Manual Therapy for the Thorax: A Biomechanical Approach

THERAPY THE THORAX MANUALTHERAPYFORTHETHORAX A biomechanical approach DIANE LEE BSR MC PA COMP Instructor/Chief E...

Author: Diane Lee

158 downloads 1164 Views 20MB Size Report

This content was uploaded by our users and we assume good faith they have the permission to share this book. If you own the copyright to this book and it is wrongfully on our website, we offer a simple DMCA procedure to remove your content from our site. Start by pressing the button below!
Report copyright / DMCA form

DOWNLOAD PDF

THERAPY THE THORAX

MANUALTHERAPYFORTHETHORAX

A biomechanical approach

DIANE LEE BSR

MC PA COMP

Instructor/Chief Examiner for the Or t hop a e d i c Division of the Canadian

Physiotherapy Association

Dope De lta British Columbia, Canada, ,

1 994

PREFACE In the literature pertaining to back pain, the muscul oskeletal com ponents of the thorax have received Ittl e attention. T h e reference l ist at the end of this text reflects the paucity of research availabl e for review. And yet, clinicians are presented d a i l y with t h e chal lenge of treating both acute and chronic thoracic pai n . It was this cl inical work presented this texL chall enge which initiated A biomechanical approach to treatment of the thorax requires an understanding of its normal behaviour. Without a working mode l , using unrel i able symptoms direction the clinician l imited and treatment planning. If we understand how the muscul oskel e tal system behaves normally, we can then apply this knowledge to thorax. A systematic examinati on the examination of the ity of associated bones j o i nts then of done . Since function is related to structure, an understanding of the anatomy i s required.

1990 when Jan Lowcock prc� The clinical investigation began sented a paper on stab i l i ty testing of the thorax to the Canadi an Orthopaedic Manipu l ative Physiotherapists. I am indebted to her, and any others, for the suhsequent academic and clin ical discus� to the evolution the biomechan i cal mo del pre� sions w h i ch sen ted here. Much of this material remains empirical and requires validation through research. The chapter reviews anatorny of the thorax as pertains the biomechanical model. The emphasis h as been p laced on osseous and articul a r anatomy a l though the muscu lar and neural contribution function acknowledged. Chapter two descrihes the b iomechanieal model and chapters three to five c l i nical appli cation of this model to examination and treatment of the tho rax . The purpose of this text is to provi d e the clinician with the abi l t o assess and treat articular dysfunction of the thorax. The postural analysi s , reader is referred to other texts for review myofascial syndromes and neural dysfunction . I would l ike Crymbl e who

extend gratitude and recognition responsible for cover desi gn

Mr. Fra n k all of

art work and photographs i n this text. To my col leagues at DOPC and constructive reviews ' yet another their ongoing speci al thanks. And final ly, to presentation on the thorax ' , Thomas, Michael and Chelsea, thank you. British Col umbi a,

D.L

CONTENTS

1. ANATOMY

10

VERTEBROMANUBRJAL REGION

11

VERTEBROSTERNAL REGION

13

VERTEBROCHONDRAL REGION

20

THORACOLUMBAR JUNCTION

21

2. BIOMECHANICS

23

LITERATURE REVIEW

23

DEFINITION OF TERMINOLOGY

24

HABITUAL MOVEMENTS

25

Forward bending

25

Backward bending

31

Lateral bending

36

Rotation

42

Respiration Unilateral elevation of the arm

3. CONDITIONS MEDICAL MODEL OF C LASSIFICATION

47 51 51

Visceral

51

Metabolic

51

Infection

51

Neoplastic

52

Spondylogenic

52

MANUAl TIIERAPY MODEL OF ClASSIFICATION

55

HEALING PROCESS

56

Substrate phase

56

Fibroblastic phase

56

Maturation phase

56

Clinical application to treatment

57

4. ASSESSMENT

59

surUECTIVE EXAMINATION

60

OBJECTIVE EXAMINATION

62 63 63 63 64 65 66 67 68

Postura l Analys i s Habitual movement Forward and backward bending Lateral bending Axia l rotation Resp iration Combined movement testing Unilateral elevation of the a rm Articular function Active mobility, osteokinematic Forward Backward Lateral bending Rotation Respiration

68

70 70

75 76 77 78

Passive physiological mobility tests

79

Passive a rthrokinem a tic Zygapophysea l Costotransverse Mediola teral translation

80 81 82 87

Passive stability tests of a rthrokinetic function Vertical (traction/compression) Anterior translation - spinal Posterior

88 88 91 92

92 93 Inferior - posterior costal Anterior/Posterior translation - anterior costa l

96 97

Superior/Inferior transla tion anterior costa l Mediolatera l translation

Muscle function Nerve function Adj unctive tests

97

103

CLINICAL SYNJ)ROMES

HYPOMOBILITY WITH OR WITHOUT PAIN

105

Vertebromanubrial region Bila tera l restriction offlexion Un ilateral restriction offlexion Bila tera l restriction of extension Un ila tera l restriction of extension Un ilatera l restriction of anterior rotation - first rib Unilatera l restriction of posterior rotation rib

Vertebros ternal and vertebrochondral regions

109 111

115

118

Bilatera l restriction offlexion 118 Un ila teral restriction of flexion Un ila teral restriction of extension 125 Unilateral restriction of rota tion (posterior or anterior) - rihs 3 to 10 127

Thoracolumbar j u nction Unilatera l restriction offlexion Unilateral restriction of extension

130 132

HYPERMOBILITY WITH OR WITHOUT PAIN Subluxation of the costotransverse and costovertebral Vertebromanubrial region Vertebrosternal and vertebrochondra l region s Thoraculwnbar junction

Subluxation of

138

'Ring'

STABILIZATION THERAPY NORM AL MOBILITY WITH PAI N

143

10

-

Manual Therapy For The Thorax

1

ANATOMY

The thorax can be divided into four regions according to anatomi cal and biomechanical differences. The vertebromanubrial region (upper thorax) includes the first two thoracic vertebrae, ribs one and two and the manubrium. The vertebrosternal region (middle thorax) includes T3 to T7, the third to seventh ribs and the sternum. T8, T9 and TI0 together with the eighth, n inth and tenth ribs form the vertebrochondral region (middle/lower thorax). The lowest region is the thoracolumbar junction which includes the Tll and T1 2 vertebrae and the eleventh and twelfth ribs. The regional anatomy pertinent to the biomechanical model will be described in this chapter.

Figure 1. The superior a spect of the first thora c i c v ertebra. The

zygapophyse a l joints lie in the coronal pla ne.

Manua l Therapy For The Thorax

-

11

VERTEBROMANUBRIAL REGION The first tho racic vertebra is atypical. It has a large , nonbifid s pin ous process, club like at its end. The superior aspect of the spinous process tends to lie i n the same transverse plane as the TI-2 zygapophys eal jo ints . The facets on the superior articular process es lie in the coronal body plane (Fig. 1) w hile those o n the i nferi o r articul ar process (Fi g .

2) present a gentle curve i n

both the trans

verse a n d sagittal planes. The zygapophyseal joints are s y n ovial. The transverse processes are long and thick. The y are located between the s u perior and i n ferior articu l ar processes (Fig.

3)

at the

dorsal aspect of the pedicle and are ideal ly s i tuated for palpation o f i ntervertebral motio n . O n the ventral aspect o f the transverse process there i s a deep, concave facet which articu l ates w i t h a con v ex facet on the first rib to form the costotransverse j o i n t. In the normal upright posture, the orientation of this joint is an teroinferior

Figure 2. The i nferio r aspect of the first thorac i c

vertebra.

The

zygapophyseal jo ints are gen tly convex in both the trans verse and sag i t tal plan es. The ventral aspect

of the

trans

verse process contains a con cave

face t

fo r

a r t i culat i o n

with t h e firs t rib. Figure 3. Anterolateral v i ew of the first t horacic vertebra.

The unci

nate process at each postero lateral corner creates a con cav i t y on the superior aspect of the vertebral body.

There

is a full facet at the supe rolat eral

aspect of the vertebral

body for the head of the firs t rib.

A

demi-facet

on

the

infero lateral aspect art i culates with the head o f the second rib in the second decade of life .

Note the concave facet

on the transverse process for art iculati o n w i th the first rib.

12

-

Manual Therapy For The Thorax. (Fig. 4). Like the zygapophy seal joint, the costotransverse joint is synovial.

The superior aspect of the ver tebral body of T1 is concave in A"'''---'� - the coronal plane. This con ��......... cavity is formed by the unci....._""" �1111. 1 ....... nate process at each posterolateral corner. These processes �....� articulate with the inferior jill...... aspect of the body of C7 to the form non-synovial, uncovertebral joint1. There are two ovoid facets on either side of the vertebral body for artic ulation with the head of the first rib. The inferior aspect of the vertebral body of T1 is fiat and contains a small facet at each posterolateral corner for articulation with the head of the second rib. This articulation is incomplete until early adolescence when a secondary ossification centre appears to complete the formation of the head of the rib2,3. In children, the head of the second rib only articulates with T2.

