OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY

Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

MRAT 211: THORACIC REHABILITATION IF: Due to Bony Dysfunction

• Acquired Bony Pathology
SPINAL DEFORMITY • Fracture and/or Dislocation of Spinal Elements
• Most Common: Kyphosis
Intrinsic Factors • Tumors
• Bony Anomalies • Osteoporosis
• Supporting Elastic Tissue Anomalies • Tuberculosis
• Neuromuscular Anomalies
IF: Due to Elastic Tissue Dysfunction
Extrinsic Factors Congenital
• Mechanical • Osteogenesis Imperfecta
• Neuromuscular • Achondroplasia
• Marfan Syndrome
Congenital • Ehlers-Danlos Syndrome
• Vertebral Anomaly Present at Birth
• Abnormal Development in the Embryo Acquired
• Hemivertebra • Trauma
• Failure of the Vertebra to Form • Infection
• Bloc Vertebra • Neoplasm
• Failure of the Vertebra to Properly Segment • Contractures (e.g. burn)

Marfan Syndrome Ehlers-Danlos

Syndrome

Definition Is an inherited Is an inherited

connective tissue connective tissue
disorder that primarily disorder that
affects skin, joints, and primarily affects
blood vessels. the heart, eyes,
blood vessels, and
skeleton.

Causes Mutation in genes such Mutation in the

as COL5A1, COL5A2, gene FBN1
and rarely COL1A1. (Fibrilin-1).

Diagnosis Family History, Physical Family History,

Examination, and Physical
Genetic Testing. Examination,
Heart Test, Eye
Test, and Genetic
Testing.
DIFFERENCES:
Treatment Medications (pain Medications
Incarcerated Vertebra Vertebral bodies above relievers; (Blood Pressure
and below the abnormal acetaminophen), Blood lowering Drugs),
Pressure, Physical Vision Therapies,
segment accommodate Therapy, Surgical & and Surgeries.
the hemivertebrae. other Procedures.
Aortic Repair,
Non-Incarcerated Failure of Scoliosis Surgery,
Vertebra accommodation, usually Breastbone
resulting in spinal Correction, and
Eye Surgery.
curvature.
Inheritance Autosomal Dominant Autosomal
Pattern Dominant or
Recessive.

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 OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY
Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

Marfan Syndrome Ehlers-Danlos

Syndrome

Skeletal • Tall & Slender Stature • Joint Hyper-

• Arachnodactyly: Mobility
Long arms, legs, & • Scoliosis
fingers.
• Joint Hyper-Mobility
• Scoliosis: Abnormally
curved spine
• Pectus Deformity:
Breastbone protrudes
outward or dips
inward.

Dermal • Hyper-Extensive Skin • Hyper-Extensive IF: Due to Neuromuscular Dysfunction

• Striae / Stretch Marks Skin
• Translucent & Congenital
Fragile Skin that • Peripheral Weakness (Charcot-Marie-Tooth
is Easy in Disease, Meningomyelocele, Muscular
Bruising /
Scarring. Dystrophy)
• Abnormal Central Control (Cerebral Palsy)
Vascular • Aortic Root Dilation • Mitral Valve • Abnormal Sensory Afferent Input (Riley-Day
• Mitral Valve Prolapse
Prolapse / • Aortic Familial Dysautonomia)
Malformation: Heart Dissection:
Murmurs Weaken aorta Acquired
• Aortic Dissection that tends to
• Berry Aneurysms rupture. • Spinal Cord Injury
• Berry • Neurofibromatosis - Most common benign
Aneurysms: tumor.
Fatal ruptures in
major blood
vessels. EF: Mechanical
Other Signs / • High arched palate. • Weaken walls of
• Leg:
Symptoms & • Crowded teeth. the uterus and - length discrepancy
Complications • Extreme large intestine - Deformities/bowing
nearsightedness
(myopia), upward lens
that tends to
rupture.
- Contractures
dislocation, retinal • Early onset - Hypermobility
problems, early onset arthritis. • Pelvic Asymmetry
glaucoma, & • Distinctive
cataracts. Facial: Thin
• Above Pelvis:
• Flat feet. nose, thin upper - Rib Cage
lip, small - Arm asymmetry
earlobes, &
prominent eyes.
- Head and Neck Symmetry
• Myopia or - Hyper-mobility
Retinal
Detachment.
EF: Neuromuscular
• Weakness
• Spasticity / Motor Control
• Disordered Sensation

Euler's Theory
• Elastic buckling of a slender column.
• Axial compressive forces evidently cause a
column to buckle.
• Associated with height growth and weight gain
(growth spurts).

