M C P T. "Excellence in Education" NECK AND THORACIC SPINE. Part 1. Advanced Anatomy 1 Part 2. Assessment

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1 M C P T Melbourne College of Professional Therapists "Excellence in Education" NECK AND THORACIC SPINE Part 1. Advanced Anatomy 1 Part 2. Assessment 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

2 M C P T Melbourne College of Professional Therapists "Excellence in Education" Suite 5 Ground Floor (Right path way entrance, next door to Lifestyle Gym) Cnr: Ferntree Gully Rd & Jells Rd Wheelers Hill (Vic) 3150 Postal: P.O Box 3171 Wheelers Hill (Vic) 3150 Facsimile: Some images from: Spence, A P: Basic Human Anatomy, The Benjamin/Cummings Publishing Co, Redwood City 1990 These notes are SDCA PTY LTD trading as Melbourne College of Professional Therapists - MCPT. All rights reserved. No part of these notes may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the express written permission of SDCA PTY LTD. These notes are intended as a guide only, and do not take the place of attendance in scheduled classes. Revised February MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

3 PART 1. ADVANCED ANATOMY A. Osteology Review Bones & markings B. Kinesiological Review (Movements) i. Flexion / Extension / Hyperextension ii. iii. Lateral flexion (sidebending) Rotation C. Arthrology Joint classifications Ligaments Cartilages D. Skeletal Muscles i. Head to spine ii. iii. iv. Spine to spine Spine to scapula Spine to ribs v. Ribs to scapula vi. Spine to clavicle E. Other Structures i. Circulatory ii. Nerves PART 2. ASSESSMENT 1. Assessment of Cervical Spine. Headache and Neck Pain 2. Assessment of Thoracic and Shoulder Girdle Pain 3. Practical examination of the head & neck: palpation, visual inspection, range of movement, special tests. 4. Practical examination of the thoracic region: palpation, visual inspection, range of movement MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

4 PART 1. ADVANCED ANATOMY A. Osteological Review Skull: Occipital, Temporal (Mastoid process). Frontal, Parietals, Zygomatic Vertebrae: Common features: Centrum (body) except for C1, vertebral foramen, neural arch (lamina, pedicle, superior articular process & facet, inferior articular process & facet, transverse processes, spinous process) Cervical (C1 - C7) Special features: Cervical Vertebrae: C1 (Atlas oratlantal bone) C2 (Axis) (dens or odontoid process) Transverse foramen Bifurcated spinous processes Attachment for Levator Scap., Rhomboids, Scalenes, Splenius, Semispinalis, Multifidi, Sub-Occipital and Ligamentum Nuchae. Thoracic (T1 - T12) Special features: Increase in size from T1 - T12. The ribs attach to the bodies (demi-facets) and the transverse processes (costal facets). Spinous processes are long and hook sharply downwards. Thoracic Vertebrae: Attachment for Trapezius, Rhomboids, Latissimus Dorsi, Serratus Posterior Superior, Semispinalis & Multifidus. Scapula: Functions as point of attachment for muscles and ligaments. Involved in scapulo-thoracic / scapulo-humeral rhythm. By using labelled diagrams be able to clearly locate these landmarks and understand their function: Borders (margins) Medial (vertebral). Lateral (axillary), Superior Angles (superior & inferior) Processes (acromion & coracoid) Fossa (glenoid, supraspinous, infraspinous, subscapular) Spine of scapula Tubercles (supraglenoid & infraglenoid) 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

5 Ribs: Attached to sternum via costal cartilage anteriorly. Posteriorly attached to costal facets of transverse processes and bodies of T1 - T12. Act as attachment sites for Serratus (Anterior & Posterior), Subclavius, Scalenes and Pectorals (Major & Minor) There are 12 pairs of ribs: 1 7 = true ribs, 8 10 = false ribs, = floating ribs. Ribs consist of a head, neck, tubercle and body. - head. Articulates with the bodies of the 2 adjacent vertebrae. - neck. Narrow section of the bone. - tubercle. A knoblike process lateral to the head. A large articulating portion attaches to the costal facet on the transverse processes of the thoracic vertebrae. A small non-articulating portion is the attachment for the costotransverse ligament connecting the rib to the transverse processes of the thoracic vertebrae. - body (shaft). Composed of parts of different curvature meeting at the angle. The angle curves downward and forward and cannot be flattened. The superior surface is blunt or rounded, the inferior surface is sharper. Except for the 1st rib both surfaces are attachments for the intercostal muscles Sternum Other Landmarks: Manubrium, central body, xiphoid process - Hyoid bone. Superior to thyroid. Level of C3. Attachment for muscles of tongue and throat. - Thyroid cartilage ("Adams Apple") C4 - C5-1st cricoid ring. Anterior to body of C6 - External occipital protuberance - Inion. ("Bump of knowledge") On the midline of the occiput, marking the centre of the superior nuchal line. - Superior nuchal line. Radiates laterally and upwards from the inion MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

