Thoracic Instability: Difference between revisions
m (Text replace - '- Your name will be added here if you are a lead editor on this page.' to ' ') |
No edit summary |
||
Line 1: | Line 1: | ||
<div class="noeditbox">Welcome to [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]]. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div> <div class="editorbox"> | |||
'''Original Editors ''' - [[User:Assia Dad|Assia Dad]] [[User:Soumaya Ajattar|Soumaya Ajattar]] [[User:Gülcan Karatas|Gülcan Karatas]][[User:Sefora Bakkioui|Sefora Bakkiouias]] part of the [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]] | |||
{ | '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} | ||
</div> | |||
== Search Strategy == | |||
Databases: web of knowledge, Pubmed<br>Key words: Thoracic spine, Thoracic instability, spine instability, Trunk stabilisation<br>Medical library ULB/VUB with key words: Thoracic spine, Thoracic instability, physical therapy thoracic spine<br> | |||
== Definition/Description == | |||
== | Instability in the thoracic spine is as lumbar instability. If this instability in thoracic spines is present, it manifests as a spondylolisthesis or the forward translation of the cephalad vertebra on the caudal one.<br>Furthermore lateral listheses in thoracic spines are rare, possibly due to restraints provided by the rib cage and the uncovertebral joints. The degenerative thoracic spondylolisthesis is uncommon, as the thoracic spine is inherently more stable in the anterior to posterior direction than the cervical or lumbar. This is due to the rib cage and the coronal orientation of the facet joints.<ref name="A. Zahrai et al">A. Zahrai et al, Cervical and thoracic degenerative spinal instability, 2013, Semin Spine Surg (Lvel of evidence 3A)</ref> <br>Instability is a loss of the functional integrity of a system which provides stability. The osteoarticularligamentous and the myofascial are two systems in the thorax that contribute stability. In the midthorax the rotational instability involves the spinal and costal components of the segment. <ref name="D.G. Lee">D.G. Lee, Rotational instability of the mid-thoracic spine : assessment and management, 1996, Manual Therapy (Level of evidence 2C)</ref><br><br> | ||
== Clinically Relevant Anatomy == | |||
The costovertebrals joints and rib cage are very important when it comes to stabilizing the thoracic spine. | |||
<br>The rib cage is fixed to the thoracic spine by the costovertebral joints, which consists of costotransverse joints and joints of the head of the ribs. Thoracic vertebrae are connected to adjacent vertebrae by the bilateral costovertebral joints. <br>The costovertebral joints and their surrounding ligaments, such as the costotransverse, superior costotransverse, radiatie, and intra-articular ligaments, connect nearby vertebrae and ribs. <ref name="I. Oda et al">I. Oda et al, Biomechanical role of posterieur elements, costovertebral joints, and rib cage in the stability of the thoracic spine, 1996, Spine (Level of evidence 2C)</ref> (Level of evidence 2C) | |||
= | <br>The biomechanical and stabilization role of the costovertebral joints and rib cage in the thoracic spine is evidential, even more in lateral bending and axial rotation. When the posterior elements and bilateral costovertebral joints are destroyed, the thoracic spine may become unstable. The costovertebral joints are important stabilizers of the thoracic spinal motion segments. <ref name="I. Oda et al" /><br> | ||
== Epidemiology /Etiology == | |||
There are many causes that induce thoracic spondylolisthesis. The first cause is the dysfunction of the intervertebral disc which can lead to instability because of a lack of disc height. Furthermore this leads to a relative laxity in the motion segment. ‘Horizontalization’ of the lamina is the second cause that can lead to instability. <br>Lastly, thoracic instability can occur due to severe spondylosis or the presence of a long segment surgical arthrodesis below the unstable segment. [2] (Level of evidence 3B)<br> | |||
== Characteristics/Clinical Presentation == | |||
add text here <br> | |||
== Differential Diagnosis == | |||
add text here | |||
== Diagnostic Procedures == | == Diagnostic Procedures == | ||
Thoracic Examination | |||