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 OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY
Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

Lordosis
• Greek word "lordos" - Excessive posterior
bending.
• Exageration of the normal curves found in the
cervical and lumbar spines.

CAUSES:
• Postural or functional deformity.
• Lax muscles.
• A heavy abdomen.
• Compensatory mechanisms that result from
another deformity.

Hump Back (Gibbus)

• Localized, sharp posterior angulation in the
thoracic spine.
• Fracture or pathology.

Flat Back
• Decreased pelvic inclination to 20° and a
mobile lumbar spine.
4 Types of KYPHOSIS:

• Round Back
• Hump Back
• Flat Back
• Dowager's Back

Round Back
• Long, rounded curve with decreased pelvic
inclination (<30°) and thoracolumbar kyphosis.
• Trunk flexed forward and a decreased lumbar
curve.
• Tight hip extensors and trunk flexors with weak
hip flexors and lumbar extensors.

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 OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY
Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

Dowager’s Back Kyphosis

• Seen in older patients. • Greek “kuphos" - Bent forward or humped.
• Osteoporosis • Exaggeration of the normal curve found in the
thoracic spine.

CAUSES:
• Tuberculosis
• Tumors
• Senile Osteoporosis
• Vertebral Compression Fractures
• Ankylosing Spondylitis
• Compensation in Conjunction with Lordosis

Pathological Lumbar Lordosis

• Sagging shoulders (scapulae are protracted and
arms are medially rotated).
• Medial rotation of the legs and poking forward
of the head so that it is in front of the center of
gravity.

Tuberculosis
• TB Osteomyelitis / AKA Pott's Disease.
• Produces a sharply localized kyphosis (gibbus
deformity).

Tumors
• Spine - Most common site of metastases.
Common Sites:
- Malignant: Vertebral Body or Pedicle.
- Benign: Posterior Elements.

Swayback Deformity
• Increased pelvic inclination to ~40°
thoracolumbar kyphosis.

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 OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY
Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

BENIGN MALINANT Scheuermann’s Disease

• Inflammation of the bone and cartilage occurs
• Grow slowly & have • Grow quickly / fast & around the ring epiphyses of the vertebral body.
distinct or clear have irregular borders. • Anterior wedging of the vertebra.
borders. • Invade surrounding • Most common areas between T10 and L2.
• Do not invade tissues & spread to
surrounding tissues & other parts of the body
other parts of the body. through a process
• May cause called Metastasis.
compression without • Cancerous Cells can
tissue invasion. travel to other parts of
• Treatment: Consists the body through the
of surgical removal if Blood & Lymphatic
tumors compress System.
nearby structures and • Treatment: Consists
may not require of surgery,
treatment if not health- radiotherapy
threatening. (radiation),
• Normally don’t return chemotherapy, and
after they’re removed. immunotherapy Scoliosis
• Usually have a smooth medications to prevent • Greek word “skolios” - Bent, twisted, or curved.
& regular shape. cancerous spread. • Abnormal lateral curvature of the spine.
• Typically not life- • Can return after being • Medically significant frontal plane curve
threatening. removed.
(scoliosis) as any curve which is greater or
• Non-cancerous. • Have an uneven shape.
• Typically capsulated. • Can be life- equal to 10 degrees, with or without a rotatory
• Cells are generally threatening. component.
well-differentiated • Cancerous. • Deviation to the RIGHT - DEXTRO
(normal appearance). • Non-capsulated. • Deviation to the LEFT - LEVO
• Not attached to deep • Cells can be poorly • MC Scoliotic Curve - DEXTROTHORACIC
tissue structures. differentiated Scoliosis
(abnormal • C - Curve or S - Curve
appearance).
• Attached to deep tissue
structures.

Senile (Geriatric) Osteoporosis

• Onset: 5th decade of life.
• Osteoarthritis:
- Cartilage Degeneration.
- L2 - 2 or L3 - 4.

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 OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY
Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

CURVE SEVERITY Structural Scoliosis

MILD < 20 Degrees Exercise • Lacks normal flexibility.
• Side bending becomes asymmetrical
MODERATE 40 Degrees Exercise & Bracing • Commonly seen in thoracic or thoracolumbar
spine.
SEVERE > 40 Degrees Surgery • Progressive.
• Curve does not disappear on forward flexion.

CURVE MAGNITUDE
< 30 Degrees No progression if skeletally
mature.
30 - 50 Degrees 10° - 15° lifetime
progression.
> 50 Degrees 1° - 2° per year.