. �.......;:;a

Figure 4. Postero l ate r a l

v i ew

artic u l a ted t horax.

of

the

Note the

cha nge in the orientat ion of the costotra nsverse joint from the v ertebromanubrial region to

the

region.

v erte brochondral

The first rib (Fig. 5) is the shortest of the twelve and the broadest at its anterior end. The first sternochondral joint is unique in that it is fibrous rather than synovial. The first costocartilage is the short est and this, together with the fibrous sternochondral joint, con tributes to the stability of the first ring. The convex head of the first rib articulates with the body of T1 at the costovertebral joint. The neck of the rib is located between the head and the tubercle. The articular portion of the tubercle is convex and directed posterosu periorly when the head and neck are in the normal upright posture. The second rib is about twice as long as the first and its features are similar to the vertebrosternal region described below. Anteriorly, the cartilage of the second ring articulates with both the manubri um and the sternum at the manubriosternal symphysis. The manubrium (Fig. 6) is a broad triangular shaped bone which articulates with the clavicle and the costocartilage of the first and second ribs. The manubriosternal symphysis usually remains sep arate throughout life although ossification can occur (Fig. 7).


-

13

Figure 5. Superior aspect of the rib.

Figure 6. The manubrium.

VERTEBROSTERNAL REGION

The vertebrae in th is region (T3 to T7) have long, thin, overlapping spinous processes (Fig. 8). The tip of the spinous process can be three finger widths inferior to the transverse process of the same vertebra and frequently deviates from the midline. Consequently, it is an unre liable point for palpating intervertebral motion. The facets on both the superior and inferior articular processes pre sent a gentle curve in both the transverse and sagittal planes 4 (Fig. 9). This orientation permits multidirectional movement. If two mixing bowls are placed one inside the other, a model of the zygapophyseal joints can be made (Fig. 10). The top bowl can rotate forward, backward, s ideways and around the bottom bow l . Transl ation o f the top bowl meets immediate resistance. The coro-

fi rst

14 - Manual Therapy For The Thorax

Figure 7. The m anubriostern a l symph ysis

is

u s u ally

main t a i n e d

thro ugh l i fe, however ossifi cation can occur.

Figure 8. Poster ior view of the articu l ated thor a x .

nal orientation of the superior articular processes resists pos teroanterior translation of the superior vertebra. The transverse processes, located at the dorsal aspect of the pedi cle between the superior and inferior articular processes, are ideal ly situated for palpation of intervertebral joint motion. The ventral aspect of the transverse process (Fig. 1 1 ) contains a deep, concave facet for articulation with the rib of the same number. This curva-


-

15

Figure 9.

The superior aspect of the fourth thoracic vertebra. The zygapophyseal j oint is ge ntly convex in both the transverse and sagittal planes. The ven tral aspect of the transve rse process contains a concave facet for articulation w i t h the fourth rib.

Figure 10.

Two mixing bowls model the potential biomechanics of the zygapophyseal j oints in the thorax.

Figure 11.

Ante rola tera l v ie w of the fourth t h o racic vertebra. Note the concave facet on the transverse process for articu lation with the fourth rib as we ll as the two demi-facets on the lateral aspect of the vertebral body for articula tion with the heads of the fo urth and fifth ribs. ture (Fig. 12) influences the conjunct rotation which ocCurs when the rib glides in a superoinferior direction. When the tubercle of

the rib glides superiorly, the curvature forces the rib to rotate ante riorly. Conversely, posterior rotation of the rib occurs when the

16

-


Figure 1 2 . Posterola t eral articu lated

view

o f the

th orax,

verte

brosternal region.

Note the

curvature of the fifth costo transverse joint (arrow).

Figure 13. Anterola teral

view

articulated thorax. costovertebral

of

the

Note the

joint,

v erte

brosternal region (arrow).

�

tubercle glides inferiorly relative to the transverse process. In the normal upright posture, the orientation of the facet on the trans· verse process is anterolateral. The posterolateral corners of both the superior and inferior aspects of the vertebral body contain an ovoid demifacet for articulation with the head of the rib (Fig. 11). Development of the superior cos tovertebral joint is delayed 'until early adolescence2,3 accounting for the flexibility of the young thorax.


-

17

Figure 14. The fourth rib. Figure 15. The sternum.

In the skeletally mature, the joint between the head of the rib and the adj acent vertebral bodies i s div ided into two synovial cav ities, separated by the intra-articular ligament (Fig. 13). The capsule i s supported by t h e radiate l i gament which sends fibres from the head of the rib both anteriorl y and posteriorly to b l end with the vertebral bod y of the l evel above, the intervertebral disc and the vertebral body of the level below. The costovertebral joint i s a compound, synovial joint. The n eck of the rib l i es parallel to the transverse process, joined by the costotransverse or interosseous l igament. The non-articular portion of the tubercle receives the lateral attachment of the short, l ateral costotransverse l igament. Thi s l igament lies in the trans verse plane between the transverse process and the rib . The s upe rior costotransverse l i gament has a variable number of bands which run in a superoinferio r direction from the inferior aspect of the transverse process to the neck of the rib below. The neurovas cular elements of the thoracic segment emerge between the bands of this ligament. The shaft of the rib i s long and thin and twists to a variable degree at the posterior angle (Fig. 14). Very little is known about the anatomy and age related changes of the intervertebral disc in the thorax. They are thinner than the cer vical and lum bar intervertebral d iscs even i n youth. They are sup ported anteriorly and posteriorly by w ide longitud inal ligaments.

18

-


Figure 1 6. An terior view of t h e articu lat ed t ho rax.

Figure 17. An terola teral eighth

view

thora cic

of

the

vertebra .

Note the p l a n ar facet on the transverse process fo r artic u l a tion with the e ighth rib as well

as

the

dem i-fa c e t

l a rge fo r

sup e rior

articu l a t i o n

w i t h t h e h e a d of t h e eighth rib and the small demi-facet for

a r t i culation with the head o f the n in th rib .

The sternum (Figs. 7, 15) has eight full concave facets which artic ulate with the costocartilages of ribs three to six. Superiorly, the second rib articulates with the sternum at a demi-facet; inferiorly, the seventh rib articulates with both the xiphoid and the sternum. These joints are synovial unlike the lateral costochondral joints which are fibrous, the periosteum and perichondrium continuous. The costocartilage increases in length from the first to the seventh ribs and then decreases to the tenth (Fig. 16). Thus the lower part of the vertebrosternal region (ribs 6, 7) has greater flexibility ante riorly than the upper part (ribs 3 , 4).


-

19

Figure 18. Postero l a ter a l

view

of

the

art i cul a ted thorax, vertebro chondral region . planar

Note the

n a ture of the

nin th

costotransverse joint (arrow).

Figure 19. Pos terior view o f the articu l a ted

t h orax,

regi o n .

thoracolu m b a r

Occa s i o n a lly

the

spinous processes a re bifid .

20

-


Figure 20.

Lateral view of the twelfth thoracic vertebra. Note the change in directio n of the facets on the superior and inferior articular p rocesses. There is one facet on the lat eral aspect of the vertebral body for articu lation with the head of the twelfth rib. There is no facet on the small trans verse p rocess, there is no cos totransverse join t .

Figure 21.

The eleventh and twelfth tho racic and the first lumbar ver tebrae. Note the orientation of the zygapophyseal joints.

VERTEBROCHONDRAL REGION

The vertebrae in this region (T8, 9, 1 0) differ from the verte brosternal r egi o n in the follo w ing aspects . The spi nous process is shorter (Figs. 8, 17), altho ugh still directed inferiorly such that the tip lies close to the transverse plane of the transverse process of the inferior vertebra . The facet on the ventral aspect of the transverse process is flat and faces anterolateral and superior (Fig. 18). Therefore, when the tubercle of the rib glides superiorly, it also glides posteromedially with minimal con junct rotation. When the tubercle of the rib glide s inferiorly, it also glides anterolaterally following the plane of the costotransverse joint.

Manual Therapy For The Thorax - 21

Figure 22.

The transverse processes of the twelfth thoraci c vertebrae are small tubercles (arrow) and cannot be used for pal pating i ntervertebral mot ion. T8 and T9 have four demifacets for articulation with the head of the eighth and ninth ribs.

T10

is variable. Often, there is only a

small articulation between the superior aspect of the head of the tenth rib and the inferior aspect of the vertebral body of T9. Occasionally, the tenth rib will articulate only with

T10

at the base

of the pedicle via an unmodified ovoid joint. Anteriorly the eighth, ninth and tenth ribs articulate indirectly with the sternum via a series of cartilaginous bars which blend with the seventh costocartilage (Fig. 16). There is a variable number of syn ovial joints between the costocartilages (interchondral joints). This arrangement permits greater flexibility.

THORACOLUMBAR JUNCTION The spinous processes of Tll and T12 are short, stout and con tained entirely within the lamina of their own vertebra (Figs. 8, 19,

20).

The facets on the articular processes of Tll (Fig. 21) resem

ble those of both the vertebrosternal and vertebrochondral regions. The facets on the inferior articular process of T12 resemble the lumbar region. They have a coronal and sagittal component and when articulated with Ll restrict axial rotation. The orientation of Tll-12 does not restrict axial rotation. Laterally, the transverse processes are small tubercles (Fig. 22), the mamillary processes are larger and more superficial. The spinous process is a more reliable point for palpating intervertebral motion in this region.

22

- Manual

Therapy For The Thorax

Figure 23. Lateral view of the thoracic spine.

Note the unmodified

ovo id facet (arrow) for the head of the twelfth rib.

The heads of the eleventh and twelfth ribs articulate o nly with the vertebral body at the base of the pedicle via an unmodified ovoid joint (Fig. 23). There is no costotransverse j oint in this region. The

ribs do not have a neck and do not twist significantly. They remain detached from the rest of t he tho r ax a n terio rly (Fig.

