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thoracic manipulation would lead to decreased pain and

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improved function in individuals with primary neck pain. ese theories include both mechanical and neurophysiological mechanisms and it is most plausible that a combination of these mechanisms leads to the observed changes. e clinical bottom line is that there is suﬃcient evidence to warrant examining the thoracic spine in patients with neck pain and to consider using thoracic spine manipulation. In patients with acute or irritable cervical conditions such as a radiculopathy or post-whiplash injury, thoracic spine manipulation can be well tolerated and lead to a reduction in pain and disability. Once the level of irritability has decreased, the cervical spine can then be directly addressed.

For patients with mechanical neck pain, a recent systematic review concluded that thoracic spine manipulation was more beneﬁcial for pain and disability reduction than standard care in the short term, but no better than cervical manipulation or placebo thoracic spine manipulation.

138

Shoulder

ere is conﬂicting evidence for the eﬀectiveness of manual therapy directed toward the thoracic spine and ribs for patients with shoulder pain.

133,139

Bizzarri et al

139

conducted a systematic review of 4 articles and concluded a single session of thoracic spine manual therapy is not more eﬀective than placebo for the short term. is result is not unexpected in that manual therapy to any region should be part of a broader multimodal treatment

140

plan. In a recent trial by Rhon et al,

104 individuals with subacromial impingement syndrome were randomized into a manual physical therapy or corticosteroid injection group. In the manual physical therapy group, each examiner was allowed to pragmatically provide manual therapy interventions including thoracic spine thrust and nonthrust manipulation, cervical nonthrust manipulation, and shoulder girdle nonthrust manipulation. In this trial, both of the groups experienced improvements in disability and pain rating that remained at 12-month follow-up. e manual physical therapy group did have a lower rate of health care utilization compared to the injection group. Similar to the cervical spine, multiple theories exist to explain the potential mechanisms by which manipulative therapy of the CT spine can lead to decreased shoulder pain. Several recent studies have examined the kinematics of the spine and scapulae as a potential explanation for the changes in clinical

141

presentation. Haik et al

randomized 50 individuals with subacromial impingement syndrome to receive either thoracic spine manipulation or a sham manipulation. In this study, the experimental group had an immediate decrease in reported pain, while very small and likely not clinically important changes in scapular kinematics were observed. Kardouni et al.

compared thoracic spine manipulation to sham in individuals with subacromial impingement and determined that no changes occurred in scapular or thoracic spine kinematics. In this study, both the experimental and sham groups experienced improvements in patient-reported outcomes indicating a

potential placebo eﬀect. Based on the above-mentioned studies, there is preliminary evidence to suggest that patients with a primary complaint of shoulder pain may beneﬁt from manual therapy directed toward the thoracic spine for patientreported outcomes. However, this intervention is unlikely to alter kinematic parameters of the shoulder girdle, scapular, or thoracic spine, and placebo likely contributes a large part to the immediate eﬀects.

Key Takeaway Points

• Research evidence for rehabilitation of primary thoracic spine disorders is lacking. For the majority of primary thoracic spine or rib cage

• musculoskeletal disorders a speciﬁc pathobiological diagnosis cannot be identiﬁed and they are considered nonspeciﬁc.

•

Borrowing from the literature on LBP, individuals with nonspeciﬁc thoracic spine disorders can be triaged based on their risk for prolonged pain and disability.

• Individuals with low to medium risk should respond to a multimodal approach including education, exercise, and manual therapy.

• Individuals who are high risk may beneﬁt from more intensive education, a graded exposure approach to rehabilitation, and referral for multidisciplinary management.

•

Older adults with thoracic vertebral compression fractures are at risk for subsequent fractures and morbidity and mortality. Exercise programs focusing on spinal extensor strengthening have been shown to reduce the incidence of future vertebral compression fractures.

• Chest wall pain that is musculoskeletal in nature can arise from a variety of traumatic and atraumatic conditions including rib fractures, Tietze syndrome, costochondritis, rib stress injuries, slipping rib syndrome, and postoperative chest wall pain. Individuals with these conditions can beneﬁt from targeted rehabilitation involving manual therapy and exercise.

