T-spine technique and Management MIDTERM 1 REVIEW

Trigger Point Massage:

- Focus of hyperirritability in a tissue that, when compressed, is locally tender
and, if sufficiently hypersensitive, gives rise to referred pain and tenderness, and
sometimes to referred autonomic phenomena and distortion of proprioception.
MRT and Graston technique:
- Break up adhesions realignment of collagen cross-bridging
- Increase blood flow
RI Reciprocal Inhibition
- Natural phenomenon allow the contraction to occur by making the opposing
muscle relax.
- Contract the antagonist and the agonist will relax
Pulsed MET (Muscle Energy Technique)
- Alternate between contracting the antagonist and agonist on 5-10 second
contractions, repeat several times.
- Lasting Effect 7-10 second PIR (Post-Isometric Relaxation) or RI done on
people showed ROM of 10-15 % several hours later.
Concentric Vs Eccentric:
a. Concentric Isotonic Contraction:
- Mm contracts and shortens simultaneously.
- In exercise workouts, the concentric contraction builds mms.
b. Eccentric Isotonic Contraction:
- When mm contracts and lengthens simultaneously.
- Theory: Eccentric contraction coordination and proprioceptive sense
SEIS (Slow Eccentric Isotonic Contraction Stretch) or Resisted Eccentric Contraction
stretch
- Doctor resists the slow motion of the eccentric contraction.
- NOT FOR ACUTE CASES
Stretch or Exercise or Both?
a. Type 1 static mms: Postural, Endurance
b. Type 2 Phasic mms: Movement
c. Stretching the tight muscles first before strengthening the weak mms had a
better overall effect

Stretches:
1. Wall Angels/Floor Angels = Pecs
2. Doorway stretch = Pecs, good to treat for upper cross syndrome, do in 3 different
positions (high, middle, low)
3. Shower Stretches: Warm loosens tissues
4. Passive stretching = Flex, lateral bend, rotate head to stretch scalenes, semispinalis
mms, levator scapula, and traps
5. Stretching the shoulder mms:
a. Infraspinatus + supraspinatus
i. Mouth Wrap abduction + external rotation of the arm
ii. Hand-to-shoulder blade test of adduction and internal rotation of the
arm at the shoulder.
6. Levator Scapula: Laterally flex and rotate the neck away while holding onto the chair
seat.
Exercises:
1. Resistance Bands:
a. Rows: For rhomboids and upper to midback
b. Standing Row: for Rhomboids and Triceps
NOTE: Rows are essential for UPPER CROSSED SYNDROME AND
POSTURAL SYNDROME.
c. Shoulder Blade Squeeze: For scapular retraction, rhomboids
d. Pull downs: Lats
e. Shrugs + Shrug-squeeze: Upper traps and levators
f. Overhead
g. Shoulder external rotation: Rhomboids, post. Shoulder, rotator cuff
h. Punches: Serratus Ant., stabilizes scapula
f. Reverse Flies: Rhomboids, Lats
g. Thoracic Extension
h. Thoracic/trunk rotation
2. Spray and Stretch:
a. Intermittent cold and stretch technique
b. Stretch is the ACTION and the cold spray is the DISTRACTION
c. Spray at a 30 degree angle at about 18 inches away from the skin. The sweep
should be slow and about 1 inch/sec.
d. Especially good for rhomboids and QL
3. Self-Treatments:
1. Foam Roll: Stretches out the back mms.
2. Ball on the Wall Therapy: Massages upper back and shoulder mms.
3. Theracane Massage Tool
4. Mini thumper messager
5. Ice and Heat Packs:

i. Ice sore areas (20 mins on/20 mins off) for flared up areas and reduce
swelling and inflammation. Ice emersion usually is good for this.
ii. Heat sore areas (20-30 mins on/20 mins off) to soften tight mms and
loosen tight joints
6. QL Hip Hiker
Evaluating the Bed (Mattress)
a. Too soft:
i. Sleeping supine = flexion all night and check fore soreness of post. Structures
ii. Sleeping on side = Lateral bend so check for tightness of upper sleeping side
b. Too firm:
i. Sore shoulders, sore hips, sore side on down sleeping side
Evaluating the Bed (Pillow)
a. Side Sleeping:
i. 2x the height of the pillow you use when sleeping on your back.
ii. Too big or too thin a pillow ill cause side-bending of the neck.
iii. Prop pillow under arm to avoid prolonged horizontal adduction.
iv. Bottom arm Problem: set it up to avoid sustained shortening of the
subscapularis.
b. Back Sleeping;
i. Not too much flexion
Note: Make sure head/neck is not rotated. So avoid sleeping on stomach to avoid rotating
the neck.
Note: Wrap hand with towel to avoid wrist issues
SCOLIOSIS:
4 curve patterns:
a. Thoracic
b. Lumbar
c. TL
d. Double
Idiopathic Curves management Guidelines:
a. Curves less than 20 degrees:
- Conservative care
- WATCH AND WAIT
- Skeletal immature patients:
- Tx with non-invasive means (unless growth spurt or evidence of
progression).

- Skeletal mature patients:

- Tx for progression is not needed. Correct any biomechanical
faults.
b. Curves 21-40 degrees (TEST QUESTION):
- Still w/i conservative management range, bracing referral
- Any immature skeleton and curve > 30 degrees, monitor progression
with vigilance.
- Skeletal mature patients:
- Progression unlikely, correct any biomechanical faults and
observe periodically.
c. Curves greater than 40 degrees:
- Surgical Referral
- Remember, the consequences for progressive curves is MAINLY
COSMETIC.
- As an adult, chance chronic back pain
CONSERVATIVE TREATMENT OPTIONS:
1. Lateral Surface Stimulation:
- Low rate of success
- Good for pain modulation not curve fixing
2. Bracing:
a. Girls who were braced before and at the time or menarche have the best results.
b. Those braced months or more post-menarche had the least success.
c. Curves < 20 degrees and NOT PROGRESSING will probably do as well w/o
bracing. The doctor will choose to monitor the curve rather than bracing. TEST
QUESTION --- Take x-ray every year or every 4 months in rapid growth years.
d. Curves > 40 degrees are likely to lose substantial degrees of correction post
bracing.
e. Girls who are at pre-menarche or menarche with curves 20-40 degrees
have the greatest chance of success with bracing.
f. Milwaukee brace = exerts pressure to the spine, pushing it into a straighter
position. An effective brace, but has to be worn entire day, very embarrassing to wear.
g. TEST QUESTION:
- TO BE EFFECTIVE brace correction should be > 50 %
h. Thoracolumbosacral orthosis:
- Supports several parts of the spine
- Not suitable for all types of curves
- Allows for brace-free time
- Ex. Boston Brace
- Plastic body jacket that hugs the body and puts pressure on the
ribs and back. The pressure pushes the spine into a straighter position.

i. Charleston Bending Brace;

- Some flexibility and some rigid areas
j. SpineCor Bracing system:
- Flexible
- Accommodates the 4-D components of scoliosis
- For < 20 degrees scoliosis
3. Surgery
a. Two main goals:
i. Straighten the spine in the coronal plane and correct for sagittal contour
(kyphosis or lordosis)
ii. Stabilize the spine through arthrodesis
b. Anterior Instrumentation;
- Corrects curve by going into the abdominal and chest cavity.
- Limited to the area between T9-L5
- Use of pedicle screws and spinal fusion
c. Posterior Instrumentation:
- Approach is through the back
- Use of pedicle screws and spinal fusion
d. Types surgical rods and screws;
i. Harrington rods:
- Rarely used anymore
ii. Multi-level hooks and pedicle screws
- Involves several points of hardware fixation to the spine with the
use of hooks, rods, and pedicle screws.
- Allows for complex curve correction and fewer segments of the
spine having to be immobilized, and preservation of the lumbar spines curve.
- Disadvantages: Takes more time and manipulation during surgery
than other posterior techniques.
iii. Cotrel-Dubousset Instrumentation (CDI)
- Flexible rods and pedicle screws
- If there is only one thoracic curve, this method is most often
used.
e. TEST QUESTION: Minimally Invasive LATERAL ENTRY
- 5 small incisions
- Disc removal and rib graft
- Screws placed in the anterior vertebral body
ADULT SCOLIOSIS
a. May be a residual from earlier idiopathic development OR may have
developed in later years