16)

and pro

vide attachment for the diaphragm and trunk musculature. The shape of the costovertebral joint facil i tate s multi-directio nal move ment of the vertebral b ody even when the large muscles contract

and fix the eleventh and twelfth ribs. The eleventh segment

T12, eleventh rib) is the most flexible in the thorax.

(Tll,

Man u a l

For The Thorax

23

BIOMECHANICS m ateri a l been previousl y published, The of Manual Manipulative Therapy5 and in the Therapy of the Cervical and Thoracic Spine6 and is reproduced here with perm ission from the author and the publishers. to the assessment and treatment of A biomcchanical musculoskeletal dysfunction of the thorax requires an understand ng model, ml normal behav iour. Without a ing cian is l i m i ted to using often unreliable symptoms for direction and treatment planni ng. If we understand how the osteoarticular system behaves norm a l l y, we can then apply this knowledge when examthorax . A dev iant movement patterns o f the associ ated bones of mob i l can done. The of this to present of in vivo biomechanics of the thorax which has been used cli ni cally as the basis for assessing and treating mechanical dysfunc tions of hath the spi n a l a n d costal joi nts. Some parts of this m odel have substantiated through scientific research 7 while others rema i n empirica l . LITERATURE REVIEW

Reference to the l i terature reveals very that is known ab out the biomechanics the thoracic Four studies the human thorax8,9,1O,1l based on three imensional ical models and are difficu lt to apply clinically. Andriacchi 10 noted that the rib cage increased the bending sti ffness of the spine by a factor of two in extension. He fo und that when the rib cage w as l eft spine could intact, load in com three times before i nstability occurred . The impl ication is that loss of the segmental thoracic would impair the ab i lity of the entire cage to sustai n a vertical load.

24

-


Saumarez8 noted that there can be considerable independent move ment of the sternum and the spine, "thus allowing mobility of the spine without forcing concomitant movements of (the) rib cage". Neither study8,10 proposed a kinematic model of the in vivo bio mechanics of the thorax. y

Figure 24. In

an

in

v i tr o

s t u dy

Panjabi, B r a n d and

by

Wh ite 7,

396 load d isplacement curves

were obta i ned for six degrees of

motion

segm e n t.

at The

each

thoracic

a m p l i tude

of

the i n d u ced m otion as well as the ampl itude and direct i o n of any

consequ ential

coupled

motion was recorded. From Lee 5,6 w ith perm ission.

Panjabi, Brand and White 7 investigated the mechanical prop erties of the thoracic spine through an in vitro study. Three hundred and ninety six load displacement curves were obtained for six degrees of motion, comprising z three translations and three rotations along and about the X, Y and Z axes for each of the eleven motion segments of the tho racic spine (Fig. 24). The specimens tested ranged in age from 19 to 59 years. The motion segment included the anterior interbody joint, the posterior zygapophyseal joints, the costovertebral and costotransverse joints. The ribs were cut 3 cm lateral to the costo transverse joints and the front of the chest was removed. The func tional spinal unit was left intact, however, the functional costal unit was not. The results of this study will be discussed later. DEFINITION OF TERMINOLOGY

To facilitate the subsequent discussion, the terminology used requires definition. Osteokinematics12 refers to the study of motion of bones regardless of the motion of the joints. Angular motions are osteokinematic motions and are named according to the axis about which the bone rotates. Flexion/extension occurs about a coronal axis, anterior/posterior rotation about a paracoronal axis, sideflexion (lateral bending) about a sagittal axis and axial rotation about a vertical axis. Coupled motion refers to the combination of movements which occur as a consequence of an induced motion. Linear motions are named according to the axis along which the bone translates. Mediolateral translation occurs along a coronal axis, anteromedial!posterolateral translation along a paracoronal


Flexion

Anterior

-

25

Translation

Figure 25. Forward

sagittal

around the

rotation

X axis induced

anterior translation along the

Z axis and slight distraction

along the Y axis.

Anterior

translation along the Z axis induced forward sagittal rota

tion around the X axis and slight compression along the

Y

From: Panjabi

et al 1976

axis, traction/compression along a vertical axis, and anteroposteri or translation along a sagittal axis. Arthrokinematics 12 refers to the study of motion of joints regard less of the motion of the bones. These movements are named according to the direction the jo int surfaces glide. HABITUAL MOVEMENTS

The thorax i s capable of six degrees of motion along and about the three cardinal axes of the body; however, no movement occurs in isolation 7. In other words, all angular motion is coupled with a lin ear motion and vice versa. The habitual movements of the thorax include forward and backward bending, lateral bending and axial rotation of the head and trunk. Elevation of the arm also requires movement of the upper thorax . Simultaneously, the chest moves during i nspiration and expi ration. The biomechanics of the thorax varies according to the region cons idered. The common features and the regional differences will be described. Forward bending

Flexion of the thoracic vertebrae occurs during forward bending of the head and trunk. Panj abi, Brand and White 7 found that forward sagittal rotation (flexion) around the X axis was coupled w i th ante rior translation along the Z axis (.5 mm) and very slight distractio n (Fig. 25). W h e n anterior translation along t h e Z axis (1 mm) was induced i n the experimental model, forward sagittal ro tatio n around t h e X a x i s w a s coupled with slight compression .

axis.

Panjabi,

Redrawn

from

Brand and White 7.

From Lee5,6 with permission.

26

Figure 26.

Flexion of the thoracolu mbar in a 6 year o l d .

spine

Figure 27. Flexion of the thoracolumbar

spine in a

71

year

old.

-


Th e osteokinematic motion o f the ribs during forward sagittal rotat i o n of the thoracic verte brae was not noted in the study by Panja b i et a17 . three C l i n i ca l l y, m ovement patterns can o ccur and are dependant upon the rel ative flex ibil ity between the verte bral column and the rib cage . In the very yo ung (less than 1 2 y e a rs of age), the head of the rib does not a rticulate with the inferior aspect of the superior ve rte bra . The secondary ossification centre for the superi or aspect of the head of the rib does not develop until puber ty, therefore the young chest is very mobile (Fig. 26) . In ske letally the m ature, the superior costovertebral j oi nts limit the quantity of vertebral rotation i n all three planes. With increasing age, the costocartilages stiffen and decrease the flex ibility of the rib cage (Fig. 27). This change in rel ative flexibility between the vertebral column and the rib cage is apparent when examining the specific costal osteokinematics dur i ng forward and backward bending of the trunk. Mobile thorax

During forward bending of the mobile thorax, forward sagittal rotation of the superior vertebra couples with anterior translation. This anterior translation 'pulls' the superior aspect of the head of the rib forward at the costovertebral j oint inducing an anterior rota-


-

27

Flexion

Figure 28. The

osteokinematic

and

arthrokinematic motion pro posed to occur in the mobile thorax during forward bend ing - vertebrosternal region. From Lee5,6 with permission.

tion of the rib. The rib rotates about a paracoronal axis along the l ine of the neck of the rib such that the anterior aspect travels infe riorly while the posterior aspect travels superiorl y (Fig. 28). At those l evels where the superior costovertebral j oint does not exist (1, 11, 12) or i s very small (10), the anterior translation of the supe rior vertebra cannot facilitate anterior rotation of the rib below. Arthrokinematically, the inferior facets of the superior thoracic vertebrae glide superoanteriorly at the zygapophyseal joints during flexion. The superior articu lar processes of the inferior thoracic vertebrae present a gentle curve convex posterior in both the sagit tal and transverse plane. The superior motion of the inferior artic ular processes follows the curve of this convexity and the result i s a superoanterior glide. Thus, the arthroki nematic motion o f the joint surfaces supports the osteokinem atic motion of the vertebrae, anteri or translation being coupled with forward s agittal rotation. In the vertebrosternal region of the thorax, the anterior rotation of the neck of the rib results in a superior glide of the tubercle at the costotransverse joi nt. Since the costotransverse j o i nts of T3 to T7 are concavoconvex (the facet on the transverse process is concave) in both the sagittal and transverse plane, the superior glide of the

28

-


Facet Plane -i--+---:,r

Figure 29.

osteokinematic The and arthrokinematic motion pro posed to occur in the mobile thorax during forward bend ing - vertebroc hondral region.

Figure 30.

The oste okinemat ic and arthrokinematic motion pro posed to occu r in the mobile thorax during forward bend i n g - thoracolumbar region.


-

29

Figure 31.

and osteokinematic The arthrokinematic motion pro posed to occur in the stiffer thorax during forward bend ing - vertebrostern al r egion .

tubercle results in anterior rotation of the neck of the rib. Once again, the arthrokinematic motion at the costotransverse joint sup ports the osteokinematic motion of the rib during forward bending of the trunk. In the vertebrochondral region of the thorax (T8

- T10)

the costo

transverse joints are planar and oriented in an anterolateral and superior direction (Fig.

18). The posteromediosuperior (PMS)

glide of the tubercle (Fig.

29)

does not induce an anterior rotation

of the neck of the rib to the same degree as the middle and upper ribs. The first rib is always less mobile than T1 and the movement pat tern in the vertebromanubrial region is described b elow (stiffer thorax). In the thoracolumbar region (Fig.

30),

the eleventh and

twelfth costovertebral joints are unmodified ovoid in shape and flexion of the thoracic vertebra can be a pure spin. Stiffer thorax

The ribs are less mobile than the vertebral column when the stiffer thorax is flexed. During forward bending of the head and trunk, the anterior aspect of the rib travels inferiorly while the posterior aspect travels superiorly. Once the mobility of the rib cage is

30

-


Figure 32. The

o s t e okinematic

and

art hrokin e m a tic motio n pro posed to occur in the verte broma nubrial

regio n

during

forward ben d i n g.