<br>The state of the costovertebral joints and rib cage should be assessed to evaluate the stability of the thoracic spine. [1] (Level of evidence 2C)<br>The rotational instability of the thorax will cause an increase in the neutral zone. This instability is palpated during segmental lateral translation test. The unstable segment has a softer feel of motion, an increased quantity of translation and variable symptom response. The test may provoke pain if the joint is irritable. When the instability is long standing and asymptomatic, the tests are mostly not provocative. | |||
<br>The second test for lateral translation stability (rotation) [1] is to evaluate the stability of a midthoracic segment. | |||
<br>It is necessary to first determine the available mobility in lateral translation. The most instability can be found in the region between T3- T7. | |||
<br>This motion is tested in the following manner: the patient is sitting with his arms crossed on his chest. The therapists’ left hand fixes the transverse process of T6. With the other hand you translate the T5 vertebra and the sixth ribs to the right in the transverse plane. <br>The quantity and the end feel of motions are reported and compared to the levels above and below. | |||
<br>The stability of the T5-6 spinal component can be assessed by constraining the sixth ribs from gliding relative to their transverse processes and then applying a lateral translation force. No motion should occur when the ribs are fixed.<br><br> | |||
== Outcome Measures == | == Outcome Measures == | ||
add links to outcome measures here (see [[Outcome Measures|Outcome Measures Database]]) | add links to outcome measures here (also see [[Outcome Measures|Outcome Measures Database]]) | ||
== Examination == | |||
add text here related to physical examination and assessment<br> | |||
== Medical Management <br> == | |||
add text here <br> | |||
== Physical Therapy Management <br> == | |||
• Conservative management should be attempted and considered as first-line treatment on patients with suspected iatrogenic instability resulting from posterior foraminotomy. [3] (Level of evidence 2A)<br>• The thoracic spine can be regarded as a hidden source for improving overall postural stability. It may be suitable to focus on thoracic region in the kinetic chain for the treatment or training. [6] (Level of evidence 1B)<br>• The multifidi and erector spinae muscles contribute to force closure of the midthoracic region. Therefore it is really important that these muscles have to be addressed in the rehabilitation of the unstable thorax. The region can become dynamically stable and the neutral zone can be controlled, through appropriate training. [4] (Level of evidence 2C)<br>• The exercise programs were composed of 10 min- warm-up exercises, 40 min-stabilization exercises, 10 min-cool-down, and stretching exercises in a group set-up. If needed a gymnastic ball or proprioceptive, balance and resistive work can be integrated into the program. The exercise velocity can be increased according to the patients work and recreation demands. The load should be applied bilaterally and then progressed to unilateral work. [6] (Level of evidence 1B) | |||
The program consists of <br> 1) General exercises for de spine:<br> The contraction of the related muscle activity according to the spine segment with the usage of Stabilizer Pressure Biofeedback unit (Chattanooga,USA). <br> The training programs aimed at creating neutral spine and activation of deep muscles of the spine. | |||
<br> 2) Specific exercises for the thoracic spine:<br> Postural alignment and minimal multifidus activation with scapular orientation for thoracic group <br> The participants were asked to maintain the positions and contractions during the exercises and throughout the day as much as possible. | |||
<br>• Abdominal bracing was also shown to be one of the most effective exercise techniques for muscles even compared to dynamic exercises involving trunk flexion/ extension movements. Furthermore abdominal bracing should be included in exercise programs when the goal is to improve trunk stability. Moreover, abdominal bracing also shows an increase in stiffness of the spine, promoting stability in the vertebral segments, and is frequently recommended and/or included in rehabilitation. Further investigation focusing on its actual effects on spinal stability in rehabilitation is needed. [5] (Level of evidence 2B)<br><br> | |||
== Key | == Key Research == | ||
add | add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br> | ||
== Resources <br> == | == Resources <br> == | ||