• e ﬁrst and second ribs can be implicated in individuals reporting posterior shoulder girdle and supraclavicular pain. Careful assessment of the cervical spine and shoulder is recommended prior to making the diagnosis of ﬁrst or second rib syndrome.

• Addressing the thoracic spine, particularly with manual therapy interventions, has been shown to be beneﬁcial as part of a multimodal program for individuals with neck and shoulder disorders.

OUTCOME MEASURES AND RETURN TO FUNCTION

e use of patient self-reported functional scales is

recommended for both clinical and research purposes. Clinicians have historically relied most heavily on physical

impairments, such as ROM and strength, to track patient

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outcomes. In many cases, physical impairment measures account for only a small portion of a patient’s disability.

142,143

No speciﬁc measures for function and disability have been reported for patients with thoracic spine and rib cage pain. One option is to use a cervical-speciﬁc scale such as the Neck Disability Index for patients reporting upper thoracic spine pain above the level of T4, and to use a lumbar-speciﬁc form such as the Oswestry Disability Index for patients complaining of pain below T4. Another option is to use a generic tool like the patient-speciﬁc functional scale (PSFS).

144

With this tool, patients list up to 5 important functional activities and rate their ability to complete them on a numeric rating scale. e average score (from 0 to 10) of these activities is then used. e PSFS has been shown to be reliable, responsive, and valid in patients with neck pain and LBP.

144

e PSFS is a generic functional measure that can assist the clinician and the patient in tracking the progress of the patient’s individual functional limitations. Due to the individualized nature of the items on the scale, the PSFS is not designed for use in comparing outcomes across patients. e PSFS has not been speciﬁcally validated for use in patients with thoracic spine pain. To assess pain at baseline the NPRS is recommended, which is a reliable, responsive, and appropriate measure for pain for patients with musculoskeletal conditions.

145

e TLS test is a performance-based outcome measure designed to assess back extensor muscle endurance in individuals with osteoporotic vertebral compression fractures. For this test, the patient is standing while holding 1 kg (2.2 pounds) dumbbells in their hands with their shoulders in 90° of ﬂexion, elbows fully extended, and forearms in neutral pronation/supination. If the patient is unable to hold 1 kg dumbbells, 0.5 kg dumbbells may be used. e test measures how long, in seconds, the patient can maintain this position. e patient may self-select to end the test or they continue until unable to maintain the position. Newman et al

146

assessed the TLS using surface electromyography (EMG) electrodes placed bilaterally on the thoracic extensor muscles at the T3 and T12 levels on 36 individuals with osteoporotic vertebral compression fractures (average age 71.6 years). ey measured the association between the participants’ TLS time and the rate of surface EMG frequency decline during the test. ey reported an r

value of 0.71, indicating these 2 measurements were highly correlated, both measurements being reﬂective of muscular fatigue.

146

Normative data by age and sex for the TLS

are not available.

Key Takeaway Points

• Research-validated outcome measures speciﬁc to the thoracic spine are lacking.

• One approach is to use the Neck Disability Index for individuals with upper thoracic spine pain and the Oswestry Disability Index for individuals with middle to lower thoracic spine pain.

• e PSFS and the NPRS used for individuals with any musculoskeletal disorders are suitable for individuals with thoracic spine disorders.

• e TLS test is a performance-based outcome measure to assess back extensor muscle endurance in individuals with osteoporotic vertebral compression fractures.