Razorback Deformity Idiopathic Scoliosis

• Thoracic scoliosis results in a very poor • NO Anomalous Vertebrae
cosmetic appearance or greater visual defect. • NO Spinal Tumors
• Deformation of the ribs along with the spine. • NO Other Neurologic Abnormalities
• Vary from a mild rib hump to a severe rotation
of the vertebrae. Cobb's Angle: Measurement
• With a structural scoliosis, the VERTEBRAL • Simple investigation to quantify the degree of
BODIES rotate to the CONVEXITY of the Kyphoscoliosis.
curve. • Requires only AP & Lateral X - Rays.

Structural Scoliosis Moe-Nash Classification of Spinal Rotation

• Congenital or acquired • Grade 0 - Pedicles are seen symmetrically
- Bony deformity. positioned at the lateral border of the vertebral
- Excessive muscle weakness bodies.
A. Long term quadriplegia • Grade 1 - Slight asymmetry.
• Grade 2 - One pedicle is almost out of view.
Causes: • Grade 3 - Only one pedicle is seen, positioned
• Wedge Vertebra at the center of the vertebral body.
• Hemi-Vertebra • Grade 4 - Only one pedicle is seen, positioned
• Failure of Segmentation / Unsegmented Bars lateral to the center of the vertebral body.
• Bifid Processes

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 OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY
Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

Growth Potential / Skeletal Maturity Adam's Forward Bending Test

• Tanner Staging - Evaluate bone age based on • The purpose of this test is to detect structural or
x-rays of the wrist and hand. functional scoliosis.
• Risser Staging - Evaluates bone age based on • The scoliosis is functional when the
the degree of fusion and ossification (the characteristics of scoliosis becomes more
process of laying down new bone) of the pelvic visible while the patient bends. With a
bones (which include the iliac bones). structural scoliosis, the scoliotic deformity will
remain the same as in the standing position.
Risser Staging
• Helps estimate the bone age (and thus skeletal
maturity and risk for scoliosis progression) it is
easily done during a x-ray as the pelvis is
imaged at the time of the spine.
• Specifically, the Risser sign evaluates the new
bone ossifying along the ilium on a scale of 1 to
5 as visualized below:

BODY TYPE

A Risser scale of 0 corresponds to an immature

skeleton of someone with a lot of growing left to
do, and no ossification is observed along the
ilium. As they go through puberty, new bone is
laid down until they reach Risser 5, at which point
all new bone has fused to the ilium and now
appears as one solid bone.

Plumb Line
• This is a quick visual check to see if the spine is
straight. In scoliosis, the plumb line will fall to
the left or right of the spine instead of through
the middle of the buttocks.
• Scoliometer: If the doctor sees a rib hump, he
or she can use a scoliometer to measure the size
of the hump.
ACTIVE MOVEMENTS

• Forward flexion (40-60°)

• Extension (20-35°)
• Lateral flexion, left & right (15-20°)
• Rotation, left and right (3- 18°)
• Sustained postures (if necessary)
• Repetitive motion (if necessary)
• Combined movements (if necessary)

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 OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY
Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

• PT looks for limitation of movement and its • Arms are crossed at the chest. The cadence is
possible causes, such as pain, spasm, stiffness, twenty-five repetitions per minute.
or blocking.
• As the patient reaches the full range of active • Normal (5) = With hands clasped behind the
movement, passive overpressure may be head, extends the lumbar spine, lifting the head,
applied, but only if the active movements chest, and ribs from the floor (20 to 30 seconds
appear to be full and pain free. hold).
• Good (4) = With hands at the side, extends the
Dynamic Abdominal Endurance Test lumbar spine, lifting the head, chest, and ribs
• POSITION: Supine hook-lying with hands at from the floor (15 to 20 seconds hold).
sides. • Fair (3) = With hands at the side, extends the
• Draw an 8cm line (for patients over 40 years of lumbar spine, lifting the sternum off the floor
age) or 12 cm (for patients under 40 years of (10 to 15 seconds hold).
age) distal to the fingers. • Poor (2) = With hands at the side, extends the
• ACTION: Tucks in chin & curls trunk to touch lumbar spine, lifting the head off the floor (1 to
the line with the fingers (repeat as many as 10 seconds hold).
possible [25reps/min] or by holding it). • Trace (1) = Only slight contraction of the
muscle with no movement.
• Normal (5) = Hands behind neck, until
scapulae clear table (20 to 30 seconds hold).
• Good (4) = Arms crossed over chest, until
scapulae clear table (15 to 20 seconds hold).
• Fair (3) = Arms straight, until scapulae clear
table (10 to 15 seconds hold).
• Poor (2) = Arms extended, toward knees, until
top of scapulae lift from table (1 to 10 seconds
hold). • Perform only when “normal" in dynamic
• Trace (1) = Unable to raise more than head off abdominal endurance test.
table. • Supine and flexes the hips to 90°& straightens
the knees with hip in neutral.