Facet Plane -+--i='7FII

Figure 33. The

o s t e ok i n e m a tic

and

arthrokin e m a tic m o tion pro posed to occur in the stiffer thorax d u r i n g forward bend ing

-

vertebrochondral region.

exhausted, the thoracic vertebrae continue to flex o n the stationary ribs (Figs. 31, 3 2). The arthrokinematics of the zygapophyseal joints rem ain the sam e as in the mobile thorax, however the degree of anterior translation is less . At the costotransverse j o ints , the arthrokinematics are different.· As the thoracic vertebrae continue to flex, the concave facets superiorly relative

to

inferior glide of the

on

transverse processes of Tl to T7 glide of the ribs. The result is a rela tive of the rib at the costotransverse j o int

the

the tubercle

tubercle

.

Manual Therapy For The Thoraxthe vertebrochondral region

33),

the facets of

costo-

transverse joints are planar and the relative glide of the rib is. anterolateroinferior. Rigid thorax When the relative flexibil

between the vertebral column and the

rib cage is the same, there is no palpable movement between the thoracic vertebrae and the ribs. Some superior gliding occurs at the but very

zygapophyseal

if any posteroanterior transla

tion occurs. Limiting factors of the ligaments posterior to

including the posterior half

the intervertebral disc limit flexion of the thoracic spinal unit. In a study by Panjabi, Hausfeld and White13, the thoracic spinal unit loaded to failure in both flexion and extension. Failure was defined as complete separation of the two vertebrae or more than

10 mm of translation or Iransected sequentially

45

degrees of rotation. The ligaments were the contribution of

various liga

ments to stability was noted. In flexion, they found that the unit remained stable until the costovertebral joint was transcctcd. The integrity

the posterior one-third of the disc and the costoverte

bral joints is critical to anterior translation stability in the thorax.

Backward bending Extension of the thoracic vertebrae occurs during backward bend ing of the trunk and during bilateral elevation of the arms. Flexion of the upper thorax occurs when the head is bent backward. Panjabi, Brand

White7 found that backward sagittal rotation

(extension) around the X axis was coupled with posterior transla tion along the Z axis

(1

mm) and very slight distraction (Fig.

When backward translation along the Z

(2.5

34).

was induced

in the experimental model, posterior sagittal rotation around the X and very

compression also occurred.

The osteokinematic motion of the ribs that occurs during backward sagittal rotation Panjabi et

the thoracic vertebrae was not noted in

study

. Clinically, the movement patterns observed

depend on relative flexibility between the vertebral column and the cage. ]'hree patterns have been noted.

32

-


Posterior Translation

Extension

vJ

I

vi

Figure 34. Backw a r d around

sa gittal

the

I

rotation

X axis ind uced

posterior translation al ong the

Z axis and slight dis tract i o n along

the Y

ax i s .

Posterior

t ra n s l a t i o n a l o n g the Z axis in duced rotat i o n

b a ckward around

the

----

3------

sagittal

X axis

and slight compression along the

axis .

Y

Panjabi,

Red rawn

fro m

Bra nd a nd Wh ite 7.

From: Panjabi et al 1976

From Lee5•6 with permiss i o n .

Extension

Figure 35. The

o s t e o k i n ema tic

and

arthro k i n e m a tic motion pro posed to occur in the mob i l e thorax bending

duri n g

b a ckw ard

-

v e r t e brostern al regi o n . From Lee 5.6 with per m i ss i o n.

Mobile thorax

During extension of the mobile thorax, backward sagittal rotation of the superior vertebra couples with posterior translation and 'pushes' the superior aspect of the head of the rib backward at the costovertebral joint i nducing a posterior rotation of the rib (Fig. 35). The rib rotates about a paracoronal axis along the line of the neck of the rib such that the anterior aspect travel s superiorly while the posterior aspect travels inferiorly. At those levels where the superior costovertebral joint does not exist (1, 11, 12) or is very sm all (10), the posterior trans lation of the superior vertebra does not force the rib to posteriorly rotate relative to its transverse process . Arthrokinem atically, the i nferior facets of the superior thoracic vertebrae glide inferoposteriorly at the zygapophyseal j oints dur ing extensi on. The superior articular processes present a gentle curve that i s convex posteri orly i n both the sagittal and transverse


-

33

Figure 36. The

osteokinematic

and

arthrokinematic motion pro posed to occur in the mobile thorax

during

bending

-

backward

vertebrochondral

region.

Figure 37. The

osteokinematic

and

arthrokinematic motion pro posed to occur in the mobile thorax bending region.

plane. The inferior motion of the inferior articular processes fol lows the curve of this convexity, and the result is an inferoposteri or glide. Thus the arthrokinematic motion of the joint surfaces sup ports the osteokinematic motion of the vertebrae; posterior transla tion being coupled with backward sagittal rotation. In the vertebrosternal region of the thorax, the posterior rotation of the neck of the rib results in an inferior glide of the tubercle at the costotransverse joint. The costotransverse joints of T3 to T7 are concavoconvex in both the sagittal and transverse plane, thus the inferior glide of the tubercle results in posterior rotation of the neck of the rib. Once again, the arthrokinematic motion supports the osteokinematic motion of the rib during backward sagittal rotation. In the vertebrochondral region of the thorax (T8 - Tl0) the costo transverse joints are planar and oriented in an anterolateral and superior direction (Fig. 18). The anterolateroinferior glide of the tubercle does not induce a posterior rotation of the neck of the rib to the same degree as the middle and upper ribs (Fig. 36). The first rib is always less mobile than Tl and the movement pat tern is described below. In the thoracolumbar region, the eleventh and twelfth costovertebral joints are unmodified ovoid in shape and extension of the thoracic vertebra can be a pure spin (Fig. 37). Stiffer thorax

The ribs are less mobile than the vertebral column when the stiffer thorax is extended. Initially, the anterior aspect of the rib travels superiorly and the posterior aspect travels inferiorly. Once the mobility of the rib cage is exhausted, the thoracic vertebrae con-

during

backward

thoracol umbar

34

-


Figure 38. The

o s t e ok i n e m a t i c

and

arthro kine m a t i c motion pro posed to occur in the s tiffer thorax bending

duri n g -

backward

vertebrostern a l

region .

tinue to extend on the stationary ribs (Figs. 38 , 39). The arthrokine matics of the zygapophyseal j o ints remain the same as in the first movement pattern described, however, the degree of posterior translation is less . At the costotransverse j oints, the arthrokinemat ics are different. As the thoracic vertebrae continue to extend, the concave facets on the transverse processes of Tl to T7 travel infe riorly relative to the tubercle of the ribs . The result is a relative superior glide of the tubercle of the rib at the costotransverse j oint. In the vertebrochondral region, the facets of the costotransverse j oints are planar and the relative glide of the rib is posteromedio superior (Fig. 40) . Rigid thorax

When the relative flexib i l ity between the vertebral column and the rib cage is the same, there is no palpable movement between the thoracic vertebrae and the ribs. Some inferior gliding occurs at the zygapophyseal j oints, but very l ittle anteroposterior translation occurs. L imiting factors

All of the l igaments anterior to and including the posterior longi tudinal ligament limit extension of the thoracic spinal unit. Panj abi et al 1 3 sequentially transected the anterior longitudinal ligament, the anterior half of the intetvertebral disc, the costovertebral j o ints


-

35

Figure 39. The

and

osteokinematic

arthrokinematic m o t i o n pro posed to occur i n the verte brom a nubrial bi l a te r a l

reg i o n

e l ev a t i o n

d uring of

the

arm s .

Figure 40. The

o s te o k i n e m a t i c

and

arthroki n e m a t i c m o t i o n pro posed to occur i n the s t i ffer

t h o ra x

d u r i ng

be n d i n g

-

reg i o n .

and the pos teri o r half of the i nterv ertebral disc and noted the c on

tribution of each to st a b i l i ty in extension . In ex t en sion they found ,

that the unit remained stable until the p o sterio r l o ngitu d i n al liga ment was transected.

b a c k w a rd

v ertebro c h o n d ral

36

-

Manual Th erapy For Th e Thorax Right Sideflexion

Right

Tra n s l ation

Figure 41 .

Right sideftexion around the Z ax is ind uced left rotation around the Y axis and right translation along the X axis. Right lateral translation along the X axis induced right side flexion around the Z ax is and left rotat ion aro und the Y axis. Redrawn from Panjabi, B rand and W h i t e 7 From Lee 5 , 6 with perm ission.

From :

Panjabi

et a l 1 976

Lateral bending

Sideflexion of the thoracic vertebrae occurs during lateral bending of the head and trunk. Panj abi et a1 7 found that sideflexion, o r rota tion around the Z axis, was coupled with contralateral rotation around the Y axis and ipsilateral translation along the X axis (Fig. 4 1 ) . Translation along the X axis was coupled with ipsilateral side flexion around the Z axis and contralateral rotation around the Y axis . is i n teresting t o postulate on what produces this coupling o f motion i n t he thorax. In t h e m i dcervical spine, i t is thought2 , 14 that the oblique orientation of the zygapophyseal j oints together with the uncinate p rocesses directs the ipsilateral rotation which occurs with lateral bending of the head . In the lumbar spine, the zygapophyseal j o ints also are thought 15 to influence motion cou pling. However, the facets of the zygapophyseal j o ints in the tho racic spine lie in a somewhat coronal plane and would not l i m it pure sideflexion during lateral bending of the trunk. It is difficult to see how they could be responsible for the contralateral rotation found to occur during sideflexion 7 . A clinical hypothesis of the factors wh ich produce motion coupl ing during l ateral bending of the thorax is proposed .