CASE SCENARIOS

Case Scenario 1

A 42-year-old female presents with a chief complaint of mid-

thoracic spine pain that has been gradually increasing over the last 6 weeks. She recently transitioned to working from home as a website developer and spends about 8 hours per day (40 hours per week) on her computer. She reports that her pain is centrally located between the scapulae with the most intense location over T6. She denies any radiating symptoms but does feel the pain with deep inhalation. Additionally, her symptoms increase with prolonged sitting/driving (> 30 minutes), lifting both upper extremities overhead simultaneously, and with activities that require a sustained forward ﬂexed position. She enjoys hobbies including swimming, walking, gardening, and reading. Her past medical history is positive for borderline diabetes, but she is not currently on pharmacological management. She reports a family history of diabetes and hypertension. She denies having any thoracic spine pain before but has had intermittent low back pain. Her low back pain was successfully managed with physical therapy in the past. She lives in a 2-story home with her husband and 2 teenage children. She reports her current pain on the Numeric Pain Rating Scale (NPRS) is 1/10 at rest and 5/10 following aggravating activities. Her symptoms immediately reduce to baseline following moving out of the aggravating position. Her score on the Neck Disability Index (NDI) is 28%. Physical examination is positive for limited cervical spine and thoracic extension range of motion (ROM) and for hypomobility of the upper and mid-thoracic spine. Her concordant symptoms were reproduced with active thoracic extension and posterior-anterior pressure applied over the T6 and T7 vertebrae.

1. Based on the location of symptoms, what primary visceral pathology should be considered in the diﬀerential diagnosis?

a. Myocardial infarction. b. Pneumonia. c. Cholecystitis. d. Esophagitis.

e correct answer is c. Cholecystitis. e patient reports scapular region pain as well as pain with deep inhalation. In this case, the gall bladder should be considered on the diﬀerential diagnosis list. e clinician should further investigate by determining the presence/absence of right upper quadrant pain,

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if symptoms occur following 1-2 hours after eating a meal and if

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the patient reports any fever, nausea, or vomiting. e clinician could also perform Murphy’s sign by palpating the right subcostal region and asking the patient to take a deep breath.

Based on the history and examination ﬁndings and response to testing, what level of symptom irritability would be most

accurate? a. Low. b. Medium. c. High. d. Very high.

e correct answer is a. Low. Symptom irritability is in part determined by the amount of time it takes for the symptoms to return to baseline levels following an aggravating stimulus. e patient reports pain severity/intensity ratings of 1/10 at rest and a 5/10 with aggravating activities that immediately return to baseline following cessation of the activity. is would be most consistent with low irritability. e symptom irritability status can be useful to clinicians to determine how many provoking or aggravating tests/measures can be used during the examination.

Given the patient’s aggravating activities and her reported hobbies, which hobbies would be a key target for education/

intervention to help the patient avoid aggravating activities? a. Swimming. b. Walking. c. Gardening. d. Reading.

e correct answer is d. Reading. In this instance, the patient has aggravating activities that include a forward ﬂexed position. Of all of her hobbies, reading is the only one that is typically stationary and has the greatest chance to foster a sustained forward ﬂexed position. Educational interventions should target that hobby to encourage optimal positioning and movement to avoid aggravating her symptoms.

4. e patient is provided a supine mid-thoracic thrust

manipulation in the clinic. She immediately verbally reports that she feels better and does not feel the pain currently. What objective measure would be ideal for the clinician to

assist in tracking the eﬀectiveness of this technique? a. Cervical spine range of motion. b. oracic spine range of motion. c. Pain after sitting for 30 minutes. d. Hypomobility of T6 and T7.

symptoms. Pain after prolonged sitting is not a realistic measure in the clinical setting and relies only on the verbal report of the patient. Mobility testing of the thoracic spine and the determination of the change in joint mobility is possible, but caution should be used when re-assessing the joint mobility as it is subject to expectation bias on the part of the therapist.

Case Scenario 2

A 72-year-old female presents with a chief complaint of lower thoracic spine pain. Onset of her symptoms occurred 8 weeks prior while she was bending down to lift her grandson. She experienced immediate pain and went to the emergency department where she underwent radiographs that revealed an osteoporotic vertebral compression of the T9 vertebra. She has been resting and using nonsteroidal anti-inﬂammatories for pain management. She was referred to physical therapy for ongoing pain and diﬃculty with standing greater than 20 minutes, lifting greater than 10 pounds, and performing sustained overhead activities. Her medical history includes osteoporosis, hypertension, and a past history of a half pack a day smoking for 30 years. She quit smoking 20 years ago. Her goals are to be able to stand in the kitchen long enough to cook meals, be able to lift her grandson, and put dishes away in her upper cabinets.