6 B. Kinesiological Review Cervical. 1. Flexion. Mainly at 0-A joint (occiput & C1) 2. Extension. Mainly at 0-A joint. 3. Lateral flexion (sidebending). Mainly in C3 - C7 4. Rotation % occurs at the A-A joint (C1 & C2) NB. Normally vertebrae rotate and laterally flex to the same side. Exception = 0-A joint where rotation & lateral flexion occur to opposite sides. Thoracic 1. Flexion & Extension. Occur in facet joints 2. Lateral flexion 3. Rotation Scapula Elevation, Depression, Retraction (Adduction), Protraction (Abduction), Upward Rotation. C. Arthrology Atlanto-occipital joint. These are synovial joints formed between the occipital condyles found on either side of the foramen magnum above, and the facets on the superior surfaces of the atlas below. Atlanto-axial joints. These are 3 synovial joints, one of them being between the dens or odontoid process of C2 and the anterior arch of the atlas. The other two are between the lateral masses of the two bones. Intervertebral discs. (Amphiarthrodial or secondary cartilaginous joint) The vertebrae are separated by the intervertebral discs which cushion the bodies of the vertebrae and act as shock absorbers. They make up one quarter of the length of the vertebral column and are thickest in the cervical and lumbar regions where the movements of the column are greatest. Their elasticity allows the rigid vertebrae to move on each other, however this elasticity decreases with age. Each intervertebral disc is made up of a central gelatinous nucleus pulposus surrounded by a strong ring of fibrocartilage called the annulus fibrosus. Facet joints. Each vertebrae have 2 superior and 2 inferior articular processes and facets (L & R) with the superior facet articulating with the inferior facet of the vertebrae immediately above it. These are synovial gliding joints and on trunk flexion these facet joints will open and on extension they will close. A facet joint may be stuck closed and therefore not open (extended lesion) or may be stuck open and will not close (flexed lesion) MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

7 Costal joints. Each rib is attached to the transverse process (costal facet) of its corresponding vertebrae (T1 - T12) and to the bodies of the same vertebrae (demi-facet). These are also synovial gliding joints. Therefore each thoracic vertebra has 10 joints, viz; superior & inferior intervertebral discs (2), 4 costal joints,4 facet joints. Ligaments of the vertebral column Anterior & posterior longitudinal ligaments: run as continuous bands down the anterior and posterior surfaces of the vertebral column from the skull to the sacrum. The anterior ligament is wide and is strongly attached to the front and sides of the vertebral bodies and to the intervertebral discs. The posterior ligament is weak and narrow and is attached to the posterior borders of the discs. These ligaments hold the vertebrae firmly together while still allowing a small amount of movement between them. Anterior atlanto-occipital membrane: is a continuation of the anterior longitudinal ligament and connects the anterior arch of the atlas to the anterior margin of the foramen magnum. Posterior atlanto-occipital membrane: connects the posterior arch of the atlas to the posterior margin of the foramen magnum. Apical ligament: connects the apex of the odontoid process (dens) to the anterior margin of the foramen magnum. Alar ligaments: connect the dens to the medial side of the occipital condyles. Cruciate ligament: has two parts. The strong transverse part is attached on each side of the inner aspect of the atlas and binds the dens to the anterior arch of the atlas. The vertical or weak part runs from the posterior surface of the atlas to the anterior margin of the foramen magnum. Membrana tectoria: is a continuation of the posterior longitudinal ligament. It attaches above the occipital bone within the foramen magnum, covering the posterior surface of the dens and the apical, alar and cruciate ligaments MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

8 The ligaments between the vertebrae are: Supraspinous ligament: running between the tips of the adjacent spinous processes. Interspinous ligament: connects adjacent spinous processes. Intertransverse ligaments: run between adjacent transverse processes. Ligamentum flavum: connects laminae of adjacent vertebrae. In the cervical region the supraspinous and interspinous ligaments are greatly thickened to form the very strong ligamentum nuchae. This extends from the spinous process of C7 to the external occipital protuberance. Its anterior border is strongly attached to the cervical spinous processes between. D. Skeletal Muscles 1. Head to spine a) Anterior pre-vertebrals - Rectus capitis anterior - Rectus capitis lateralis - Longus capitis b) Posterior/lateral Splenius capitis c) Posterior Upper trapezius Semispinalis capitis Longissimus capitis Sub-occipitals - (postural muscles, not P.M.) - Rectus capitis posterior major - Rectus capitis posterior minor - Obliquus capitis inferior - Obliquus capitis superior 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

9 2. Spine to spine a) Anterior Longus colli b) Posterior Splenius cervicis Longissimus cervicis Longissimus thoracis Semispinalis cervicis Semispinalis thoracis Spinalis thoracis Multifidus Rotatores Interspinalis Intertransversarii 3. Spine to scapula Trapezius Levator scapulae Rhomboids 4. Spine to ribs Iliocostalis cervicis Iliocostalis thoracis Scalenes (anterior, posterior, middle) Serratus posterior superior 5. Ribs to scapula Pectoralis minor Serratus anterior 6. Head to clavicle/sternum Sternocleidomastoid 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

10 Sternocleidomastoid This muscle arises from 2 heads : 1. a sternal head from the anterior surface of manubrium 2. a clavicle head from the upper surface of the medial thirds of the clavicle the fibres converge as they pass obliquely upwards to insert onto the lateral surface of the mastoid process just behind the ear, and to the lateral part of the superior nuchal line of the occipital bone these muscles contracting together flex the cervical vertebral column, and the chin is slightly elevated as the head moves forward. acting singly, one side only contracts, the head is rotated laterally towards that side, bringing the head closer to the shoulder of the same side while the chin is rotated upward towards the opposite side. Torticollis a twisted neck or wry neck may result from injury to one of the Sternocleidomastoid muscles. One muscle contracts unilaterally. It sometimes is caused by damage to an infant's neck muscles during childbirth and usually can be corrected by exercising the muscles. NERVE SUPPLY Accessory Nerve 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

