By Joe Ventress and Emily Fincher
With the patient in standing, assess overall spinal posture for normal curves including lumbar lordosis, thoracic kyphosis, and cervical lordosis. Any gross deviation from normal should be noted. Scoliosis is a common thoracic problem, so lateral curvature of the spine should be assessed. The position of the feet, knees, and hips should be observed from an anterior, posterior, and lateral view. The position of the scapulae should be observed for winging, tipping, or differences in height or position on the thorax. Specific to the thoracic spine, breathing patterns and chest abnormalities should be observed.
Special Test For Scoliosis: Adam's Forward Bend Test
The patient is asked to face away from the examiner and remove his or her shirt so that the spine may be clearly seen. The patient is then asked to bend forward as if to touch his or her toes. If a unilateral prominence is noted, scoliosis may be a possibility.
[Image from: http://www.spinemd.com/images/Fig2_000.gif]
For more detail, refer to the Spinal Scoliosis page.
Postural Examination: Kyphosis
Postural examination should involve a thorough assessment of thoracic kyphosis. Several types of thoracic kyphosis exist:
- Round back is a postural kyphosis characterized by decreased pelvic inclination and increased thoracic kyphosis. The patient may have a forward head and increased cervical and lumbar lordosis. This type of kyphosis is most common in young adults. Since it is due to poor posture, round back kyphosis is generally reversible with postural correction exercises and education.
- Hump back is a structural kyphosis characterized by a sharp, posterior angulation called a gibbus, usually in the upper thoracic spine. The gibbus is a result of anterior wedging of the vertebral bodies due to fracture, tumor, or bone disease. This type of kyphosis is not reversible.
- Flat back is characterized by decreased pelvic inclination with a mobile spine. Since the spine is still mobile, it compensates for the shifted center of gravity that results from decreased pelvic inclination. The end result is the presence of thoracic kyphosis seemingly without a kyphotic curve.
- Dowager's hump is a structural kyphosis characterized by anterior wedge fractures of the vertebral bodies in the upper and middle thoracic spine, and is caused by post-menopausal osteoporosis. The result is excessive rounding in the majority of the thoracic spine, causing a decrease in height. Dowager's hump may be accompanied by a structural scoliosis.
- The examiner should also be aware of postural signs that may indicate kyphosis when it is not present. Winging or flat scapulae may give the appearance of excessive kyphosis.
[Image from: http://www.medical-definitions.com/images/thoracic-kyphosis.jpg]
Assess gait as the patient walks into the clinic. The patient may have excessive kyphosis or a lateral shift that is apparent during gait, which may be indicative of a spinal pathology.
- Soft Tissue: upper/middle/lower traps, rhomboids, levator scapulae, serratus anterior, rectus abdominis, obliques
- Anterior Structures: sternum, clavicle, first rib, additional ribs and costal cartilage, abdomen
- Posterior Structures: scapulae, thoracic spinous and transverse processes, ribs
Passive Accessory Motions
- PA Central Vertebral Pressure
- PA Unilateral Vertebral Pressure
- PA Costotransverse
Lumbar Spine Clearing
- Motions: flexion, extension, lateral flexion, rotation, quadrant
Cervical Spine Clearing
- Motions: extension, rotation, quadrant
- Palpation: central vertebral pressure, unilateral vertebral pressure
- Motions: flexion, abduction, internal rotation (hand behind back)
- Strength: abduction, internal rotation (scaption plane), external rotation (scaption plane), biceps
Range of Motion Testing
Normal ROM Values
|Motion||Normal Values||Normal End Feel|
|Flexion||20-40 degrees||Tissue stretch|
|Extension||15-30 degrees||Tissue stretch or bony block|
|Lateral Flexion||25-30 degrees||Tissue stretch|
|Rotation||5-20 degrees||Tissue stretch|
General assessment of costal motion
- Assess the quality and quantity of movement as the patient inhales and exhales. Additionally, assess for motion of the ribcage and presence of pain when the patient coughs and sneezes.
This test is performed to assess for thoracic outlet syndrome. The patient is seated with arm at 90 degrees shoulder abduction, external rotation, and elbow flexion. The arms are then slightly extended. The patient is instructed to open and close the hands repeatedly for 3 minutes (some sources say 90 seconds). A positive finding is reproduction of the patient's symptoms or a feeling of heaviness in the arms.
For more information, refer to the Thoracic Outlet Syndrome page.
This test is performed to assess for thoracic outlet syndrome at the scalene triangle. The patient is seated or standing. The examiner palpates the radial pulse, and then moves the patient's arm into extension, abduction, and external rotation. The patient then turns his or her head to face the examiner. The patient is instructed to take a deep breath and hold it. A positive test is a diminished or absent radial pulse.
For more information, refer to the Thoracic Outlet Syndrome page.
This test is performed to assess costovertebral movement. The examiner encircles the chest with a tape measure at the level of the fourth intercostal space. The patient maximally exhales, and the examiner takes a measurement. The patient then maximally inhales, and the examiner takes a second measurement. The difference between the two numbers is the amount of chest expansion the patient has. The normal value is between 3-7.5 centimeters (1-3 inches).
This test is performed to assess the thoracic spine for stress fractures, bone demineralization, and bone tumors. If a patient has full, symptom-free active ROM, the tap test may be used to attempt to elicit the patient's symptoms. This test is performed with the patient short sitting on a table with the spine flexed (slump position). The examiner uses a reflex hammer to tap each spinous process and each rib angle. If one segment is extremely
Slump Test: Neural Tension
The slump test is performed to assess neural tension of the dura, spinal cord, and nerve roots. This test is performed with the patient short sitting on a table. Resting symptoms are established. The patient is asked to slump while holding the head erect. If the patient's symptoms are not reproduced, the patient flexes the neck. Symptoms are reassessed. If there is no change in symptoms, the patient extends one leg. If there is no change in symptoms at this point, the patient dorsiflexes the foot. If sciatic pain or the patient's symptoms are reproduced, the patient extends the neck. If the patient's symptoms decrease with neck extension, the test is positive for neural tension.
Upper Limb Tension Tests
Upper limb tension tests may be performed as needed if the patient exhibits upper limb nerve root symptoms, such as numbness and tingling in the hands and arms. These tests are useful as assessment and reassessment tools.