Outcome measures:

Start Back Screening Tool: 4/9

•

• Patient Speciﬁc Functional Scale: Stand 5/10, lifting 4/10,

overhead activity 4/10

• Numeric Pain Rating Scale (average): 5/10

• Time Loaded Standing test: 45 seconds

Physical examination ﬁndings:

• Ectomorphic body build with increased mid-thoracic

kyphosis

• Bilateral shoulder ﬂexion is limited to 135°

• Trunk rotation, side bending, and extension are all signiﬁcantly

limited and concordantly painful

Gentle spring testing over the T8-10 region is concordantly

•

painful

1. Aside from radiographs to diagnose the fracture, what other

diagnostic imaging study would be useful in managing this

patient’s condition? a. Bone scan. b. Magnetic resonance imaging (MRI). c. Computed tomography (CT) scan. d. DXA scan.

e correct answer is b. oracic spine range of motion. oracic spine ROM is an objective measure that is directly related to the patient’s reported symptoms. While cervical spine ROM may also be measured, it is not the primary region of

e correct answer is d. DXA scan. A DXA scan provides information about the amount of bone mineral density in key body regions including the spine and femurs. is information is used to guide decision making on pharmacological and non-

pharmacological interventions for individuals with low bone

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mineral density. e imaging studies listed for answers a, b, and c are usually not necessary as radiographs are adequate in the diagnosis of a vertebral compression fracture although MRI could be useful in determining the stage of the fracture but is not necessary for the diagnosis.

A primary goal in individuals with thoracic hyperkyphosis is to improve thoracic extension mobility in an attempt to reduce the kyphosis. What manual therapy technique is most appropriate for this patient to improve thoracic extension

mobility? a. Seated middle thoracic thrust manipulation. b. Supine middle thoracic thrust manipulation. c. Prone middle thoracic nonthrust manipulation. d. Prone rib nonthrust manipulation.

e correct answer is c. Metastatic bone disease. Insidious onset of thoracic spine pain in an older adult that is constant in nature with the patient feeling systemically unwell should be cause for concern. Although she does not have a past history of primary cancer, she does have a history of long-term smoking which puts her at risk for cancers, particularly of the lung. Metastatic bone disease from a primary cancer such as the lung can often aﬀect the thoracic spine. Answer a. Ankylosing spondylitis is incorrect because she is older and female and does not report the hallmark morning pain and stiﬀness. Answer b. Cardiac disease is incorrect because you would expect cardiac referred pain to occur mostly with exertion in a person with a history of cardiovascular disease. Answer d. Vertebral osteomyelitis is a possibility, but she does not have any risk factors for infection such as a recent surgery, history of intravenous drug use, or history of an infection.

e correct answer is c. Prone middle thoracic nonthrust manipulation. is technique is considered safe and could be eﬀective as part of a multimodal approach to address thoracic extension mobility. It can be graded based on the patient’s tolerance and the clinician’s best judgement for safety. Answers a and b are incorrect because thrust manipulation is contraindicated in the presence of osteoporosis. Answer d is also incorrect because the patient does not report rib pain and it is generally advised that direct rib mobilization is avoided in individuals with osteoporosis given the fracture risk.

3. Aside from thoracic spine mobility, what other impairment

should be addressed with the goal of not only improving

function but also prevention of future fractures? a. Soft tissue ﬂexibility particularly of the pectoralis muscles. b. Periscapular muscle strength. c. Spinal extensor muscle strength and endurance. d. Shoulder ﬂexion range of motion.

e correct answer is c. Spinal extensor muscle strength and endurance. Studies have shown that this intervention reduces the incidence of future vertebral compression fractures. e interventions listed in a, b, and d are all viable options and have been used as part of multimodal programs for individuals

shown to speciﬁcally reduce future fractures.

4. If this patient denied any trauma and presented with similar

symptoms that were more constant in nature, including at night, and reported feeling systemically unwell, what other

condition should you suspect? a. Ankylosing spondylitis. b. Cardiac disease. c. Metastatic bone disease. d. Vertebral osteomyelitis.

Case Scenario 3

A 25-year-old female graduate student presents with a chief complaint of chest wall pain. She is self-referred to your clinic. She has undergone numerous investigations including radiographs, abdominal ultrasound imaging, and abdominal computed tomography to rule out visceral causes. Her physician placed her on a proton-pump inhibitor medication after diagnosing her with gastroesophageal reﬂux disorder, but this medication has not changed her symptoms. Her symptoms are located in the right anterior to middle lower rib cage region. e symptoms began after doing abdominal exercises in the gym 4 months ago. Her symptoms increase with carrying her backpack over her right shoulder, twisting her trunk, performing abdominal exercises, and sitting for prolonged periods of time in class. She reports low level symptoms (2/10) at rest that increase to 6/10 with activity. Her symptoms settle to baseline within a minute of ceasing the activity. She denies a clicking or subluxing sensation of the involved region. She reports intermittent pain in the right upper abdominal quadrant and denies bowel or bladder changes, changes in symptoms with eating, or recent weight loss. She is otherwise healthy with no signiﬁcant past medical history. Her goals are to return to exercising in the gym including abdominal exercise, being able to carry her backpack, and being able to sit through class. She reports being frustrated by a lack of improvement in her symptoms and not having a deﬁnitive diagnosis.

Outcome measures:

•

Numeric Pain Rating Scale (average): 6/10 Patient Speciﬁc Functional Scale: 5/10

•

Physical examination ﬁndings:

• Observation: posture is unremarkable, no swelling or deformity

is present about the involved rib cage or costochondral region

• Trunk extension, rotation to the left, and side bending to the

right are limited and reproduce concordant pain

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• Spring testing over the angles and costochondral junction of

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the right 8th and 9th ribs is concordantly painful

•

Spring testing over the spinous processes of T8 and T9 is locally painful and considered hypomobile

•

Palpating the lower rib cage region bilaterally while the patient performs deep inspiration and expiration suggests reduced excursion of the right side compared to the left. She reports a ‘tightness’ in the right rib cage region during deep inspiration When performing the hooking maneuver of the right 8th and

• 9th rib region, there is some tenderness but no sensation of clicking Palpation of the abdomen and 4 abdominal quadrants reveals

• no tenderness, masses, or hardness

1. What diagnosis for this patient is the most accurate?

a. Tietze syndrome. b. Slipping rib syndrome. c. Costochondritis. d. Rib fracture.

e correct answer is c. Costochondritis. She has a chief complaint of pain along the costochondral margin in multiple ribs after a repetitive loading of the region. Tietze syndrome is incorrect because that typically involves the upper ribs with visible swelling. Slipping rib syndrome is incorrect because the patient does not report clicking/subluxation and the hooking maneuver does not cause a clicking sensation. Rib fracture is incorrect as that would have been found on imaging and there was no signiﬁcant trauma to cause a fracture.

What manual therapy technique should be trialed ﬁrst to help with pain modulation and improving mobility of the thoracic spine and rib cage?

Posterior to anterior thrust manipulation directed toward

the right 8th and 9th ribs with the patient prone.

Posterior to anterior nonthrust manipulation directed toward the right 8th and 9th ribs with the patient prone.

c. rust manipulation directed toward the right 8th and

9th ribs with the patient supine.

d. rust manipulation directed toward the T8 and T9

vertebrae with the patient in prone or supine.

e correct answer is d. rust manipulation directed

toward the T8 and T9 vertebrae with the patient in prone or supine. A general rule of thumb is to target the thoracic spine

prior to the ribs in the presence of rib pain as direct treatment to the rib can be more pain provoking. After reassessment, the clinician may then elect to perform direct rib manipulation taking into consideration the severity and irritability of the patient’s symptoms. e other answers all involve direct manipulation of the ribs so they are incorrect as the technique to perform ﬁrst.

What exercise intervention is the best choice for this patient at this time?

a. Seated rowing exercise to strengthen the latissimus and

scapular retractors.

Supine punch exercise to strengthen the serratus anterior.

b. c.

oracic extension and rotation mobility exercises incorporating breathing to mobilize the ribs.