It

Clinical hypoth esis

As the head and trunk bends laterally to the right, a left convex curve is produced . The thoracic vertebrae sideflex to the right, the ribs on the right approximate and the ribs on the left separate at their l ateral m argins (Fig. 42). In both the mobile thorax and the

Manual

Therapy For The Thorax

-

37

®

t

Figure 42 . As t he

thorax s i d e fl exes to the the ribs on the righ t approximate and the ribs on the l eft separate a t their later al ma rgin s The costal motion stops fi r s t , the thoracic verte brae then con t i n u e to s i d eflex s lightly to the right. From Lee5, 6 with permi ss io n

right,

.

.

@ Figure 43 . In the vertebrostern al region, the superior glide of the right rib at the costotran sverse j o i n t i nduces anterior rotation of the same rib d ue to the c u rv a ture of the j o int surfaces. The inferior glide of the left rib at t he co s t o t r a n sverse j oint induces posterior rotat ion of the same r i b . From Lee5.6 with permiss ion.

stiffer thorax, the ribs appear to stop moving before the thoracic vertebrae. The thoracic vertebrae then continue to sideflex to the right. This motion can be palpated at the costotransverse j oint. In the vertebrosternal region (T3 to T7), this slight increase i n r ight sideflex ion of the thoracic vertebrae against the fixed ribs causes a relative superior glide of the tubercl e of the right rib and a relative inferior glide of the tubercle of the left rib at the costotransverse j oi nt (Fig. 43). Since the costotransverse j oint is concavoconvex in

38

-

Manual Th erapy For Th e Thorax

Figure 44.

In the vertebrosternal region, anterior rota t ion of the right rib and posterior rotation of the left rib facil itates a con tra l ateral rotation of the supe rior vertebra due to the attachment of the rib to the inferior aspect of the superior vertebral bod y .

---

-/..?-a sagittal plane, the superior glide of the right rib produces a rela tive anterior rotation of the neck of the rib with respect to the trans verse process. The inferior gl ide of the left rib produces a posteri or rotation of the neck of the rib relative to the transverse process. It is important to note that the moving bone is the thoracic verte bra, not the rib ; however, the relative motion is described as though the rib was moving. Bilaterally, the effect of this rotation is to rotate the superior vertebral body to the left (contralateral to the sideflexion) (Fig. 44). Panj abi, Brand and White 7 found that right lateral translation along the X axis (.5 1 mm) occurred during right sideflexion (Fig. 41) . The effect of this right lateral translation is negated by the left lat eral translation which occurs as the superior vertebra rotates to the left. The net effect is minimal, if any, mediolateral translation of the ribs along the l ine of the neck of the rib at the costotransverse j o i nts. The clinical impress ion is that no anteromedial or postero lateral sl ide of the ribs (relative to the transverse process to which they attach) occurs during l ateral bend ing of the trunk. -

At the zygapophyseal j oints, the l eft inferior articular process of the superior thoracic vertebra glides superomedially and the right process glides inferolaterally to facilitate right sideflexion and left rotation of the superior vertebra. The arthrokinematic motion of the j oint surfaces supports the osteokinematic motion of the verte brae and ribs . In the vertebromanubrial region, the head of the first rib does not articulate with C7 and the superoi nferior glide of the ribs and the conj unct rotation which occurs cannot influence the di rection of


-

39

Figure 45. The

o s t e okin e m a tic

and

arthrokin ematic motion pro posed to occur in the verte broma nubria l

region

during

l atera l bend ing of the head to the righ t .

Figure 46. R ight l a tera l bending of the trunk w i t h the apex a t the left grea ter troch a n ter.

40

-


movem e n t cou pling between C7 a n d T l . C7-T l a n d TI -T2 fol l ow t h e s a m e pattern of moti o n cou p l i n g as t h e m i dc e rv i ca l s p i n e w h e n t h e head i s b e n t l aterall y ( F i g . 45) . S idefle x i o n i s c o u p l e d w i t h i ps i * l a t e r a l r o t a t i o n o f t h e superio r vertebra. T h e u n c i n ate p r o c e s s e s a t i n fl u e nce the d i r e ct i o n o f m o t i o n coupl i ng h e r e .

C7-T l

D u r i n g right l a t e r a l b e n d i n g o f the

h ead/neck the

transverse

rel ative to the rib o n the right a n d s u p e r i

process gl i des

o r l y r e l a t i v e t o the rib o n t h e l eft . The b i om e ch a n i cs of t h e vertebrochondral regi o n d u r i ng lateral b e n d i n g o f the trunk i s dependant upon the apex o f t h e c u r v e p r o � d u c e d i n s i d eflexion . I f t h e apex of t h e l ateral b e n d i n g c u r v e i s at the l ev e l o f t h e greater trochanter o n t h e l e ft (Fig . 46), t h en a l l o f t h e thoracic vertebrae s i d e fl e x to t h e r i g h t a n d the r i b s appro x i m ate on t h e right and separate o n the l eft . A s t h e rib cage is com pressed on

right a n d stops

furth er r i g h t s i de fl e x i o n o f t h e l ow e r

t h o r a c i c vertebrae resu l ts i n a superior g l i de o f t h e t u b ercle o f the r i g h t r i b and a n i n ferior g l i d e o f t h e tubercle o f t h e l e ft . G iv e n t h e o rientat ion o f the articular s urfaces, t h e d i rection o f t h e g l ide w h i c h occurs i s posterom e d i osuperior o n t h e right a n d a n t e r o � l atero i n fe r i o r o n t h e l eft w i t h m i n i m a l rotation of the n e c k o f the r i b (Fig . 47) . The ribs do n o t appear to d i rect the s u p e r i o r vertebra i nt o contral ateral rotation as they

in the vertebro s t e r n a l regi o n ,

Th e vertebrae a r e t h e n free to fo l low t h e rotati o n w h i c h is congrue n t with

If

levels above a n d b e l ow,

ape x of the l ateral b en d i ng curve

w i t h i n t h e t h o r a x , (Fig.

48), then t h e o s teok i n e m atics o f the lower thoracic v e rtebrae appear to h e d i fferent T h e r i b

rem a i n s co m prcssed o n the

right and separated o n t h e left, b u t the thoracic vertebrae s id c fl e x to t h e l eft b e l ow t h e apex of t h e r i g h t l ateral b e n d i ng c u r v e ( L e . T9, Tl

T 1 1 , T 1 2) . G i v e n the o r i e n tat i o n o f t h e articular su rfaces of

t h e costotransverse j o i n t s , the direction o f t h e glide which occurs is anterol ateroi n fe r i o r o n t h e right and postero m e d i osuperi o r on t h e l eft w i th m i n i m a l rotati o n o f the neck o f the r i b . O n ce aga i n , the ribs

not appear t o d irect the superior v e rtebra

rotate i n

s e n s e i ncongrue n t to t h e l e v e l s above a n d b e low. At t h e thoracolumbar j un ct i o n , pure s idcftexi o n c a n o cc u r (Fi g . 4 9 ) . The h e ads o f t h e e l ev e n t h a n d tw e l ft h r i b s do n o t art i c u l ate w i t h the v ertebr a above a n d there i s n o costotransverse

to

consider. The costoverteb ral j o i n t shape is an u n m od i fi e d o v o i d a n d therefore

s idefl e x i o n o f the thoracic v e rtebrae between

two fixed r i b s can occur.


L

-

41 Figure 47.

The osteoki nematic and a rthro kinematic motion pro posed to occur during right lateral bend ing of the verte brochondral regio n . The direction of the art hro k i ne matic glide at the costotrans verse joi nts i s posteromedio superior on the right and a n t e rolatero i n fe r i o r o n the left . Minimal rotation of the head of the rib occurs si nce the costotra nsverse j o i n t is planar. The rib, therefore, has little infl uence o n the direc tion of motion coupling of the superior vertebra. The superi or vertebra is free to fol low t h e d i rect ion of rot a t i o n which is congruent w i t h t h e levels above a n d below .

Figure 48.

Right lateral bend ing of the trunk w i t h the apex within the thorax.

42

-


Figure 49. The

o s t e o k i ne m a t i c

and

arthrokinematic motion pro posed to occur duri n g right l ateral b e n d i n g of the thora columbar regio n .

Rotation

Figure 50. Panj ab i , fo u n d

Brand that

and

right

W h ite7 rotation

aro u n d the Y axis i n d uced left

s i deflexion around the Z axis and left translation along the

X a x i s . From Le e5,6 with per

Fro m : Panj abi

m is s i o n .

et

al 1 976

Rotation

Panj abi, Brand and White 7 found that rotation around the Y axis was coupled with contralateral rotation around the Z axis and con tralateral translation along the X axis (Fig. 50) . This is not consis tent with clinical observation (Fig. 5 1) . In both the vertebro manubrial and vertebrosternal regions, rotation around the Y axis

Manual Th erapy For Th e Thorax

-

43

Figure 51 .

Cl i n i cally, t h e m i d thorax appears to sideflex and rotate to the same side during rota tion of the trunk.

has been found to be coupled with ipsilateral rotation around the Z axis and contralateral transl ation along the X axis. In other words , when axial rotation is the first motion i nduced, rotation and side flexion occur to the same side. It may be that the thorax must be intact and stable both a nteriorly and posteriorly for this i n vivo co upling of motion to occur. The anterior elements of the thorax were removed 3 em l ateral to the costotransverse j o i nts in the study by Panj abi et aI 7 . When the anterior elements of the thorax are removed surgically, ipsilateral sideflexion and rotati on cannot occur i n the midthorax .