b. If no previous Hx scoliosis diagnosis, then scoliosis could be due to reactive

mm spasm, visceral disorders, spinal cord or nerve root involvement, or
degenerative and osteopenic disorders of the spine.
c. Higher incidence of nonflexible lumbar curves
d. Pain is more likely a presenting complaint (dull, aching sensation of sense of
fatigue in the area)
e. If a child has pn in spine, check for organic causes.
f. Curves with Cobbs Angle > 50 degrees may progress slowly over time (one
degree per year)
g. Curves of < 30 degrees are relatively stable.
h. Same management as for adolescent but complication of surgery are much
higher.
-- Main goal here is to pain and prevent progression.
- Focus on pain amelioration and strengthening of spinal and abdominal
mms.
CHIROPRACTIC ADJUSTMENTS FOR SCOLIOSIS
a. Main goals:
i. Keep flexible, strong and healthy
ii. Manage pain
iii. Normalize proprioception
iv. Normalize righting reflexes
v. Reduce/prevent/slow curve progression?
EXERCISE FOR SCOLIOSIS
a. Main goals:
i. keep flexible, strong and healthy
ii. Exercise is key in pain management and overall strength
iii. Reduce/prevent/slow curve progression
iv. TEST QUESTION: What do the People Say?
- Swimming, stretching and/or yoga are the alternative
therapies that actually improve their curves (not just reduce pain).
v. TEST QUESTION: What do the People say about Massage Therapy +
Chiropractic?
-Good for pain
- Chiropractic manipulation helps in short run but in the long
run, EXERCISE THERAPY proved most effective.
b. Key points:
i. Strengthen:
- Abdominal muscles
- Pelvic Stabilization program
- Convex side muscles
ii. Stretch:
- Concave side mms

- Often done passively while lying on the side with pillows or

props
Short Answer (5 points)
1) Describe the three dimensional approach of rotational breathing as given in Schroth
Physiotherapy Treatment.
a. Patient focues attention to respiration in the collapsed areas
b. For instance, the doctor taps on the concave area while the patient focuses to
move her torso and works on increased respiration in that area.
c. We want to the capacity to the concave side so as to make it easer to breath
2) What is the desired outcome and purpose of this treatment?
a. The desired outcome is to the lung capacity
b. Decrease in outward deformity
c. Decrease in associated pain
Short Answer (5 points)
1) Describe the Schroth Physiotherapy approach to stretches and exercises for Scoliosis.
a. De-laterally flex and bend
b. De-rotate
2) Explain why this approach is different than regular exercises and stretching programs.
a. This exercise is begun in an asymmetric position to maximize possible trunk
symmetry.
b. Strengthen muscles to decrease the deformity.
c. We are strengthening and stretching parts that are not commonly being focused
and in uncommon positions, so as to help decrease deformity and pain.
Short Answer (5 points)
A patient has been given the diagnosis of T4 Syndrome
1) Describe the movements that can cause the onset of T4 Syndrome.
- It may have arised after prolonged pulling, shoveling, and overhead activities
2) What is the typical complaint of a person with T4 Syndrome?
- The patient will complain about:
a. Upper back stiffness + achiness
b. Upper extremity numbness/paresthesia (often in glove distribution)
c. Often associated headaches
3) What areas do you expect you need to adjust?
- I would expect to adjust the areas where there are most and
tenderness/restriction at involved vertebral segments. Since the stiffness and pain will
most likely be located at the upper back, I would expect to adjust there.

4) What muscles do you expect to see involved?