Abdominal crunch exercise to strengthen the abdominal

oblique muscles.

e correct answer is c. oracic extension and rotation

mobility exercises incorporating breathing to mobilize the ribs. At this stage of the patient’s rehabilitation, the goal is to

decrease pain and improve mobility, so this exercise is most appropriate. e other choices, strengthening exercises targeting the muscles supporting the thoracic spine and ribs, could all be considered as the patient’s symptoms reduce and she is working on returning to the gym.

What is the best explanation for the patient’s vague

abdominal pain? a. Ongoing gastrointestinal issues. b. Abdominal muscle strain. c. Gall bladder disease. d. Referred pain from the thoracic spine and rib cage.

e correct answer is d. Referred pain from the thoracic spine and rib cage. e thoracic spine and rib cage share common innervation with the abdomen and abdominal viscera. Musculoskeletal disorders of the thoracic spine can cause referred pain into the abdomen most likely due to convergence of primary aﬀerent nerves in the spinal cord. She is not reporting any signs or symptoms of gastrointestinal disorder and her symptom proﬁle does not ﬁt with gall bladder disease, so answers a. and c. are incorrect. Answer b. Abdominal muscle strain is a possibility given her symptoms location and original injury mechanism, but all her symptoms on examination were reproduced with provocation of the thoracic spine and ribs.

Case Scenario 4

A 26-year-old female graduate student presents to physical therapy with a primary complaint of mid to lower thoracic spine pain of an insidious onset beginning 4 weeks ago. She began graduate coursework for a doctoral degree in Anatomy 2 months ago, which has involved a substantial amount of studying, attending courses, and human cadaver dissection. She also reports that she is under a considerable amount of stress and has been sleeping 4-6 hours per night on a regular basis. Symptoms are dull, achy in nature, and are currently located over the central aspect of T8 to T11. She denies radiating symptoms, pain with inhalation, and any signs of suspected sinister pathology. Aggravating factors include prolonged (>20

minutes) sitting at her desk, standing hunched over at her

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dissection table (>40 minutes), and attempting yoga positions that require spinal extension. Easing factors include avoiding pain provocative positions and/or activities and nonsteroidal anti-inﬂammatory medications. Her medical history includes a diagnosis of anxiety that is pharmacologically managed. She reports her current pain on the Numeric Pain Rating Scale (NPRS) is 2/10 at rest and 4/10 following aggravating activities. Her symptoms reduce to baseline within 5 minutes of discontinuing an aggravating activity. Her Neck Disability Index (NDI) score is 22%.

1. Based upon the information provided in the patient history, which of the following diagnoses is most likely in this case scenario?

a. Mechanical thoracic spine pain. b. Mechanical rib dysfunction. c. Symptomatic thoracic disc herniation. d. T4 syndrome.

e correct answer is a. Mechanical thoracic spine pain. e source of the patient’s pain may be related to the thoracic disc or facet joint, but it is diﬃcult to ascertain the pathoanatomical cause for the pain from the history and physical examination. e patient symptom proﬁle, relationship of aggravating and easing factors, and consideration of additional pain qualifying questions indicate mechanical thoracic spine pain. Mechanical rib dysfunction is unlikely due to the location—symptoms would likely be located further laterally than described—and the patient may also report pain with inspiration or expiration. Symptomatic thoracic disc herniation is less likely given the patient’s pain distribution and lack of neurological signs and symptoms. Finally, the lack of upper or lower quarter neurogenic and sympathetic signs or symptoms, such as bilateral upper extremity paresthesias and sweating, make T4 syndrome an unlikely diagnosis.

During aggravating activities into thoracic extension, which of the following describes the arthrokinematics of the thoracic facet joints of T8 and T9?

a. Inferior and posterior sliding of the inferior facets of

the superior vertebra (T8) on the superior facets of the inferior vertebra (T9).

b. Left inferior and lateral sliding of the inferior facet of

the superior vertebra (T8) on the superior facet of the inferior vertebra (T9), and right superior and medial slide of the inferior facet of the superior vertebra (T8) on the superior facet of the inferior vertebra (T9).

c. Right inferior and lateral sliding of the inferior facet of the

superior vertebra (T8) on the superior facet of the inferior vertebra (T9), and left superior and medial slide of the

inferior facet of the superior vertebra (T8) on the superior facet of the inferior vertebra (T9).