add appropriate resources here | add appropriate resources here <br> | ||
== Clinical Bottom Line == | |||
add text here <br> | |||
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == | |||
see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]] | |||
<div class="researchbox"> | |||
<rss>Feed goes here!!|charset=UTF-8|short|max=10</rss> | |||
</div> | |||
== References == | == References == | ||
see [[Adding References|adding references tutorial]]. | |||
<references /> | |||
[[Category:Vrije_Universiteit_Brussel_Project|Template:VUB]] |
Revision as of 17:43, 9 June 2014
Original Editors - Assia Dad Soumaya Ajattar Gülcan KaratasSefora Bakkiouias part of the Vrije Universiteit Brussel's Evidence-based Practice project
Top Contributors - Kim Jackson, Rachael Lowe, Sefora Bakkioui, Lucinda hampton, Admin, Rani Vetsuypens, Mohit Chand, Esraa Mohamed Abdullzaher, WikiSysop and Evan Thomas
Search Strategy[edit | edit source]
Databases: web of knowledge, Pubmed
Key words: Thoracic spine, Thoracic instability, spine instability, Trunk stabilisation
Medical library ULB/VUB with key words: Thoracic spine, Thoracic instability, physical therapy thoracic spine
Definition/Description[edit | edit source]
Instability in the thoracic spine is as lumbar instability. If this instability in thoracic spines is present, it manifests as a spondylolisthesis or the forward translation of the cephalad vertebra on the caudal one.
Furthermore lateral listheses in thoracic spines are rare, possibly due to restraints provided by the rib cage and the uncovertebral joints. The degenerative thoracic spondylolisthesis is uncommon, as the thoracic spine is inherently more stable in the anterior to posterior direction than the cervical or lumbar. This is due to the rib cage and the coronal orientation of the facet joints.[1]
Instability is a loss of the functional integrity of a system which provides stability. The osteoarticularligamentous and the myofascial are two systems in the thorax that contribute stability. In the midthorax the rotational instability involves the spinal and costal components of the segment. [2]
Clinically Relevant Anatomy[edit | edit source]
The costovertebrals joints and rib cage are very important when it comes to stabilizing the thoracic spine.
The rib cage is fixed to the thoracic spine by the costovertebral joints, which consists of costotransverse joints and joints of the head of the ribs. Thoracic vertebrae are connected to adjacent vertebrae by the bilateral costovertebral joints.
The costovertebral joints and their surrounding ligaments, such as the costotransverse, superior costotransverse, radiatie, and intra-articular ligaments, connect nearby vertebrae and ribs. [3] (Level of evidence 2C)
The biomechanical and stabilization role of the costovertebral joints and rib cage in the thoracic spine is evidential, even more in lateral bending and axial rotation. When the posterior elements and bilateral costovertebral joints are destroyed, the thoracic spine may become unstable. The costovertebral joints are important stabilizers of the thoracic spinal motion segments. [3]
Epidemiology /Etiology[edit | edit source]
There are many causes that induce thoracic spondylolisthesis. The first cause is the dysfunction of the intervertebral disc which can lead to instability because of a lack of disc height. Furthermore this leads to a relative laxity in the motion segment. ‘Horizontalization’ of the lamina is the second cause that can lead to instability.
Lastly, thoracic instability can occur due to severe spondylosis or the presence of a long segment surgical arthrodesis below the unstable segment. [2] (Level of evidence 3B)
Characteristics/Clinical Presentation[edit | edit source]
add text here
Differential Diagnosis[edit | edit source]
add text here
Diagnostic Procedures[edit | edit source]
Thoracic Examination
The state of the costovertebral joints and rib cage should be assessed to evaluate the stability of the thoracic spine. [1] (Level of evidence 2C)
The rotational instability of the thorax will cause an increase in the neutral zone. This instability is palpated during segmental lateral translation test. The unstable segment has a softer feel of motion, an increased quantity of translation and variable symptom response. The test may provoke pain if the joint is irritable. When the instability is long standing and asymptomatic, the tests are mostly not provocative.