44 - Manual Therapy For The Thorax The costocarti lage of the left sixth rib was removed for cosmetic reasons in the 1 7 year old youth illustrated i n Figures 52 and 5 3 . H e presented four years later with pers istent pain in the m idthorax, and on examination of axial rotation he could not produce ipsilat eral rotation/sideftexion of the midthoracic region . Clinical hypothesis

During right rotation of the trunk the following b iomechanics are proposed. The superior vertebra rotates to the right and transl ates to the left (Fig. 5 4) . Right rotation of the superior vertebral body ' pulls ' the superior aspect of the head of the left rib forward at the costovertebral joint i nducing anterior rotat ion of the neck of the left rib (superior glide at the left costotransverse j oint), and ' push es ' the superior aspect of the head of the righ t rib backward, i nduc ing posterior rotation of the neck of the right rib (inferior glide at the right costotransverse joint) . In the vertebrochondral region, the rel ative glide at the costotransverse j oint is posteromediosuperior

Figure 52.

The costocarti lage of the left s i x t h rib was removed ( arrow poin t s to the inc i s ion) i n t h is seventeen year old.

Man u a l Therapy For The Thorax - -

45

Figure 53 . Note

the

i n ab i l i t y

of

the

mid thorax to rotate a n d s i de flex to the r i g ht dur i ng right rotation of the tru n k

(a rrow) .

Instab i l ity prevents the n or mal b i omechan ics of i ps i l at eral sideflex i o n/ro t a t i o n dur i n g rotation of the tru n k.

o n the l e ft and anterolatero infe r i o r on the r i gh t (Fi g .

55).

The l e ft

lateral t ra n s l a t i o n of t he superior vertebral body ' pushes ' the l eft rib posterolateral l y along the l i n e of the neck of the r i b and causes a postero l ateral tra n s latio n of the rib at the l eft costotransverse j o i n t . S i m ul taneo u s ly, the left lateral translation ' pu l l s ' the right rib antero m e d i a l l y along the l i n e of the neck of the rib and causes a n antero m e d i a l transl ation of t h e rib at the right costotransverse j o i n t .

An antero medi al!po sterolateral s l i d e of the ribs rela tive to the transverse processes to wh ich they a ttach is thought to o ccur dur ing a x i a l rotation . When the l i m i t of t h i s ho rizontal trans l at i on is reached, b o t h the

costoverte b r a l

and t h e costo transverse l igam e n t s are ten s e d .

Stab i l i t y o f t h e r i b s both anteriorly and poster i o r l y is required fo r the fol l ow i n g m o t i o n to occur. Further right rotation of t h e s u p e r i or v ertebra o c c u r s a s the superior vertebral body t i l t s to the r i gh t (gl ides s u p e r i o r l y a l o n g th e left s u p e r i o r costovertebral j o i n t a n d inferiorly along the r i g h t s u p e r i o r costoverteb ral j o in t) . This t i l t

46

-


Figure 54. The

and

osteokinematic

arthrokinematic m o t i o n p r o p o s e d to occur i n the verte brosternal region during right ro tation of the

trunk.

From

Lee5 . 6 with perm i s s i o n .

Figure 55. The

osteokinematic

and

arthrokinematic motion pro posed to occur in the verte broch o n d r a l

reg i o n

d u r i ng

right ro t a t i o n of the tru n k .

causes right sideftexion of the superior vertebra during right rota tion of the midthoracic segment (Fig. 5 6). At the zygapophyseal j oints, the left i nferior arti cular process of the superior vertebra glides superolaterally and the right inferior articular process glides inferomedial ly to facilitate right rotation and right sideflexi o n of the thoracic vertebra. The arthrokinematic motion of the joint surfaces supports the osteokinematic motion of the vertebrae and ribs. I n the vertebromanubrial region, C7 Tl and Tl -T2 follow the same pattern of motion coupling as the m idcervical spine when the -


-

47

Figure 56. the

limit

t ra n s l a t ion,

1111!! 111/ii!I!!!I!!!!!I!I!!i!!!,!I!!!I!lil !li!liii!!!iillll,; .

.

the head rotated. Rotation i s coupled with ipsilateral sideflexion superior vertebra. The two uncinate processes at C7-Tl m ay influ ence the d i rection of motion coupling here. During right rotation of the h ead/neck transverse process g lides i nferiorly relative to o n the (Fig. the o n the and superiorly relative to the

45) . Con siderable flexib il ity motion coupling apparent the lo\\'er thora x . Anatomical T11) the lower thoracic levels (T are designed t o rotate with m i n i mal restrictio n from the ribs. Passively, the T l 1 - 1 2 segment can be purely rotated about a verti restriction from the zygapophyscal j o ints the with cal ribs 57). Actively, coupled movement for rotat ion i n th is region can he ipsi l ateral s ideflexion or contralateral s i de flexion. The coronally oriented facets of t h e zygapophyseal j o i nts do dictate specific coupl i n g sidefiexi o n when induced. The absence of costotransverse j oint and the direct anterior attachment of the associated ribs facili tates this flex i b i l it y i n motion patterning at the e l eventh and twe l fth segments. Rl�spiration

The diaphragm is the most efficient respiratory m uscle. However, of con traction of d iaphragm can two different thorax . motion within

of

left

l a teral

s u perior

tebra sideflexes to the right a long the plane of the pseudo

' U ' j o i n t (analogous to the unco v erteb r a l m i dee rv i c a l

joint

of

fo rmed

the i n tervertebral d isc and the superior costoverteb ral j oi n t s . Lee5•6

permission .

48

-


Figure 5 7.

The osteokinem a tic and arthrokinematic motion pro posed to occur i n the thora columbar regio n d u r i n g right rotation of the trunk.

During i nspiration, the diaphragm descends and pulls the central tendon inferiorly through the fixed twelfth ribs and Ll to L3. When the extensibility of the abdominal wall is reached, the central ten don becomes stationary and further contraction of the diaphragm results in posterior rotation of the lower six ribs . This posterior rotation causes torsion of the cos tocartilage anteriorly. If the cos tochondral and chondrosternal joints are stable, the torsional forces are transmitted anteriorly to the sternum . As the ribs posteriorly rotate, the sternum is thrust in an anterosu perior direction thus increasing both the anteropos terior and verti cal dimensi ons of the intrathoracic cavity. During fu ll inspiration, this anterior thrust is also transferred to the manubri um. S i nce ribs one and two are s horter than ribs six and seve n , the anterior manubrial displacement is less than the anterior sternal displace ment. The manubriosternal symphysis accommodates this differ ence by bending in the sagittal plane (sternal flexion). Alternatively, the diaphragm may contract through a stationary central tendon. The central tendon is the fixed point and produces the same osteoki nematics as described above. There is no abdom inal distension with this breath ing pattern but rather lateral costal expansio n .


-

49

Expiration occurs passively du r in g relaxation of the diaphragm . Forced expiration requi res recruitment from the anterior and pos terior trunk musculature. Regardless of the pattern of respiration, the arthroldnematics of the costo transverse joints remain the same. During inspiration, the tubercles of ribs one to seven glide inferiorly, ribs eight to ten glide anterolateroinferiorly and ribs eleven and twelve remain stationary. During expiration, the tubercles of ribs one to seven glide superiorly, ribs eight to ten glide {X>Steromediosupe riorly and ribs eleven and twelve remain stationary. The arthrokinematics of the zygapophyseal joints is variable depending on the osteoldnematic motion which occurs . During quiet respiration, very little motion is required from the zygapophyseal joints.

Figure 58. D u r i n g elevation of the left arm

the

region

v e r te b r o m a n ub r i a l should

localized

p r o d u ce

concavi t y

on

side of the e lev a t i n g a r m .

a the

50

-


Unilateral elevation of the arm

During u n i l ateral elevation the arm has been noted that vertebromanubrial region rotates, l atera l l y bends and s l i gh t l y extends to the side of the elevating arm (Fig. 5 8 ) . The first t w o ribs the same side and anteriorly rotate on posteriorly rotate opposite. The arthroki n ematics at the costotransverse j oi n ts depend upon relative flexibil i ty between the thoracic verte b rae and the ribs. In a recent study by Stewart and Ju11 1 6 , the Fastrak 3-D Movement System was used measure movement of u n i l ateral e levatio n o f the The the thoracic spine confirmed that u n i lateral elevation of the arm did induce move ment i n the thoracic spine h owever, i t was noted that the pattern of sideflexion and rotatio n was variab l e . some asy m ptomatic side the elevating viduals sideflexion occurred the arm . Although asymptomatic at the time of testing, it i s fel t that this pattern indicates an articular restrictio n or m u scle i mbalance w hich when corrected results i n a return to the i ps i l ateral tion/sioeilexion

Manual Therapy For The Thorax - 5 1

3

CONDITIONS Accor d i n g to the medical m o deJ , con d i t i o n s

the t horax m a y

classified as visceral , m e t ab o l ic, i n fe ct i v e , n e o p l astic, a n d spond y l ogenic i n o r i g i n . MEDI CAL MODEL OF CLA S S IFICATION

Visceral As a p r i m ary cont act cl i n i c i a n , i t i s i mportant to recognize t h a t p r i m ar y i n trathoracic a n d i n traabom i n a l d i sorders can refer p a i n to the thorax . The p a i n ten ds to b e dull and deep a n d not i n fl u e n ce d h y p h y s i ca l activ i t i e s . R e s t m a y n o t afford rel i e f fro m the p a i n .

Metabolic Some m e t a bo l i c con d i t i o n s w h ich can e ffect the thorax i n cl u de a n ky l o s i n g spondy l i t i s , d i ffuse i d i op at h i c skeletal h yperosto s i s (DISH

Fig.

59),

rheumatoid

arthritis,

osteoporosis

(Fi g .

60) ,

fibro m y a l g i a , ochronosis, g o u t , t u bercu l o s i s and Page t ' s d i s e a s e . Although m a n u a l t h e r a p y i s n o t con t r a i n dicated w h e n these con d i tions a r e pre s e n t , t h e cl i n i ci a n m u s t m o d i fy t h e i n ten s i ty o f treat m e n t and possibly reduce the expected outcome.

Jnfection Bacter i a l a n d v i ral i n fe c t i o n s can occur w ith i n t h e skeletal compo n e n ts o f t h e t h o r a x . The patient u s u a l l y feel s syste m ical l y u n w e l l a n d t h e characte r i stics o f the p a i n behav i o u r s h o u l d a l e rt t h e cl i n i cian t o suspect a nonmechanical s o u rce o f p a i n . Ess e n ti a l l y, s y s temi c i n fl a m m atory and/or i nfective d i sorders affe ct i n g the t h o ra x

52

-


Figure 59. Ossification of the l o ngitudi nal

l iga m e n t s

of t h e

spine

occurs w i t h d i ffuse i d iopathic skeletal hy perosto sis .

can be differentiated from traumatic inflammation (i .e. sprain) by the lack of trauma in the h istory, the inconsistent response of the j o int to mechanical stress and rest as wel l as the lack of resolution with appropriate therapy over a short period of time. The experi enced clinician will quickly recognize the pattern o f response to therapy which deviates from the norm and question the etiology at this point. Subsequent investigation is then ind icated . Neoplastic

Both benign and malignant tumours can occur in the skeletal components of the thorax. Secondary metastases are common from the lung and breast and a past history of carcinoma should alert the clinician to this possibility. Spondylogenic

Spondylosis includes any dysfunct ion of the muscul oskeletal sys tem secondary to maj or or m inor trauma. Degenerative changes are i ncluded h ere .


-

53

Figure 60. The

typ i ca l p o s t u re of a patient with advanced osteo porosi s .

Scoliosis is a complex, multifactorial problem of both known and unknown causes (Fig. 61). It may be congenital or acquired; from disease or i nj ury. It has long been recognized 17 that idiopathic sco liosis involves muscle imbalance. Henry Kendall (1930) noted that "The muscl e weakness was almost always found in the lateral abdom inals, anterior abdominals, pelvic, hip and leg muscles. This weakness caused the body to deviate from ei ther the l ateral median plane or the anterior-pos terior median plane, causing the patient to compens ate for the deviation by substituting other m uscles in order to

54

-


Figure 61 . This

patient

has

a

ma rked

thoracolumbar scol iosis sec ondary to p o l i o m y e l i tis .

maintain e q u i l i b r ium In doing the substituting, · the patient i nvariably develops muscles which cause lateral rotatory movements and it is easy to see why we have lateral curvature with rotation." 17 .

However, even the most compl iant patient a n d d i l igent therapist can not prevent the progression of some scoliotic curves

with

exercise.

Current re search on the et iology o f idiopathic sco l iosis h a s revealed a possible centra l process i ng or neural componen t 1 8, 1 9 . The reader is referred to Kend a l l 1 7 for the ev aluation and treatment of muscle i mba l ances of t h e trunk a n d l ower extre m ities a n d to t h e refe renced m ateri ai fo r further information on the neural basis of idiopathic sco liosis.

Man u a l Therapy

The Thorax

MANUAL THERAPY MODEL OF CLASSIFICATION usefu l for of classification Although medical classifications \vhich follow etiology of standing mechan ical model based o n m ob i l ity and stab i l ity are more useful for the manual therapist. In keeping with this mode l , disorders w i th i n the thorax can be classified into three groups, each of which describes the obj ective findings noted on m ob i l ity testing and appropriate They include : gests 1 . Hypomob il ity w i th o r without pain 2. Hypermobi lity with o r without pain 3 . Normal mobil ity with

This classification does not provide a specific an atom ical nor phys iological cause for the aberrant mob i lity noted, however, since manual therapy techn iques are specific to restoring m ovement patterns, for cause is not evaluation procedures is The a i m e ffecting art i c u l ar, m y o fas c i a l , w h i ch Treatment can then be modified to e ither mob i l ize or stabilize the appropriate system . If the biomechanics are restored and if the underlying etiology i s biomechanical in nature, symptomatic and obj ective im provement fol lows . The principles upon wh ich treatment i s b ased fol l ow those of the body 's natural healing process. One of the goals of therapy i s to facilitate the natural process by preventing or reversing the factors whi ch tend to retard recovery. Long \vhen living were unicel death of cell meant death of the organism . With the evolution of m u l ticel l u l ar organ i s m s , c a m e the process of repair fol l o w i n g i nj ury. Subsequently, this repair process was perfected such that complete possible after am putation. Lizards and regeneration of a l i m b retained this capab i l i ty today. Unfortunately, newts lution complex forms ( i . e . mammal) has at the expense of such total regenerative abi l ities. The cardiac mus cle i n man does not regenerate fol l owing infarction, neural tissue does not regenerate fol l owing cellular death, skin does not regeni nj ury and amputated erate ful l not back. With few exceptions, to i nj ury repair rather regeneration .

56 - Manual

Thorax

Repair occurs by fibrous pro l i feration regardless of w hich tissue h as been damaged, The process can be d i v i ded into three substrate, fibrobl astic and m aturation. Treatment varies according to the stage o f tissue repai r. HEALING PROCESS Substrate phase

The substrate phase extends the time of i nj ury the fourth t o sixth and i s characterized the response, inflammatory reaction prepares the wound for subsequent healing by removi ng necrotic t i ssue and b acteria, At the same time, fibroblasts to wound The wound is weak this time it is the action fibrin, has very low breaking strength, wh ich holds the wound edges together. Fibrobla stic phase

The fibroblast i c phase l asts up to fou r to ten weeks post t rauma 20 , Manual t herapy has its greatest influence during this t i m e when the s y n th e s i ze p ro l i ferat i n g fib r o b lasts b e g i n m ucopo l y saccharides and glyeo proteins, Fibrobl asts repai r th e wounded t issue b y replacing i t w i t h fibrous tissue. Tropocol lagen i s secreted from the fibroblasts and quickly aggregates into col l aThe orientation the fibres can be i nfluence d gen mechan ical forces t h e wound s i te 2 0 , tensile strength the wound at this time is proportional to the quantity of COl l agen pre sent as opposed to crossl i nking between the co l l agen fibres, Matm"ation phase

There is n o sharp demarcati o n between the end of the fibrobl astic maturation phase, quan t i ty of phase the begin n i ng of between the t h i rd and col lagen within wound remains fourth weeks a lthough the wound conti nues to gain i n tensi l e strength. T h i s strength gai n i s due t o crosslinking a n d remode l l ing to give stronger \veave, The q uant ity of the l agen l agen equi librium, however, the organ izati o n u n dergoing change . This process of remo de l l i n g may requ ue s i x to twelve m o n th s for completion20 .

Man u al Therapy For The Thorax

-

57

C l i n i c a l application to tre a tment Scar t i s s u e can create p a i n an d d i s ab i l i t y w i t h i n the m u s c u l o s k e l e t a l s y stem depen d i n g o n how t h e repai r e d t i s s u e d i ffers fro m t h a t i t replace s . Essent i al ly, t h e repa i r process restores the structure with l i t t l e regard to fu ncti o n . For exa m p l e , col l agen is n o n - c o n tract i l e a n d w h e n i t rep a i rs a torn m us c l e , b o th the contract i l i ty a n d extensib i l i t y of t h e m u s c l e w i l l be effected . The a i m o f treatme n t , therefo r e , m u s t b e t o c o n t r o l a n d to g u i d e t h e r e p a i r process such that optim a l structure and functi o n are restore d . In t h e substrate and the e a r l y fibrob l a s t i c stage, v igorous e x e r c i s e program s o r aggres s i v e passive m o b i l izations are contra- i n d i cated s ince t h e r e i s m i n im a l cross l i n k i n g o f co l l agen fibres . Gentle p a s s i v e m ob i l i za t i o n s and exercises w i t h i n the p a i n free r a n g e of m o t i o n w i l l fac i l i tate the proper orientation of co l l agen depo s i t i o n at the w o u n d s i t e . T h e p a t i e n t w i l l find t h a t t h e b e s t rest i n g posi t i o n for acute thoracic p a i n i s s e m i -s i t t i n g . S up i n e l y i ng o n a h ard surface forces t h e t h o r a x i nto an extended posture w h i l e s i d e l y i n g often i nduces s i de ft ex i o n and r ot at ion . O rga n i ze d , restrictive a d h e s i o n s can develop d u r i n g t h e m at u r a t i o n p h a s e o f t i s s u e repai r if t h e r a n g e of m o t i o n i s n o t r e s t o r e d w i t h i n t h e fibrob l a s t i c p h a s e . W h i l e t h e structure m ay b e restored, fu n c tion m a y be adverse l y effected b y the adhes i o n . More v i go r o u s mob i l i za t i o n t e c h n i q u e s and frequent e x e r c i s e s at h o m e w i l l b e requ ired to faci l i tate a r e t u r n of the range of m o t i o n .