Superior and anterior sliding of the inferior facets of

the superior vertebra (T8) on the superior facets of the inferior vertebra (T9).

e correct answer is a. Inferior and posterior sliding of

the inferior facets of the superior vertebra (T8) on the superior facets of the inferior vertebra (T9). is biomechanical

relationship of the arthrokinematics of the thoracic facet joints describes movement into extension. Options b. and c. describe left and right thoracic lateral side bending, respectively. Option d. describes the arthrokinematics of the thoracic facet joints during ﬂexion.

Which spinal ligament will provide bony stability of the vertebral segments and intervertebral discs during

cervicothoracic extension? a. Anterior longitudinal ligament. b. Interspinous ligament. c. Intertransverse ligament. d. Posterior longitudinal ligament.

e correct answer is a. Anterior longitudinal ligament. e anterior longitudinal ligament spans the anterior aspect of the vertebral column from the atlas to the sacrum. Given the anatomical relationship of the ligament to the biomechanical movement of adjacent vertebrae the anterior longitudinal ligament is taut during extension. e interspinous ligament and posterior longitudinal ligament will serve to resist cervicothoracic ﬂexion. e intertransverse ligament is primarily responsible for osteologic stability between segments during lateral side bending.

Pertinent physical examination ﬁndings include limited cervical spine range of motion (ROM) into extension and bilateral side bending, limited thoracic extension and rotation ROM, and hypomobility of the mid-thoracic spine. Her concordant symptoms were reproduced with end range thoracic extension, thoracic ﬂexion, and posterior-anterior segmental mobility testing to T8-10.

4. Which of the following muscles originates at the angle of

ribs 7 through 12 and inserts at the angles of ribs 1 through

6 and the transverse process of C7? a. Iliocostalis thoracis. b. Longissimus capitis. c. Quadratus lumborum. d. Splenius capitis.

e correct answer is a. Iliocostalis thoracis. is muscle originates at the angle of the 7th to 12th rib and inserts at the angles of ﬁrst to 6th ribs and the transverse process of C7.

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Bilateral contraction results in spinal extension, and unilateral

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contraction results in ipsilateral side bending. e longissimus capitis inserts on the mastoid bone. e quadratus lumborum inserts on the inferior border of the 12th rib and the transverse processes of L1 to L4. e splenius cervicis inserts on the transverse processes of the ﬁrst 3 cervical vertebrae.

Using the rule of 3s, what arrangement best describes the

5. anatomical relationship of the spinous process to the transverse process of the T8 vertebra?

e spinous process is located at the same level as the transverse process.

b. e spinous process is located 0.5 vertebral level below

the transverse process.

REFERENCES

c. e spinous process is located 1 vertebral level below the

transverse process.

d. e spinous process is located 1.5 vertebral level below

the transverse process.

e correct answer is c. e spinous process is located 1 vertebral level below the transverse process. According to the rule of 3s, the spinous processes of T1 through T3 are at the same level as the transverse processes, the spinous processes of T4 through T6 are 0.5 vertebral level below the transverse processes, the spinous processes of T7 through T9 are 1 full vertebral level below the transverse processes, and the spinous processes of T10 through T12 are at the same vertebral level to which they are attached.

1. Fouquet N, Bodin J, Descatha A, et al. Prevalence of thoracic spine pain in a surveillance network. Occup Med (London). 2015;65(2):122-125. doi: 10.1093/occmed/kqu151 Roquelaure Y, Bodin J, Ha C, et al. Incidence and risk factors for

2. thoracic spine pain in the working population: e French Pays de la Loire Study. Osteoarthritis Symptoms. 2014;66(11):1695-

1702. doi: 10.1002/acr.22323

3. Dreyfuss P, Tibiletti C, Dreyer SJ. oracic zygapophyseal joint pain patterns: a study in normal volunteers. Spine (Phila Pa 1976). 1994;19(7):807-811. doi: 10.1097/00007632199404000-00014

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