- The following muscles I would expect to be involved are:
i. Levator scapula
ii. Trapz
iii. Rhomboids
iv. Serratus Posterior Superior
v. The Scalene muscles
vi. Suboccipital muscles
Short Answer (5 points)
Describe the key points of the Woggon approach to treating scoliosis
a. He states that forward head posture and loss of lordosis always precedes the
scoliosis. Therefore, before the A-P dimension of the scoliosis can be corrected, the
cervical lordosis must be re-established first.
i. His treatment plan for this is to put tape on the inside, superior of a
pair of glasses. This would in turn, the anterior head carriage.
b. He states that Right high hip and right high shoulder are common signs.
i. Corrected with therapeutic glasses, shoulder weights and hip weights.
c. He states that spinouses rotate into the concave rather than the convex side.
Therefore, adjusting on the high side of the rainbow is contraindicated.
d. He believes bilateral simultaneous anterior and posterior hip weighting will
have and effect on the torque component of the scoliosis.
e. He stated that a vibration of 20-50 Hz gave a small mechanical buzz to the
bones via muscles.
i. BONE DENSITY INCREASED BY 33%!
f. He stated that Scoliotic spine compresses and rotates 3-dimensionally
i. To correct this, the spine must be TRACTIONED (DE-COMPRESSED)
AND DE-ROTATED.
ii. Tx: Vibrating scoliosis traction chair or a vibrating platform with
mechanical spinal traction.
Short Answer (5 points)
Describe at least 3 varieties of modified adjustment techniques to use to treat a 20 degree
Right Thoracic Scoliosis.
a. We can use a leander mechanical traction table where we set the patient up as if
he had a left scoliosis. The pts hip should be pointing to the right whereas, his/her upper
thoracic should be pointing to the left. Than we would adjust accordingly from left to
right (pushing the spinouses from left to right)
b. We can do the same thing using cox flexion
c. If the patient prefers A-P, than we can set up the patient the same way as above
but we would use an anterior thoracic adjustment instead. So the patient would be seated
supine, with hip and legs shifted to the right and his/her upper thoracic should be shifted

to the left. Than we would take a tissue pull where most of our tension will be on the pts
left side. Than we do our chiropractic thing and adjust.
Essay Question (10 points): Please write out an extensive and complete treatment plan
for a patient to do at home over the next month to help with Upper to Mid-thoracic
discomfort. Include exercises, stretches, ice/heat, ergonomic tips, etc. Give instructions
on how to do the various procedures and if appropriate discuss the intent of the
procedures. Drawings are welcomed. Go for it MORE is better. (Of course in your
office you will do adjusting, this is just for the patients home care.)
Take home exercises protocol:
A. Heat any areas that are really tender or really restricted first. This can be done using
heat pads put on for 15-20 mins or coming right out of a hot shower or bath. Than finish
with preventative icing of the involved area after strength training.
B. Stretching comes first before any strength training. This should be done before and
after strength training. I would demonstrate all these exercises and get the patient to do it
right after. All stretches should be for about 15-30 secs and should be done 3 times.
I. Stretching exercises are:
1. For trapezius muscle:
a. Wall Angels:
- Prayer hands + elbows together
- Elbows above head
- Than do a regular snow angel
2. For Pec muscles so as to avoid upper cross syndrome which can affect
the upper to mid-thoracic area:
a. Doorway stretch
3. Passive stretching will help for the upper and mid-back mm as well:
a. Side bending of the neck with your hand to apply extra pressure
b. Rotation of the neck with your hand to apply extra pressure
4. For Levator scapula:
a. Laterally flex and rotate neck away with the ipsi hand applying
more pressure while contralateral hand holding onto the chair seat.
5. For rhomboid and lat stretch:
a. Hold onto a pole and do a cut purr as far as you can.
b. This can be done in 3 different positions (upper, middle, lower)
to hit all the fibers of the rhomboids
C. Strength training using weights, free weights, or resistant bands. This will dependent
on the patient (we will assume patient wants to use only the theraband and that he/she
will be a moderate level so probably green theraband). Also patient shouldnt do all these
exercises at once but should mix it up to keep things not too boring. So one day, patient
will do Rows, Standing rows and shoulder blade squeeze to effectively work the
rhomboids.

