonly assessed after an orthopedic injury. The spinous process is the most central bony protrusion. Hyper-extension can occur from injury. The normal ROM for lateral flexion, or dropping the ear to the shoulder, is also 45 degrees. If you glide even more laterally, you can feel the costotransverse groove, a useful point to be able to locate when trying to determine whether ribs are correctly aligned. Being able to assess whether a client has a hypomobile or hypermobile thoracic spine is useful as increased or decreased mobility in this part of the spine can cause or contribute to pain. Is there evidence of a forward head posture (a)? For more information on flat back, see Tip 4. Thoracic disc displacement usually results from degeneration as part of normal aging. A flattened thoracic curve can contribute to localized pain. For two interesting case studies, see Proctor et al (1985). 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