11 Scalenes There are three scalene muscles on the side of the neck: 1. Scalenus anterior arises from the anterior surface of the cervical vertebrae (except the atlas and axis). The fibres coverage as they pass downward in an oblique and lateral manner. 2. Scalenus medius is larger than Scalenus anterior and arises from the posterior surfaces of the same cervical transverse processes plus the axis. The fibres converge and lie m a similar plane but anterior to Scalenus anterior. 3. Scalenus posterior is really the posterior part of Scalenus medius but its fibres insert onto the upper surface of the second rib. Scalenus anterior inserts onto the upper surface of the first rib. Scalenus medius inserts onto the upper surface of the first rib. Scalenus posterior is really the posterior part of scalenus medius but its fibres insert onto the upper surface of the 2 nd rib. These muscles have much less effect on the action of the head and neck than the Sternocleidomastoid muscle Their most important function is to suspend and maintain the level of the thoracic inlet. This inlet or aperture is bounded posteriorly by the first thoracic vertebra, anteriorly by the upper surface of the manubrium and laterally by the first two ribs. They also flex and rotate the cervical vertebra and elevate the first rib during forced respiration. NERVE SUPPLY from the cervical and brachial plexus 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

12 Mastoid process Semispinalis Capitus Splenius Capitus Splenius These are the two most important muscles of this area: The splenius muscle serves as a strap covering and holding in the deeper muscles of the back and neck. Its originates from the Ligamentum nuchae and the spinous processes of the C7 to T6. The muscle divides into two parts the splenius capitis muscle which passes upward and obliquely to insert onto the mastoid process and the lateral third of the superior nuchal line of the skull and the splenius Cervicis muscle which terminates in the posterior tubercles of the first two or three cervical vertebrae. The Cervicis portion is the outer and lower portion of the splenius muscle and its inserting bundles curve deeply along its lateral margin. Both sides contracting together extend the neck. These muscles extend the head, or if contracting on one side only will turn the head and tilt the chin upward The nerve supply is the lateral branches of the dorsal rami of the 2nd to 5th cervical nerves. It lies directly under the trapezius and is covered by the nuchal fascia. Its mastoid insertion is deep to that of the Sternocleidomastoid and it overlies the erector spinae and the semispinalis MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

13 Erector spinae Transversospinalis M a s t o i d Longissimus p r o c e s s Ilium I l i o c o s t a l i s Posterior view Erector Spinae (superficial group) A complex massive muscle occupying the vertero-costal groove of the back, lying under the posterior layer of thoracicolumbar fascia. It begins below in a broad thick tendon that is attached to the posterior surface of the sacrum, the posterior portion of the iliac crest and the spinous processes of the lumbar vertebrae and supraspinal ligament. Muscular fibres beginning on me anterior surface of the tendon split into three columns at the lumbar levels: 1. a lateral column (iliocostalis) which inserts into the posterior angles of the ribs and continues upward to the cervical transverse processes. 2. a middle column (longissimus) which inserts into the thoracic transverse processes & continues upward to the cervical transverse processes and onto the mastoid processes MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

14 3. a small column (spinalis) which is confined to the thoracic region and lies between the others and adjacent to the tips of the spinous processes to which it attaches. The erector spinae muscle ascends throughout the length of the back, but its columns are composed of fascicles of shorter length. Each column contains a rope like series of fascicles, various bundles arising as others are inserting; each fascicle spans from 6 to 10 segments between attachments. The iliocostalis (lateral) begins at the iliac crest and inserts on the angles of the lower 6 or 7 ribs. This portion is the iliocostalis Lumborum muscle. i. The succeeding iliocostalis Thoracis muscle arises from the upper borders of the lower 6 ribs just medial to the insertion of the fascicles of the iliocostalis Lumborum; ii. it slips inserts into the upper 6 ribs. The iliocostalis Cervicis muscle arises medial to the thoracic portion from the angles of approximately the upper 6 ribs and inserts into the transverse processes of the 4 th,5 th and 6 th cervical vertebrae. The longissimus muscle has thoracic, Cervicis and capitis portions. i ii The longissimus thoracic muscle ascends as the intermediate part of the erector spinae muscle and inserts into the lower 9 or 10 ribs and into the transverse processes of the same levels. The longissimus Cervicis arises medial to the upper end of the longissimus thoracic, from the transverse processes of the upper T4 to T6. It inserts in the transverse process of C2toC6. iii The longissimus capitis connects the articular processes of the lower 4 cervical vertebrae with the posterior margin of the mastoid process. The spinalis muscle the most medial division, is the thinnest and most poorly defined portion. It too has thoracic, Cervicis and capitis portions, i ii Spinalis thoracic arises from the spinous processes of the last two thoracic and first two lumbar vertebrae. Its thin tendons inserts into the spinous processes of between 4 to 8 of the upper thoracic vertebrae. Spinalis Cervicis is frequently absent or poorly developed. When completely represented it arises from the Ligamentum nuchae and from the spinous processes of the C7 and upper thoracic vertebrae. It inserts onto the axis and perhaps the C3 and C4 vertebrae. iii. Spinalis capitis is not a separate muscle but blends laterally with the semispinalis capitis. The erector spinae extends the vertebral column and acting one side bends the column toward that side. The capitis insertion serves to bend the head and rotate the face toward the same side. It is also active in flexion of the trunk, controlling the degrees and speed of flexion that is primarily produced by gravity and the abdominal muscles MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