1. Rows:
- For rhomboids and upper to midback strengthening.
2. Standing Rows;
- For Rhombooids
- For upper cross syndrome and postural syndrome.
3. Shoulder blade squeeze:
- Scapular retraction
- Rhomboids
- Squeeze your shoulder blades together. Hold and slowly return.
4. Pull downs:
- Lats
5. Shrug + Shrug
- Upper traps
- Levators
6. Punches:
- Serratus Anterior
7. Reverse Flies:
- Rhomboids
- Lats
Ergonomic tips to avoid upper back problems:
1. When using computer or laptop:
- Try avoiding prolonged computer use. If needed, than get up every 15
mins and perform the stretching exercises given.
- Elbows and forearms should be parallel to the desktop and floor.
- The monitor should be at upper 1/3 of eye level.
2. When Driving:
- Make sure to drop shoulders when driving.
- Keep your head rest up as high as the top of your head.
Essay Question (10 points)
Please write out a treatment plan for a 14 year old asthenic female patient who has come
to your office with a 20 right thoracic idiopathic scoliosis. Her Risser sign is 4. The
scoliosis was diagnosed when she was 12 years old at 15 and the treatment has been to
monitor the progression. She has a 35 thoracic kyphosis and anterior head carriage- her
EAM is 1 inch anterior to her AC joint. Her shoulders are rolled forward. The plumb line
falls anterior to her knees by 1 inch. She has some aches and pains in her back and neck
and decreased mobility on motion palpation in various areas of her spine.
Part 1: Describe to the patient what it means to have scoliosis. Tell her what things
seem to work, what risk of progression there is, etc.
Part 2: Describe what exercises and stretches, and any other things she should do at
home to help her control her scoliosis.
Part 3: Describe at least 3 varieties of modified adjustment techniques to fix her
scoliosis. Include any other procedures you would like to do to treat her in your office.

TREATMENT PLAN
1. Description to patient about her scoliosis:
- Scoliosis is occurring more and more during these days. I see that you were
diagnosed at the age of 12. I just want to let you know that females most commonly get
scoliosis. Your scoliosis is a little different b/c adolescents who are diagnosed with
scoliosis have a higher chance of progression. However, in your case you are almost
fully mature in your skeletal growth, so progression wont probably be as severe.
Conservative care has been shown to be very promising for ppl who have scoliosis curves
of 20 degrees or less. There has been promising research that suggest chiropractic care
with exercise therapy in combination, helps reduce progression of scoliosis.
2. Home exercises and stretches:
- People who have scoliosis usually have really tight on muscles on the side where
rib humping is located and weak mms on the concave side of the scoliosis. We want to
really focus on those tight mms and weak mms so as to have a good balance. B/c you
have signs of upper cross syndrome we will also strengthen and stretch those mms
involved in that syndrome.
- Exercises will include, rhomboid, trapz, serratus anterior, pecs strengthening for
the weak muscle. Stretching of the overactive mms to allow easier strength training for
you.
- Woogon research that might help with her anterior head carriage. Typing the
upper 1/3 superior of the glasses to reduce her anterior head carriage.
- Teach her the Schroth physiotherapy System
- Rotation breathing and exercises
3. Assuming right thoracic:
a. We can use a leander mechanical traction table where we set the patient up as if
he had a left scoliosis. The pts hip should be pointing to the right whereas, his/her upper
thoracic should be pointing to the left. Than we would adjust accordingly from left to
right (pushing the spinouses from left to right)
b. We can do the same thing using cox flexion
c. If the patient prefers A-P, than we can set up the patient the same way as above
but we would use an anterior thoracic adjustment instead. So the patient would be seated
supine, with hip and legs shifted to the right and his/her upper thoracic should be shifted
Essay Question: (10 points)
A 30 year old mesomorphic female patient presents with classic symptoms of Postural
Syndrome.
1) Describe Postural Syndrome in detail.
- Postural syndrome is commonly presented in people who tend to have faulty
posture. People who are in desk jobs commonly get this b/c of there computer overuse.
Patients will have burning pain between scapula.
- Upper cross syndrome will probably be presented in correlation with people who
have postural syndrome..
a. Tight mm in:

- Upper trapz
- Levator scap, scalenes, SCM
- Pec major and minor
b. Weak mm in:
- Deep neck flexors
- Lower stabilizers of scapulae
2) Create an Incremental Home Treatment Plan. This means give a week by week plan of
what exercises, stretches, any modifications in activities of daily living that you would
give. You may assume that she will be in your office weekly for her adjustments
- Look abovethat will be my treatment for this as well. But more focus with
rhomboids and serratus anterior. We need to really strengthen the serratus anterior. In
addition, ergonomics will be a HUGE player in this case.