The second test for lateral translation stability (rotation) [1] is to evaluate the stability of a midthoracic segment.
It is necessary to first determine the available mobility in lateral translation. The most instability can be found in the region between T3- T7.
This motion is tested in the following manner: the patient is sitting with his arms crossed on his chest. The therapists’ left hand fixes the transverse process of T6. With the other hand you translate the T5 vertebra and the sixth ribs to the right in the transverse plane.
The quantity and the end feel of motions are reported and compared to the levels above and below.
The stability of the T5-6 spinal component can be assessed by constraining the sixth ribs from gliding relative to their transverse processes and then applying a lateral translation force. No motion should occur when the ribs are fixed.
Outcome Measures[edit | edit source]
add links to outcome measures here (also see Outcome Measures Database)
Examination[edit | edit source]
add text here related to physical examination and assessment
Medical Management
[edit | edit source]
add text here
Physical Therapy Management
[edit | edit source]
• Conservative management should be attempted and considered as first-line treatment on patients with suspected iatrogenic instability resulting from posterior foraminotomy. [3] (Level of evidence 2A)
• The thoracic spine can be regarded as a hidden source for improving overall postural stability. It may be suitable to focus on thoracic region in the kinetic chain for the treatment or training. [6] (Level of evidence 1B)
• The multifidi and erector spinae muscles contribute to force closure of the midthoracic region. Therefore it is really important that these muscles have to be addressed in the rehabilitation of the unstable thorax. The region can become dynamically stable and the neutral zone can be controlled, through appropriate training. [4] (Level of evidence 2C)
• The exercise programs were composed of 10 min- warm-up exercises, 40 min-stabilization exercises, 10 min-cool-down, and stretching exercises in a group set-up. If needed a gymnastic ball or proprioceptive, balance and resistive work can be integrated into the program. The exercise velocity can be increased according to the patients work and recreation demands. The load should be applied bilaterally and then progressed to unilateral work. [6] (Level of evidence 1B)
The program consists of
1) General exercises for de spine:
The contraction of the related muscle activity according to the spine segment with the usage of Stabilizer Pressure Biofeedback unit (Chattanooga,USA).
The training programs aimed at creating neutral spine and activation of deep muscles of the spine.
2) Specific exercises for the thoracic spine:
Postural alignment and minimal multifidus activation with scapular orientation for thoracic group
The participants were asked to maintain the positions and contractions during the exercises and throughout the day as much as possible.
• Abdominal bracing was also shown to be one of the most effective exercise techniques for muscles even compared to dynamic exercises involving trunk flexion/ extension movements. Furthermore abdominal bracing should be included in exercise programs when the goal is to improve trunk stability. Moreover, abdominal bracing also shows an increase in stiffness of the spine, promoting stability in the vertebral segments, and is frequently recommended and/or included in rehabilitation. Further investigation focusing on its actual effects on spinal stability in rehabilitation is needed. [5] (Level of evidence 2B)
Key Research[edit | edit source]
add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)
Resources
[edit | edit source]
add appropriate resources here
Clinical Bottom Line[edit | edit source]
add text here
Recent Related Research (from Pubmed)[edit | edit source]
see tutorial on Adding PubMed Feed
Extension:RSS -- Error: Not a valid URL: Feed goes here!!|charset=UTF-8|short|max=10
References[edit | edit source]
see adding references tutorial.
- ↑ A. Zahrai et al, Cervical and thoracic degenerative spinal instability, 2013, Semin Spine Surg (Lvel of evidence 3A)
- ↑ D.G. Lee, Rotational instability of the mid-thoracic spine : assessment and management, 1996, Manual Therapy (Level of evidence 2C)
- ↑ 3.0 3.1 I. Oda et al, Biomechanical role of posterieur elements, costovertebral joints, and rib cage in the stability of the thoracic spine, 1996, Spine (Level of evidence 2C)