The thoracic and cervical spines

Each lab group needs:
  1. Use your stethoscope to compare lung sounds over the lung field and nearby, in areas close to but not on the lung field. Refer to diagrams, including ones in your anatomy atlas, that illustrate the surface landmarks that identify the lung fields.

  2. Assess your partners' quiet and forced breathing patterns. You may do this through observation. You can amplify your visual assessment by:

    1. placing your hands on the upper anterior thoracic wall to palpate the superior/anterior movement of the upper ribs.

    2. placing your hands on either side of the lower lateral ribcage, at about the level of the xiphoid process, where you can palpate superior/lateral movement in the lower ribs.

    3. palpating the anterior abdominal wall during inspiration, observing the extent to which it moves anteriorly as the diaphragm descends.

  3. Patients with chronic obstructive pulmonary disease (COPD) must compensate for their poor ventilatory endurance. Develop at least two alternative resting positions for someone whose ventilatory endurance is poor. Account for:

    1. the effect on diaphragmatic movement of forces like gravity or resistance from abdominal organs

    2. how postures helps or hinders the person's ability to stabilize the attachments of accessory muscles of inspiration or expiration.

    Compare your thoughts with those of a brief commentary on this question. You can also analyze the advice provided to people with COPD on patient education web sites provided by the Canadian Lung Association and by a pharmaceutical company that markets a bronchodilator used in the treatment of asthma, chronic bronchitis, and emphysema.

  4. Allow your lab partner to rotate passively your trunk, then try to inhale deeply. Describe how a rotated trunk posture alters your ability to inhale deeply. Relate this observation to the influence of trunk rotation on rib movement. Predict how a structural scoliosis affects breathing mechanics. Compare your thoughts with those of a brief commentary on this question.

  5. Inspiration requires concentric activity in the diaphragm. Singing and speaking require _______ diaphragmatic activity.

  6. Palpation of cervical and thoracic structures

    • With your lab partner lying supine so the neck musculature is relaxed, palpate the structures listed in Smith, Weiss, and Lehmkuhl (1996, p.366) for the cervical vertebrae. Locate the articular pillars, where the cervical vertebraes' "articular processes protrude laterally" (Smith, Weiss, & Lehmkuhl, 1996, p. 366). Note how your text is careful to speak of cervical "articular processes," and not transverse processes. Only C1 and C7 have transverse processes; the other cervical vertebrae have anterior and posterior tubercles, "vestiges of transverse processes that serve as sites of muscle attachments" (David Johnson PT, personal communication, 2001).

    • Palpate the sternum, and locate the manubrosternal joint, which forms a small sagittal plane angle, the "angle of Louis." Find the xiphoid process. Gently probe the area under the sternum's xiphoid process, where the diaphragm attaches. When you ask your partner to "sniff," that is, to inhale quickly through the nose, you can detect sudden and rapid diaphragmatic movement.

    • Find the sternal attachments of the first rib, and trace the rib toward its posterior attachment to the thoracic spine. Palpate gently, because you may encounter brachial plexus in your probing for the first rib.

    • With your partner lying prone, repeat your palpation of the cervical articular pillars. Then, move inferiorly to palpate the posterior aspects of the thoracic transverse processes, which form two "ridges," each about an inch lateral to the midline "ridge" formed by the thoracic spinous processes. Between the ridges are the thoracic extensor muscles, which cover the thoracic facets joints.

    • Palpate the thoracic spinous processes, and relate their locations to those of their vertebral bodies according to the "rule of 3" (Hertling & Kessler, 1996, p. 571).

    • Just lateral to the thoracic transverse processes, palpate each of the ribs 4-9 from its articulation with a transverse process (at a costovertebral joint) to the mid-axillary line.

  7. Intervertebral joints below C2 are triaxial. Above C2, the AA joint is uniaxial and the AO joint is biaxial. Examine the joints on the skeleton to verify that the AO joint primarily permits a "nodding" motion, while the AA joint's design largely permits rotation (Smith, Weiss, & Lehmkuhl, 1996, p.372). Locate the C2 spinous process as one of your lab parnters sits in a chair and looks straight ahead, then slowly turns the head from side to side. Determine whether the spinous process begins moving at the same point in the cervical ROM as the person rotates to either side.

  8. Examine the orientation of the facet joints in the cervical spine. When a cervical intervertebral joint between C2 and C7 sidebends, its left and right facet joints move in opposite directions (Smith, Weiss, & Lehmkuhl, 1996, p. 373). Examine a model spine to understand how the facets' orientations cause sidebending and rotation to be coupled ipsilaterally in this region of the cervical spine.

  9. At each cervical intervertebral joint, the surfaces of the two facet joints lie in a plane. This "facet surface plane" differs at each level of the cervical spine. In the more superior cervical intervertebral joints, the planes lie closer to a horizontal plane. Some observers claim that these planes intersect in a single line that passes through the eyes! Your analysis?
Comments

Resting positions for people with COPD

Any upright posture, like standing or sitting, eases diaphragmatic descent during inspiration. In these postures, gravity also pushes downward on the abdominal contents, moving them out of the way of the descending diaphragm. When the trunk is horizontal, as in supine or prone postures, gravity cannot help in this regard, and descending diaphragm must overcome the resistance of the abdominal contents. This is the reason some patients cannot sleep "flat," but must elevate the trunk on pillows to breathe at night. The need to be upright to breathe is called "orthopnea."

People with poor ventilatory endurance can distribute the work of breathing among a number of accessory respiratory muscles if those muscles' attachments to the head, cervical spine, scapula, or upper extremity are stabilized. Many patients with pulmonary problems find it comfortable to sit upright with their scapula elevated (as if they are shrugging their shoulders). This posture elongates the serratus anterior and the pectoralis minor, and orients their lines of application so that they are more vertical can more effectively elevate the ribcage during inspiration. Additionally, holding the hands behind or atop the head modifies the pectoralis major's line of application so that it can elevate the thorax through its sternal and clavicular attachments.

If they become short of breath while walking, people with pulmonary problems can rest by leaning against a wall. This posture has the advantage of being upright, and also helps stabilize the capital, cervical, and upper thoracic spine so people can use the SCM, scalenes, serratus posterior superior, and upper iliocostalis muscles to elevate the ribcage during inspiration.

Trunk rotation, scoliosis, and breathing

Rotating the trunk restricts the ribcage's flexibility. With the ribs less free to elevate, thoracic expansion and, therefore, inspiration become more difficult. Patients with severe scoliosis or other rotational deformities of the spine are at risk for "chronic restrictive pulmonary disease."

Last updated 10-29-01 Dave Thompson PT
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