15 Longissimus capitus (cut) Greater occipital nerve Splenius capitus (cut) Trapezius Splenius capitus Rectus capitis posterior minor Rectus capitis posterior major Transverse process C MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

16 Posterior view Levator scapulae The superior third of this strap like muscles lies deep to the Sternocleidomastoid.; the inferior third is deep to the trapezius It arises from the transverse processes of the upper 5 cervical vertebrae and inserts onto the medial border of the scapula from its spine to the superior angle. It elevates the scapula and helps to tilt the glenoid cavity inferiorly by rotating the scapula. It also helps to retracts the scapula and fix it against the trunk and to flex the neck laterally. It prevents the shoulder from being depressed when carrying weights in the hand or on the shoulder. Its nerve supply is the dorsal scapular n. and the 3 rd and 4 th cervical nerves MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

17 Coracoid process Pectoralis minor This triangular muscles lies in the anterior wall of the axilla where it is largely covered by the much larger Pectoralis major. Pectoralis minor is the landmark of the axilla. Along with the coracoid process it forms an arch deep to which pass the vessels and nerves to the upper arm. It arises from the anterior surfaces of the 3 rd, 4 th, and 5 th ribs just lateral to the costal cartilages. The fibres converge to insert onto the medial border of the coracoid process. It pulls the shoulder forward and downward. It stabilises the scapula by drawing it inferiorly and anteriorly against the thoracic wall. It also rotates the scapula thereby tilting its glenoid cavity inferiorly. When the scapula is fixed it raises the 3 rd and 5 th ribs in forced inspiration. It is used in such actions as stretching the arm forward for an object just out of reach. Its nerve supply is the medial anterior thoracic nerve 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

18 Upper Elevator Posterior view T 1 2 Trapezius This large flat, triangular muscles covers the posterior aspect of the neck and superior half of the trunk. It is also the most superficial muscle. It arises from the base of the skull, Ligamentum nuchae, and the spines of the C7 and all thoracic vertebra. It inserts into the spine of scapula and the lateral one-third of the clavicle. It is often divided into three parts. 1. The upper fibres from the base of the skull are thin and pass downward to.the back of the lateral end of clavicle. These fibres elevate and upwardly rotate the scapula. They shrug the shoulders and maintain shoulder level. 2. The middle fibres are stronger and arise from the C7 and upper 3 thoracic vertebra, to pass horizontally to the length of the spine of scapula. They are prime movers in retraction of scapula. They produce the standing to attention position. 3. The lower fibres arise from the lower thoracic vertebra and pass upwards to the tubercle on the spine of the scapula situated about 2 3 cm from the vertebral borders. Acting as a whole the trapezius is used when lifting objects such as heavy wheelbarrow and when holding an object above the head or performing handstands. It also braces the shoulders by pulling the scapula posteriorly, hence weakness of these muscles results in drooping of the shoulders. Its nerve supply is the spinal accessory nerve and the 3 rd and 4 th cervical nerves MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

19 Rhomboid major and minor These two muscles lie deep to the trapezius and are not always distinct from each other. The rhomboid major is about two times wider than rhomboid minor. They appear as parallel bands that pass inferolaterally from the vertebrae to the scapula. They have rhomboid appear (they forma an oblique parallelogram). They originate from C7 and lower part of the Ligamentum nuchae to the T5 spinous processes and supraspinous ligament. They insert into the medial border of the scapula from the spine tot he inferior angle. Rhomboid minor which lies superiorly is thin and weak while rhomboid major is thick and strong. The rhomboids retract the scapula and rotate it downwards (downward rotator) and can act in conjunction with levator scapulae to fix the scapula. They retract the scapula strongly to turn the glenoid fossa downward when forcibly pulling the arm downward as in driving a stake with a sledge hammer. They also help Serratus anterior to hold the scapula against the thoracic wall. The nerve supply is the dorsal scapular nerve MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

20 Serratus anterior (serratus serrated) This large foliate muscles overlies the lateral portion of the thorax and the intercostal muscles. The muscle arises from the outer surface of the upper 8 or 9 ribs and from the fascia covering the intercostal muscles. It inserts onto the whole length of the anterior surface of the vertebra 1 border of the scapula with most of the fibres inserting onto the inferior angle. This muscle is a prime move for protracting the scapula and holds or fixes it against the thorax wall. It is used whenever abduction and upward rotation of the shoulder girdle is required such as punching or javelin throwing. It has been called the "boxer's muscles". By fixing the scapula to the thorax it acts as an anchor for this bone and permits other muscles to use it as a fixed bone to produce movements of the humerus. Inferior fibres help to raise the glenoid fossa eg when raising the arm above the head. When the Serratus anterior is paralysed owing injury to the thoracic nerve, the medial border of the scapula stands out, especially its inferior angle, giving it the appearance of a wing when the person presses anteriorly (against a wall). When the arm is raised, the scapula is pulled away from the thoracic wall. In addition the arm cannot be abducted farther than the horizontal position because the Serratus anterior is unable to rotate the scapula and raise the glenoid fo3sa. Consequently a patient with a paralysed Serratus anterior is unable to raise the upper limb or to push with it MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb

21 SPINAL MUSCLES AND THEIR ACTIONS CERVICAL & THORACIC SPINES Muscles Flexion Extension Lateral Flexion Rotation to same side Relation to oppos. side Sternocleidomastoid PM PM PM Scalenes Assist PM Prevertebral group (Long.Colli, PM Assist PM Long.Cap, Rectus Cap Ant, Rectus Cap.Lateralis) Splenius (Capitis & Cervicis) PM PM PM Erector Spinae Group (Iliocostalis PM PM PM Cervicis, Long. Cap, Spinalis cerv.) Iliocostalis Thoracis PM PM PM Longissimus Thoracis PM PM PM Spinalis Thoracis PM PM Semispinalis Cervicis PM PM PM Semispinalis Capitis PM PM Semispinalis Thoracis PM PM PM Deep postural spinal group Intertransversarii PM PM Interspinales PM Rotatores PM PM Multifidus PM PM PM Suboccipital group Assist Assist Assist Trapezius (upper fibres) Assist Assist Levator Scapulae Assist Assist Assist 2005 MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb

22 E. Other Structures Circulatory Main blood supply to head and neck. 1. Arteries Four paired arteries provide the functional blood supply to the head and neck. These are the: - common carotid arteries - vertebral arteries - thyrocervical - costocervical The right common carotid artery arises from the brachiocephalic artery; the left common carotid is the second branch off the aortic arch. The common carotid arteries travel through the lateral neck before each divides into its two major branches, the internal and external carotid arteries. At the point of bifurcation the vessels enlarge slightly to form the carotid sinus which contains baroreceptors that assist in the regulation of blood pressure. The external 'carotid arteries supply most of the tissues of the head except for the brain and orbit. As each artery runs superiorly it sends branches to the thyroid gland and the larynx (superior thyroid artery), the tongue (lingual artery), the skin and muscles of the anterior face (facial artery) and the posterior scalp (occipital artery). The internal carotid arteries supply the orbits and most of the cerebrum. Within the cranium each artery gives off one main branch, (ophthalmic artery). It then divides into the anterior and middle cerebral arteries. Vertebral arteries spring from the subclavian arteries at the root of the neck and ascend through the foramina in the transverse processes of the cervical vertebrae and enter the skull through the foramen magnum. They send branches to the cervical spinal cord as well as to some deep structures in the neck. In the cranium the right and left vertebral arteries join to form the basilar artery. This ascends to the brainstem and branches off to the cerebellum, pons and middle ear. 2. Veins The superior vena cava receives blood draining from all areas superior to the diaphragm, except from the pulmonary circuit. The superior vena cava is formed by the union of the right and left brachiocephalic veins and enters into the superior part of the right atrium. Each of these veins is formed by the joining of the internal jugular and subclavian veins. The inferior vena cava is the widest blood vessel in the body. It returns blood to the lower part of the right atrium of the heart from all the body regions below the diaphragm. The distal end of the inferior vena cava is formed by the junction of the paired common iliac veins MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb

23 Nerves Refer accompanying Table 1. Cranial Nerves The 12 cranial nerves indicated by Roman numeral (I-XII) from anterior to posterior. They are grouped intro three categories. 1. Sensory 2. Somatic motor 3. Parasympathetic Sensory functions include the senses such as vision, touch and pain. Somatic functions refer to the control of skeletal muscles through motor neurones. Proprioception informs the brain about the position of various body parts including joints and muscles. The cranial nerves innervating skeletal muscles also contain proprioceptive afferent fibres which convey impulses to the CNS from those of the muscle. Parasympathetic function involves the regulation of glands, smooth muscles and cardiac muscle. Cranial Nerve I. Olfactory Smell Nerve Function II. Optic III. Oculomotor IV Trochlear Vision Innervates 4 of the 6 muscles that move the eyeball & raises the eyelid. The parasympathetic nerve fibres innervate smooth muscles in the eye and regulate the size of the pupil and shape of the lens of the eye. Innervates the Superior oblique muscle of the eye. V. Trigeminal Carries impulses for touch, pain, heat and cold from face, scalp and mucous membranes of the head. It also contains special visceral efferent and proprioceptive fibres VI. Abducens Supplies afferent and efferent fibres to Lateral rectus muscles of the eye. VII. Facial VIII Vestibulocochlear IX Glossophpbaryneal X Vagus XI Accessory XII Hypoglossal Controls all muscles for facial expression and innervates submandibular and sublingual salivary glands and to the lacrimal glands; Involved in hearing and balance Pharynx, Sense of Taste in the posterior 1/3. Tactile sensory innervation to posterior tongue, middle ear and pharynx and transmit sensory stimulation from receptors in the carotid arteries and the aortic arch which monitors blood pressure and blood carbon dioxide, blood oxygen and blood ph levels, Innervates muscles of the soft palate, pharynx, larynx; it sends sensory fibres to heart, digestive tract, transverse colon, respiratory tract, kidneys, spleen, liver and pancreas. Supply voluntary muscles of the pharynx, larynx and soft palate. It combines with the upper 5 segments of the spinal cord supplying the Sternocleidomastoid and trapezius muscles It innervates both extrinsic and intrinsic muscles of the tongue 2005 MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb

24 2. Nerves of the Back There is a pair of symmetrically disposed spinal nerves for each vertebral segment, except for several reduced coccygeal segments 31 pairs in all. 8 cervical 12 thoracic 5 lumbar 5 sacral 1 coccygeal Spinal nerves are all mixed nerves containing muscular, sensory and visceral fibres. Nerves are regional entities conveying all the various nerve components to the regions which they distribute. The spinal nerves arise through numerous rootlets along the dorsal and ventral surface of the spinal cord. These rootlets coalesce into one spinal nerve that represents a segment of the spinal cord. About 6 to 8 of these rootlets combine to forma ventral roots on the ventral (anterior) side of the spinal cord and 6 to 8 rootlets form a dorsal roots on the dorsal (posterior) side of the cord at each segment. The dorsal root contains afferent (sensory) nerve fibres. The ventral root efferent (motor) fibres. The dorsal and ventral roots of each segment join just lateral to the spinal cord to form the spinal nerve. The dorsal root contains a ganglion (dorsal root ganglion) or Spinal ganglion near where it joins the ventral root. Each of the spinal nerves except C1 has a specific cutaneous sensory distribution. The dermatomal map shows the distribution of the spinal nerves. A dermatome is the area of skin supplied with sensory innervation by a pair of spinal nerves. Each spinal nerve has dorsal and ventral ramus. This nerve divides almost immediately into dorsal and ventral rami. The dorsal rami innervate most of the deep muscles of the dorsal trunk responsible for movement of the vertebral column. They also supply sensation to the connective tissue and skin near the midline of the back. Throughout the length of the body, ventral rami have the greater distribution. In the thoracic region they form the intercostal (between ribs) nerves that extend along the inferior margin of each rib and innervate the intercostal muscles and skin over the thorax. The remaining spinal nerves form 5 plexuses ( plexuses means 'braid' and describes the organisation produced by the intermingling of the nerves. The ventral rami of different spinal nerves called roots of the plexus, join with each other to form a plexus MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb

25 The ventral rami of spinal nerves C1 C4 form the Cervical Plexus; C5 T1 the Brachial Plexus; LI L4 the lumbar; L4 S4 form the sacral plexus and S4, S5 and coccygeal nerve form the coccygeal plexus. The dorsal rami are restricted in distribution to the spaces between the spinous process of the vertebrae and the angles of the ribs in the thoracic region. Immediately beyond the intervertebral foramen, the dorsal ramus passes dorsally into the overlying deep musculature of the back and shortly divides into a medial and lateral branch. Each of these branches supplies the muscles of the deep group but as a rule, only one of them perforates to the subcutaneous tissues to become a cutaneous nerve. In the upper half of the trunk, down to the 6 and 7 thoracic level, the medial branch is cutaneous and supplies the" muscles adjacent to the corresponding spinous processes. In the lower portion of the back, the lateral branches terminate as cutaneous nerves, which enter the subcutaneous tissues in an increasingly lateral position, penetrating the musculature at about the junction of the muscular and tendinous portions of the latissimus dorsi muscle. In the lumbar region, there is a cutaneous distribution of only the first three lumbar nerves (L1, 2, 3) These are called superior cluneal nerves and they descend with a lateralward declination over the posterior part of the iliac crest to reach the upper gluteal region. The lateral branches of the dorsal rami of the fast, second and third sacral nerves form the middle cluneal nerves. They become cutaneous on a line connecting the posterior superior iliac spine and the tip of the coccyx and they supply the skin and subcutaneous tissue over the back of the sacrum and adjacent area of the gluteal region. The dorsal rami of the 4 th, 5 th sacral nerves and the coccygeal nerve do not divide into medial and lateral branches. They unit to form a cutaneous nerve that distributes around or through the lower fibres of the gluteus maximus muscle. 3. Thoracic Nerves The 12 pairs of thoracic nerves resemble other typical spinal nerves in their segmental attachments to the cord by dorsal and ventral nerve roots. These roots unite to form short spinal nerve trunks which emerge through the corresponding intervertebral foramina, give off the recurrent meningeal filaments, establish connections through white and grey rami communicantes with the adjacent sympathetic trunk ganglia and divide into larger ventral and smaller dorsal rami MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb

26 The dorsal rami of the thoracic nerves run backward near the zygapophyseal joints which they supply and then divide into medial and lateral branches. Both sets of branches pass through the groups of muscles constituting the erector spinae and give off branches to them. The terminations of the upper six or seven medial branches innervate the skin adjacent to the corresponding spinous processes, but the lower 5 or 6 often fail to reach the skin. The terminations of all lateral branches usually pierce the thoracolumbar fascia over the erector spinae muscles and divide into medial and lateral cutaneous branches which innervates much of the skin of the posterior thoracic wall and upper lumbar regions. The ventral rami of most of the thoracic nerves do not form plexus. They retain their segmental character and each pair runs separately in the corresponding intercostal spaces as the intercostal nerves. The intercostal nerves give off muscular, anterior cutaneous, Lateral cutaneous, mammary and collateral branches. They also supply filaments to adjacent vessels, periosteum, parietal pleura and peritoneum. The upper 6 pairs supply muscular branches to the corresponding intercostal muscles. And to the subcostal, Serratus posterior superior and transverse thoracic muscles. The lower 5 pairs supply the lower intercostal muscles and the subcostal, Serratus posterior inferior, transverse, oblique and rectus abdominal muscles. The anterior cutaneous branches supply the front of the thorax. The lateral cutaneous branches pierce the internal and external intercostal muscles and end by dividing into branches that extend forward and backward to innervate the skin covering the lateral sides of the thorax and abdomen. The small lateral branch of the first intercostal neve supplies the skin of the axilla and the lateral branch of the second is the intercostobrachial nerve which is distributed to the skin on the medial side of the arm. The lateral cutaneous branch of the subcostal nerve pierces the internal and external oblique abdominal muscles and descend over the iliac crest to supply the skin of the anterior part of the gluteal region. The mammary glands receive filaments from the lateral and anterior cutaneous branches of the 4 th, 5 th and 6 th intercostal nerves which covey autonomic and sensory fibres to and from the glans. 4. Cervical Plexus originates from spinal nerves C1- C4. Branches derived from the plexus innervate superficial neck structures. Phrenic Nerve origin C3- C5 derived from both the cervical and brachial plexus descends along each side of the neck to enter the thorax to the diaphragm which they innervate MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb

27 Suggested General Assessment by Remedial Massage Therapists (Similar to First Aid Diagnostic Approach; T.O.T.A.P.S.) T = TALK - find out history of injury, (what, when, where, how etc) - What are the symptoms described by the patient? O = OBSERVE - for signs, abnormalities, deformities, swelling, bruising etc, T = TOUCH - Feel for tenderness/pain, fluid, crepitus, swelling, heat etc. Know landmarks and check for asymmetry. Compare injured with uninjured side. A = ACTIVE MOVEMENT - Check ROM P = PASSIVE MOVEMENT - Check ROM before onset of pain. S = SKILLS TEST - If the patient "passes" the above inhibiting "tests" check they are pain free with full movement when performing their specific sporting skills before advising a return to their sport. Note, however, that training may continue with non injured parts during the recovery phases. Check STABILITY of joints for ligamentous damage. SPECIAL TESTS REFERRED PAIN A more detailed analysis of assessment and practical experience of palpation skills and ranges of movement at different joints in the cervical and thoracic regions is the subject of part 2. Treatment strategies and techniques for disorders found in the cervical and thoracic regions is the subject of Remedial Techniques MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb

28 PART 2. ASSESSMENT 1. Assessment of Cervical Spine, Headache & Neck Pain 2. Assessment of Thoracic & Shoulder Girdle Pain. 3. Practical Assessment of Head & Neck 4. Practical Assessment of Thoracic Region 1. Assessment of Cervical Spine, Headache & Neck Pain A. HEADACHE Causes of Headache Viral illnesses, eg. respiratory infections, sinusitis, influenza Vascular headaches, eg. migraine, cluster headache Cervical headache, eg. referred from joints, muscles & fascia of the cervical region Intracranial causes, eg. tumour, haemorrhage, subdural hematoma, meningitis Exercise-related headache, eg. benign exertional headache, pre-performance tension Other causes, eg. drugs, psychogenic, post spinal procedures, post traumatic Symptoms to "Flag" new or unaccustomed headache atypical headache stiff neck or meningeal signs systemic symptoms, eg. fever, weight loss, malaise neurological symptoms, eg. drowsiness, weakness, numbness of limbs local extracranial symptoms, eg. ear, sinus, teeth changes in patterns of headache sudden onset of severe headaches headaches that wake the patient up at night or in early morning 2005 MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb

29 Clinical features of 2 common headaches Features Vascular headache Cervical headache Age of onset Onset Site Type of pain Constancy Time course Neurological symptoms History of trauma Triggers Treatment years Fast Frontal or temporal Throbbing Episodic Hours Common (visual disturbances, nausea) Rare Food, drugs, stress Avoid precipitating factors Drugs Stress reduction years Slow Occipital, retro-orbital or temporal Dull ache Constant Days Occasionally (eg. parathesia) Common Trauma, posture Manual therapy Stress reduction Postural correction B. NECK PAIN Anatomical Causes History cervical discs facet joints muscles meningeal structures referred pain from other upper limb pathology, eg. rotator cuff, tennis elbow Cervical Postural Syndrome slow onset generalised ache in neck & upper shoulders headache desk job swimmers, cyclists Examination. protruding chin exaggerated thoracic kyphosis exaggerated cervical lordosis "dowager's hump" tight sub-occipital muscles hypo mobile facet joints limited ROM in cervical region 2005 MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb

30 Treatment correct posture soft tissue therapy stretches joint mobilization 2. Assessment of Thoracic & Shoulder Girdle Pain Possible structures involved. Spine ribs & their joints intercostal muscles pleura skin (eg. shingles) nerves (suprascapular, long thoracic) vessels (aneurysm, pulmonary embolism) lungs (infection, carcinoma, pneumothorax) heart & pericardium gastrointestinal tract (ulcer, gastroesophageal reflux) History site of pain (local / diffuse; focal / radiates) onset / duration constant / intermittent aggravating factors alleviating factors associated symptoms (cough, short of breath etc.) past episodes of similar pains Not to miss night pain neurological symptoms in arms, legs or bladder/bowel changes family history social history (occupational lung disease, smoking etc) Examination Observation - symmetry, muscle wasting, skin, kyphosis, scoliosis Movements - flexion, extension, rotation (plus upper lumbar & lower cervical spine) - shoulder including scapulohumeral rhythm - deep inspiration Palpation - bone; vertebrae, ribs - joints; including facets, costovertebral & costochondral (sterno-costal) - soft tissue PLUS - neural tension tests 2005 MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb

31 Investigations plain x-ray bone scan CT scan MRI (magnetic resonance imaging) Other medical paths including lung capacity (FVC) & efficiency (FEV1), ECG, stress exercise testing, sputum cytology etc) Specific Conditions Ribs Spine fractures, bruising. Usually have history of trauma; pain often localised with increase in inspiration. Rx analgesia & rest. stress fractures. Relatively rare. 1st rib in dancers and pitchers, lower ribs in rowers. Rx rest and technique assessment. costochondral strain. Activity related pain. Localised. Rx NSAID's and mobilization. costovertebral strain. Local pain, may be traumatic, increases with cough, sneeze or movement. Decreased mobility at CVJ. May have associated degenerative changes. Rx NSAID's and mobilization. Intervertebral joints - Disc. Rare in thoracic spine. Most common in T1/12. Localized pain with radicular distribution among thoracic nerve. May have localized +/- soft tissue signs. Rx mobilize, soft tissue, posture, strength. - Facet joint. May have localized hypo mobility +/- deformity. It could be either an extended lesion (stuck closed during flexion) or a flexed lesion (stuck open during extension). In either case these Type 2 lesions (involving individual facet joints) will mean the spine will sidebend (laterally flex) and rotate (transverse process moves posteriorly) to the same side. Scheuemann's Disease = most common cause of back pain in adolescence. Decreased mobility at intervertebral discs. Irregularity at ring growth plates of vertebral bodies with anterior wedging and deformity MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb

32 Referred Pain muscle strain. Muscles of glenohumeral joint and intercostals. nerves. - Suprascapular nerve (C5/6) - acute trauma with traction; after vague posterolateral shoulder pain; later muscle wasting - Long thoracic nerve (C5/6/7) - "winged scapula" scapulothoracic joint. Disturbance of scapulohumeral rhythm causing jerking of scapula. Usually with crepitus +/- pain. Causes of Thoracic & Chest Pain Common Less Common Not to be missed Intervertebral joint sprain - disc - facet joints Paraspinal muscles Costovertebral joint sprain Scheuermann's Disease (adolescents) Rib trauma - fracture - contusion Referred pain from thoracic spine to chest Fracture posterior rib Thoracic disc prolapse T4 syndrome Costochondritis Stemocostal joint sprain Intercostal muscle strain Stress fracture of rib Cardiac causes Peptic ulcer Tumour Gastro-oesophageal reflux Pneumothorax Pulmonary embolism Fractured sternum 2005 MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb

33 3. Practical assessment of the head & neck. 1. Palpate the following: a) head external occipital protuberance greater occipital nerve origin of trapezius mastoid process insertions of sternocleidomastoid & splenius capitis tempero-mandibular joint (TMJ) b) neck transverse process of C1 spinous process of C2 & C7 facet joints (articular pillars) laminar groove lymph node chain lymph nodes larynx (Adam's apple) 1st cricoid ring trachea carotid pulse thyroid gland superior nuchal ligament suprasternal notch medial clavicle sternocleidomastoid upper trapezius 2. Visual inspection/or: a) cervical high/low shoulder sidebending rotation forward head b) type 1 cervicals sidebending (supine) rotation (supine) c) type 2 cervicals 0-Ajt (in neutral, flexion, extension) atlantal-axial joint (A-A jt) - functional evaluation C2 - C5 (in neutral, flexion, extension) 3. Range of movement (ROM) a) cervical side bending extension flexion rotation 4. Special Tests a) Distraction Test Compression Test Vertebral Artery Test b) Valsalva Test Adson Test 2005 MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb

34 4. Practical assessment of the thoracic region 1. Palpate the following: a) Anterior Manubrium Sternum Xiphoid lateral clavicle coracoid process ribs sterno costal joints outline of pectoralis major pectoralis minor b) posterior spinous processes of T3 & T7 ribs spine of scapula superior angle of scapula inferior angle of scapula medial border of scapula lateral border of scapula lateral margin of trapezius upper trapezius upper splenius capitis insertion of levator scapulae 2. Observe/feel for: a) thoracic sidebending rotation b) hyperkyphosis c) scapula winging d) protruding inferior angle of scapula 2005 MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb

35 3. Range of movement a) thoracic sidebending bi-lateral extension uni-lateral extension flexion (i) standing flexion (ii) supine b) scapula elevators (i) head straight forward (ii) cervical sidebending & rotation c) scapula adductors (i) middle trapezius (ii) rhomboids d) scapula stabilizers (i) pectoralis minor (ii) serratus anterior e) scapula abductor (i) pec. major (clavicular head) (ii) pec. major (sternal head) (iii) pec major (abdominal head) 2005 MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb