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Differential Diagnosis in Physical Therapy of Upper Extremity and Lower Quadrant: Summary
Thoracic Spine Examination • Palpation • Posture • Key muscle testing • Neurological examination ○ DTRs
○ Neck Disability Index (NDI)—upper thoracic complaints ○ Oswestry Disability Index (ODI)—lower thoracic complaints It is common for cervical spine issues to refer symptoms to the thoracic spine. Screening of cervical spine including assessing for history of neck pain/trauma is necessary to rule out cervical spine involvement. Using a pain diagram and follow-up questioning, the examiner should begin to differentiate, as best as possible, if the disorder involves the upper or lower thoracic spine. • Pain Scales ○ Numeric Pain Rating Scale (NPRS) ○ Patient Specific Functional Scale (PSFS)— can be used to measure activity limitations and to compare progress from the baseline measurement
○ Sensation ○ Slump test
• Kern’s sign • Murphy’s • Thoracic ROM
○ Flexion: 20–45 degrees ○ Extension: 25–45 degrees ○ Lateral Flexion: 20–40 degrees Thoracic Spine Special Tests 1. Thoracic clearing test: AROM in all directions with overpressure 2. Forward bend test
3. Passive neck flexion test 4. Thoracic compression test 5. Thoracic distraction test 6. Thoracic foraminal closure test
Thoracic Spine Red Flags Peptic ulcer • Boring pain from epigastric area to middle thoracic spine • Triggered or relieved with meals • History of NSAID use Cholecystitis • Right upper quadrant and scapular pain
• Fever, nausea, and vomiting • 1–2 hours after a fatty meal Cardiac ischemia • History of risk factors for coronary artery disease (CAD), myocardial infarction (MI) • Angina • Nausea Dissecting thoracic aneurysm • Sudden severe and unrelenting chest pain that can radiate to the upper back • Unrelieved with laying down Renal kidney stones • Renal colic/flank pain • Fever, nausea, and vomiting • Increased risk for kidney infection with ongoing urinary tract infection (UTI)
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