NAIOMT Level II: C-613 Thoracic Spine

Faculty: Terry Pratt, MS, PT, OCS, COMT, FAAOMPT
Clock Hours: Forty (40) hours

Audience:

This course is for licensed physical therapists (copy of physical therapy license required) and final year physical therapist interns (school verification required) that are beginning to intermediate learners in the field of orthopedic manual physical therapy.

Pre-requisites:

None.

Course Description:

This course will utilize case-based instruction to illustrate specific thoracic spine and rib cage conditions, and their detailed, specific biomechanical and neurophysiological assessment. Participants will assemble an all-source evidence-informed approach to evaluation and management through consideration of normal, abnormal and applied thoracic spine and rib cage anatomy, physiology, biomechanics, and pathology. Coursework will focus on reason-based development of individualized examination sequences aimed at patient/client classification into – management of an initial diagnosis, progression to a specific biomechanical and neurophysiological examination, symptom/intervention/rule-based classification groupings, or referral to another health-care provider. Participants will compare the concepts of health, functioning, pain behaviors and their manifestations, and their role in total patient/client management. Procedural interventions will include education, manual therapy techniques, and individualized neuromuscular rehabilitation prescription, with the goal of restoring normal function and preventing disability. Joint thrust manipulation techniques to the thoracic spine and rib cage will be introduced.

Teaching methods/learning experiences:

A variety of active learning methods will be incorporated into the case-based presentation of course material, including lecture, laboratory, independent problem assignments, group-based activities, and role-playing.

Overall Course Objectives:

Upon completion of this three 21-hour module, the participant will be able to:

1. Definitively select an initial patho-anatomical diagnosis to an orthopedic manual physical therapy patient/client presenting with thoracic spine and rib cage pathology.
2.  Assess the patient/client utilizing reason-based, individualized examination sequences and classify the patient appropriately.
3. Evaluate the patient, and develop a detailed, individualized prognosis.
4. Formulate an all-source evidence-informed management plan including education, manual therapy, and individually dosed neuromuscular rehabilitation techniques.
5. Demonstrate thrust joint manipulation techniques for the thoracic spine.

Specific Course Objectives:

Affective Domain:

Upon completion of this 21-hour module, students will be able to:

1. Accept that a strong understanding of the basic sciences of normal, abnormal and applied anatomy, physiology, biomechanics, and pathology are essential to the practice of orthopedic manual physical therapy.
2. Recognize the vital role that all-source evidence-informed clinical reasoning plays in the evaluation and management of orthopedic manual physical therapy patients/clients.
3. Realize that all orthopedic manual physical therapy patients/clients present with certain unique signs and symptoms that require an individualized approach to the evaluation.
4. Accept the concept of patho-anatomical diagnosis as the important goal in the evaluation of the orthopedic manual physical therapy patient/client.
5. Accept the importance of Selective Tissue Tension Testing (STTT) to the evaluation and management of the orthopedic manual physical therapy patient/client.
6. Identify patients who are more appropriately classified using other criteria (Clinical Prediction Rules, Symptom/Intervention based systems).
7. Internalize the importance of prognosis as a central factor in the evaluation and management of orthopedic manual physical therapy patients/clients.
8. Display the judgment required to make decisions that take into account, and are in the best interests of, the overall health and function of the individual.
9. Recognize the importance of all-source evidence-informed practice and balance all sources (clinical experience, literature, and patient preference) in search of best practices.

Cognitive Domain:

Upon completion of this 21-hour module, students will be able to:

1. Analyze the current understanding of the normal, abnormal and applied anatomy, physiology, and biomechanics of the thoracic spine.
2. Interpret the biomechanics of the thoracic spine and rib cage as they relate to the specific biomechanical and neurophysiological assessment of combined movements.
3. Compare and contrast condition (illness) scripts based on patient age, gender and pain chart information, and definitively select an initial patho-anatomical hypothesis for the thoracic spine and rib-cage from the following:
   • Systemic disease (cardiovascular, pulmonary, neurological, gastro-intestinal, endocrine, vascular, gynecological, musculoskeletal, integumentary, cancers)
   • Fracture/Dislocation
   • Arthritis (degenerative/systemic/traumatic)
   • Spondylolisthesis (congenital/acquired)
   • Disc pathology
   • Radiculopathy
   • Stenosis (central/lateral canal)
   • Segmental dysfunction (hypomobility, hypermobility, instability)
   • Contractile tissue lesions
   • Non-Contractile tissue lesions
4. Question the initial hypothesis through targeted subjective questioning.
5. Interpret red and yellow flag presentations and discuss the decisions that need to be made about the management of these patients.
6. Recognize the unique ‘thoracic scanning examination’ (the scan), and differentiate the relative worth of its potential components as applied to thoracic spine and rib-cage presentations:
   • Observation
   • Range of motion (functional, active, passive, combined, overpressure)
   • Resisted testing
   • Compression and distraction
   • Dural testing
   • Neurological [CNS/PNS – Tests of motor and sensory function]
   • Vascular
   • Stability
   • Palpation
7. Review the components of the thoracic spine scan and expand on the biomechanical-neurophysiological examination to include applied normal and abnormal kinematics and kinetics.
8. Recognize the unique specific biomechanical and neurophysiological examination and differentiate the relative worth of its components as applied to the thoracic spine:
   • Passive Physiological Intervertebral Movements (PPIVM)
   • Passive Accessory Vertebral Movements (PAVM)
   • Tests of pain provocation (bone, nerve, ligament, soft tissue)
   • Joint stability and load transfer testing
9. Identify individual all-source evidence-based tests and measures that are relevant to the diagnosis.
10. Assemble all-source evidence-informed, reasoned, and individualized examination sequences specific to thoracic spine and rib cage conditions (illness) scripts.
11. Modify individual examination sequences to take into consideration the varying levels of severity and irritability in patient/client presentation.
12. Definitively select a patho-anatomical diagnosis.
13. Formulate an accurate, detailed and individual prognosis for each patient/client presentation.
14. Discuss specific indications and contraindications for orthopedic manual physical therapy intervention.
15. Describe the principles of locking/localization techniques as they relate to specific segmental assessment and management of the thoracic spine.

Utilize case examples to formulate specific, all-source evidence-informed, individualized management plans, taking into account the overall health and function of the individual.

Psychomotor Domain

Upon completion of this 21-hour module, students will be able to:

1. Demonstrate a thoracic scan examination:
   • Observation
   • Range of motion (functional, active, passive, combined, overpressure)
   • Resisted testing
   • Compression and distraction
   • Dural testing
   • Neurological [CNS/PNS – Tests of motor and sensory function]
   • Stability
   • Palpation
   • Vascular
2. Demonstrate a specific biomechanical and neurophysiological examination T1-L1.
   • Passive Physiological Intervertebral Movements (PPIVM)
   • Passive Accessory Movements (PAVM)
   • Tests of pain provocation
   • Joint stability and load transfer testing
3. Demonstrate a modified examination sequence to take into consideration the varying levels of severity and irritability in patient/client presentation.
4. Demonstrate the ability to provide education to a patient/client, including prognosis, activity modification, and postural adaptation.
5. Demonstrate orthopedic manual physical therapy intervention techniques:
   • Manual therapy techniques
     • Generalized thoracic spine and rib cage manual traction.
     • Segmental traction in the upper and mid-lower thoracic spine and rib cage with focused locking.
     • Segmental directional mobilization in the upper, and mid-lower thoracic spine and rib cage with focused locking.
     • Segmental directional manipulation in the upper and mid-lower thoracic spine and rib cage with focused locking.
   • Soft tissue techniques
   • Rehabilitation techniques (dysfunction & pathology-specific)
     • Neuromuscular rehabilitation of the thoracic spine and rib cage
     • Strength, mobility, and endurance training
   • Stabilization strategies (including external tape, body mechanics training for dysfunctional force transfer in static and dynamic postures, lifting, etc.)
   • Neurodynamic intervention
   • Neural de-sensitizing intervention
6. Demonstrate modified variations of the above interventions to take into consideration the varying levels of patient/client severity, irritability, and patient/client/therapist body type.