Physical examination

Dorn Spinal Therapy

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The principles of assessment in the thoracic spine are just the same as those applied to the cervical and lumbar spines; that is, single movements are performed to examine range, then repeated movements are performed and the symptoms and mechanical responses noted. Movements that centralise, abolish or decrease symptoms are indicated; movements that peripheralise or increase symptoms are temporarily avoided. As in other regions of the spine, clues to directional preference may be gained during the history-taking. Movements examined are flexion, extension and rotation in erect sitting. Extension can also be examined in prone or supine; pre-test symptoms are always noted prior to repeated movements.

87

Photos 86, 87, 88: From slumped position (86), genlle pressure on the spine and sternum restores the lordosis

(87). Gentle pressure at the chin and thoracic spine cormcts the head posture

(88). Symptom response is monitored before and after.

Photos 86, 87, 88: From slumped position (86), genlle pressure on the spine and sternum restores the lordosis

(87). Gentle pressure at the chin and thoracic spine cormcts the head posture

(88). Symptom response is monitored before and after.

The posture should be examined. The normal thoracic spine is kyphotic, but an increase should be noted. A protruded forward head posture is often associated with increased thoracic kyphosis, especially around the cervicothoracic junction area. Scoliosis may be present but not relevant to the symptoms (Dieck et al. 1985). The relevance or lack of relevance of any postures is best tested by changing the posture and noting symptom response. Thus, if the patient is Sitting with increased thoracic kyphosis and protruded head, symptoms are noted, posture correction is performed and any symptom change is recorded (Procedure 2).

Movements are examined in the following order: Flexion

The patient is instructed to 'bend their trunk forward, bringing their head and shoulders towards their knees and then return to the starting position'. Any loss of range of movement is gauged as major, moderate or minor and any pain with the movement is noted.

Extension

Sitting upright on the treatment table the patient is instructed to 'stretch the head, neck and trunk backwards as far as possible and then return to the starting position'. Any loss of range of movement is gauged as major, moderate or minor and any pain with the movement is noted.

Rotation

The patient sits upright on the treatment table with hands clasped across the sternum and the elbows and hands at chest height. The patient is instructed to 'turn to the right (left), keeping the hands clasped together, pointing the elbow as far behind as possible, and then return to the starting position'. Ensure that true rotation is performed by ensuring the hands remain on the sternum, rather than the patient simply sliding their arms around the trunk. Any loss of range of movement is gauged as major, moderate or minor and any pain with the movement is noted.

Repeated movements

The repeated movement part of the physical examination provides the most useful information on symptom response and is the ultimate guide in identifying the management strategy to be applied (McKenzie 1981, 1990). A decrease, abolition or centralisation of pain is a reliable indicator of which movement should be chosen to reduce mechanical deformation. An increase or peripheralisation of pain is just as reliable to indicate which movements should be avoided. This, the cumulative effect of the movement, provides the most important detail concerning the patients symptomatic response - that is, whether they are worse, no worse, better, no better or the pain has centralised or peripheralised. These responses provide the clearest indication for the appropriate management strategy. The role of repeated movements is discussed more fully in Chapter 11, and the terminology to record symptom responses is described in Chapter 12.

Erect sitting flexion

The intensity and location of existing symptoms are noted, in particular the location of the most distal symptoms. The patient sits upright on the treatment table with hands over the shoulders to apply overpressure. The patient is instructed to slump so that the spine, from the neck to the sacrum, is in a fully flexed position. On reaching maximal flexion the patient returns to upright erect sitting. The effects of performing the movement once are recorded. The test movement should be repeated ten to fifteen times, or enough times to influence the symptoms, with overpressure being applied if the initial active movements have no effect. Symptom response is noted during the repeated movements, and most importantly a minute or so after a cycle of repeated movements.

Photos 89, 90: Flexion -overpressure can be applied through the upper thoracic transverse processes.

Photos 89, 90: Flexion -overpressure can be applied through the upper thoracic transverse processes.

I Photo 91: Extension.

I Photo 91: Extension.

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Erect sitting extension

The intensity and location of existing symptoms are noted, in particular the location of the most distal symptoms. The patient sits upright on the treatment table with hands clasped behind the neck. The patient is instructed to arch backwards to extend the trunk as far as possible and point the elbows towards the ceiling. On reaching maximal extension, the patient returns to upright erect sitting. The effects of performing the movement once are recorded. The test movement should be repeated ten to fifteen times, or enough times to influence the symptoms. Symptom response is noted during the repeated movements, and most importantly a minute or so after a cycle of repeated movements. Sometimes overpressure applied by the clinician is necessary to generate the symptom response.

Erect sitting rotation

The intensity and location of existing symptoms are noted, in particular the location of the most distal symptoms. The patient sits upright on the treatment table with hands clasped across the sternum and the elbows and hands at chest height. The patient is instructed to turn to the right (left), keeping the hands clasped over the sternum, and point the elbow as far behind them as possible. Ensure that true rotation is performed by ensuring the hands remain on the sternum, rather than the patient simply sliding their arms around the trunk. On reaching maximal rotation the patient returns to upright erect sitting. The effects of performing the movement once are recorded.

The test movement should be repeated ten to fifteen times, or enough times to influence the symptoms. As repetitions are performed the patient is instructed to move further into rotation; this is best done by rotating swiftly and vigorously as if striking an object behind with the elbow. Symptom response isnoted during the repeated movements, and most importantly a minute or so after a cycle of repeated movements.

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