• Normal (5) = Able to reach 0° to 15° from table

before pelvis tilts.
• Good (4) = Able to reach 16° to 45° from table
before pelvis tilts.
• Fair (3) = Able to reach 46° to 75° from table
before pelvis tilts.
• Poor (2) = Able to reach 75° to 90° from table
before pelvis tilts.
• Trace (1) = Unable to hold pelvis in neutral at
Dynamic Extensor Endurance Test all.
• POSITION: Prone with hips & iliac crests
resting on the end of the plinth and stabilized
with straps
• ACTION: Pt's hands support the upper body in
30° flexion on a chair or bench
• Keeping the spine straight, PT instructs the pt.
to extend trunk to neutral & lower head to
starting position.

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 OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY
Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

Internal/External Abdominal Obliques Test

• POSITION: Supine lying with hands by the
side.
• ACTION: Lift head and shoulder on one side
and reach over and touch the fingernails of the
other hand.
Back Rotators/Multifidus Test
• Normal (5) = Flexes and rotates the lumbar • POSITION: Quadruped position and is asked
spine fully with hands behind head (20 to 30 to hold the "neutral pelvis" position and breathe
seconds hold). normally.
• Good (4) = Flexes and rotates the lumbar spine • ACTION: Do the following movements.
fully with hands across chest (15 to 20 seconds 1. Single straight arm lift and hold.
hold). 2. Single straight leg lift and hold.
• Fair (3) = Flexes and rotates the lumbar spine 3. Contralateral straight arm and straight leg lift
fully with arms reaching forward (10 to 15 and hold.
seconds hold).
• Poor (2) = Unable to flex and rotate fully. • Normal (5) = Able to do contralateral arm and
• Trace (1) = Only slight contraction of the leg, both sides while maintaining neutral pelvis
muscle with no movement. (20 - 30 seconds hold).
• (0) = No contraction of the muscle. • Good (4) = Able to maintain neutral pelvis
while doing single leg lift but not able to hold
neutral pelvis when doing contralateral arm and
leg (20 seconds hold).
• Fair (3) = Able to do single arm lift and
maintain neutral pelvis (20 seconds hold).
• Poor (2) = Unable to maintain neutral pelvis
while doing single arm lift.

Dynamic Horizontal Side Support (Side

Bridge) Test
• Tests the quadratus lumborum muscle.
• POSITION: Side lying position resting the
upper body on his or her elbow.
• ACTION: Asks pt to lift pelvis off the table &
straighten the spine.

• Normal (5) = Able to lift pelvis off examining

table and hold spine straight (10 to 20 seconds
hold).
• Good (4) = Able to lift pelvis off examining
table but has difficulty holding spine straight (5
to 10 seconds hold).
• Fair (3) = Able to lift pelvis off examining table
and cannot hold spine straight (less than 5
seconds hold).
• Poor (2) = Unable to lift pelvis off examining
table.

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 OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY
Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

FUNCTIONAL ASSESSMENT

• Timed 15 Meter (50 Foot) Walk

- Patient walks 7.5 m (25 ft) as fast as he or
she can, turns, and returns to the starting
position while being timed.

• Loaded Reach Test

- Patient stands next to a wall, which has a
meter ruler at shoulder height. The patient
reaches forward with weight at shoulder
height as far as he or she can while keeping
the heels on the floor. The weight shouldnot
exceedamaximum of 5% of body weight or
4.5 kg (9.9 lbs).

• Repeated Sit-to-Stand
- This timed test involves the patient starting
by sitting in a chair. The patient then stands
fully and returns to sitting, repeating the
sequence as fast as possible. The average
value of two trials is used as the time.

• Repeated Trunk Flexion

- This timed test involves the patient starting
in a standing position and then flexing
forward as far a s possible and returning to
the upright posture as fast as tolerable,
repeating the motion ten times. The average
value of two trials is used as the time.

• Biering-Sorensen Fatigue Test

- The Biering-Sørensen test is a timed
measure used to assess the endurance of
the trunk extensor muscles. It is used to
assist in the prediction of the incidence and
occurrence of low back pain in patients.

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