Left a l o n e , w o u n d e d t i s s u e w i l l repa i r. T h e e fficacy of t h e rep a i r process depen d s o n h o w w e l l t h e repl acement t i s s u e restores t h e t i s s u e ' s o r i g i n a l fu n c t i o n . T h e r o l e of therapy i s to g u i d e t h e depo s i t i o n and r e m o de l l i n g of the scar at e ach stage of rep a i r s u c h t h at the res u l ta n t structure w i l l subserve the t i s s u e 's fun ct i o n . To s u c cessfu l l y ach ieve t h i s go a l , i t i s param o u n t that the p a t i e n t b e c o m e i nv o l v e d i n t h e i r o w n r e h ab i l i t a t i o n through home e x e r c i s e pro grams w h i c h fo l l o w the p r i n c i p l es of tissue h e a l i n g .


Manual Therapy

The Thorax

AS SES SMENT When cons istent approach assessment of mechanical dysfunction the thorax this section is to outline the basic subj ective and obj ective exami nation .

Thorax

60 -

---

Ta ble I.

--........ --

Subj ective examination

Age :

Name :

Dr:

Curre n t H istory (mode of onset) :

Past Treatment:

Past History :

PAIN/DYSAESTHESIA

Location :

Rel iev ing/Aggravat i n g Activities:

Special Questions:

Distal paraesthesia, Bowel/b l adder Effect of sustain ed SLUMP n eck flexion

S LE E P

Su rfacelPos i t io n : Night wakeni n g :

Status i n a . m . :

GENERAL INFORMATION

Occupation/sport/hobbies: General Health : Resul ts of adj u n ctive tests :

Medicatio n :


-

61

SUBJECTIVE EXAM I NAT I O N T h e a n s w e r s to the s u bj ective e x a m i n a t i o n i n d icate t h e n a t u r e , i r r i tab i l i t y and seve r i t y o f t h e prese n t i n g probl e m . Mode o f onset Was t h e onset o f s y m p to m s s u d d e n o r i n s i d i ou s ? Was there a n e l e m e n t o f traum a ? I f s o , w a s there a m aj o r traum a t i c e v e n t o v e r a short p e r i o d of t i m e , such as a m o t o r v e h i c l e accident, o r was there a s e r i e s o f m i n o r traumatic events over a l o n g p e r i o d of t im e . I s the p at i e n t p r e s e n t i n g d u r i n g t h e substrate, fibrob l a s t i c or m at u r a t i o n phase o f h e a l i n g ? I s t h i s t h e first e p i sode req u i r i ng treatme n t o r i s t h i s a r e c u r r i n g proble m ? Pain/ dysaesthesia Where i s t h e p a i n a nd/or d y s aesthes i a ? I s it l o c a l ized or d i ffu s e ? Where d o e s i t r a d iate t o and c a n i t 's q u a l ity b e described? I f t h e r e i s symptom refe rral , does i t tend to refe r around t h e chest o r through t h e chest? W h a t activ i t i e s , i f a n y, aggravate t h e s y m p t o m s ? H o w l o n g does i t t a k e for t h i s act i v i t y to produce s y m p t o m s ? W h i ch act i v i ti e s ( i ncl u d i n g how m u ch) provide rel i ef? Sleep Are t h e symptoms i nterfe r i n g w i t h sleep? W h a t kind o f b e d i s b e i n g s l ep t i n and w h a t pos i t i o n i s m o s t frequently adopted? D o e s rest p r o v i d e r e l ief? Occupation/leisure activities/sports What l e v e l o f ph y s i c a l a c t i v i t y does the patient c o n s i d e r t h e i r n o r m a l a n d e s se n t i a l for return to fu l l funct i o n ? W h a t a r e t h e p at i e n t ' s goals fro m therap y ? General i n fo rmati on How i s the patient's general h e a l t h ? I s any m e d i ca t i o n being t aken for t h i s o r a n y other con d i t i o n ? W h at are t h e results of any a dj unc t i v e d i ag n o s t i c tests ( i . e . X-rays, CT scan , M R I , l aboratory tests)?

For The Thorax

62 - Ma n u a l

Table II. Obj e ctive examination

Postural Habitual movement tests

Forward and ba ckward b ending L a tera l Axial rotation Respiration Com bined movement testing Un ilatera l eleva tion of the arm Articular

ctive/passive mobility tests

osteokinematic

Forward Backward bending L a tera l bending Rota tion R espira tion Passive mobility tests of arthrokinematic function Zygapophysea l joints Costotrans verse joints Mediolatera l translation Pass ive

tests of arthrokinetic function

Vertica l (traction/compression) A nterior translation - spinal Posterior transla tion - spina l Transverse rotation - spina l A n terior translation - posterior costa l Inferior

- posterior costa l

A n terior/Posterior translation - anterior cos ta l Superior/Inferior translation - anterior costa l Mediola tera l translation Muscle function Nerve function Adj unctive

Man u a l Therapy

The Thorax

Postural Analysis

three cardinal hody planes the thorax Deviation associated with syrnptoms. necessari mon mechanical dysfunction presents with postural deviation and therefore, postural analysis i n relation to the s agittal , coronal and transverse body p l anes is essential. plane, a through the l ine should of the cervical vertebrae, the m e atus, the nal humeral j o i nt, s lightly anterior to the bodies of the thoracic verte brae transecting the vertebrae at the thoraco l umbar j unction, the bodies of the lumbar vertebrae, the sacral promontory, slightly posterior hip j oint and anterior talocrural naviculo-ca Icaneo-cubo i d I n the coronal plane, the clavicles should be horizontal, the manubrium and sternum vertical and the scapulae should rest such that the medial border is para l l e l to the thoracic spine with the infe appro x i m ated chest wall . Deviations of rior ous processes are com m o n often The restin g of the back should be noted . o f the Habitua l moveme n t tests

These examine the habitual movement patterns of m otion as and trunk. quantity quality of avai the presence/location of evoked symptoms are noted. The results of these tests alone are not sufficient to diagnose a local dysfunc tion. They are used as screening tests to localize further mobility testing. Forward

ba ckward

With the patient standing o r sitting h e/she is i nstructed to forward bend the head/trunk and the q uantity and symmetry of m o t io n i s 62, 63). Neither rotation sideftexion observed forward and if req uires further cific testing. Backward bending vertebromanubrial region i s achieved b y asking the patient to elevate their arms b i l at eral l y (Fig. 64). When exam i ning b ackward bending of the verte brosternal and vertebrochondral regions of the thorax (Fig . 65), it n ote that the is critical being i s actually ward Some m ovement m odificat i o n m a y b e m otion performed ensure

64

-


Figure 62. H a b i t u a l movem e n t testing forward bending of the h e a d .

Figure 63 . H a b i t u a l movement tes ting forward b e n d i n g of the trunk.

Figure 64. H a b i tual movemen t tes t i n g backward bending of the ver tebro m anubrial region occurs d u ring bila teral elevation of the a r m s .

Figure 65. Habitual movement testing b a c k w a rd

bending

of

the

tru n k .

Lateral bending (Figs. 66, 67, 68)

With the patient standing or s i tting he/she i s instruct ed to l ateral l y bend the head/tr u n k to e i ther s i d e . The ab i l i t y of the t h o r ax to p r o d u c e a s m o o th r e g i o n a l c u r v e i s n o t e d . A fl at r e g i o n o r a k i n k i n t h e

Manual Th erapy For The Thorax

-

65

Figure 66. Habitu a l move ment testing l ateral ben d i n g of the h e a d .

Figure 67. H a b i t u a l movement testing

-

lateral bending of the t ru n k . Note the fl e x i b i l ity of t h e 6 y ear o l d chi l d .

Figure 68. H a b i t u a l movement test i n g l a t e ra l bend ing of the tru n k . No te the rigid i ty o f the 7 1 y ear old adu l t .

Figure 69. H a b i t u a l movem e n t tes t i n g rotat i o n of the tru n k should produce a smoo t h S cu rve.

c u r v e r e q u i re s fu r t h e r to determine the cause.

s p e c i fi c m o b i l i t y t e s t i n g

Axial rota tion (Figs. 69, 70, 71)

With the patient standing or sitting he/she is instructed to rotate the

66

-


Figure 70. H a b i t u a l movement t e s t i n g rotation of t h e tru n k . Note the

flexib i l i t y of the 6 year old

child.

Figure 71 . H a b i t u a l movement testing rotation of the tru n k . Note the rigid i t y

of the

71

y e a r old

adult.

Figure 72. Hab i t u a l movement testing respi ra t i o n .

Figure 73. H a b i t u a l movement tes t i ng respi r a t i o n .

head/trunk to either side. The ability of the thorax to produce a smooth regional S curve is noted. A lack of movement or a kink in the curve requi res further specific mobility testing to determine the cause . Respiration (Figs. 72, 73)

With the patient standing or sitting he/she is i nstructed to take a


-

67

deep breath in and a long breath out. Any asymmetry of chest expansion and release i s noted and when present requires further specific m o b i l ity the cause.

Combined movement Hypomobile j o i nts bined movements are tested. he/sh e is instructed t o :

clinical picture w h e n t h e patient standing or

1 . forward bend the h ead/trun k and then right l ateral bend the head/trun k .

2. forward b e n d the head/trunk .

and then left l ateral b e n d the

3 . backward bend head/tru n k .

and then right l ateral bend

4. backward bend the head/trun k and then left l ateral bend the head/trunk.

A n y restr i c t i o n to m o v e m e n t or k i n ks in the curve are n o t e d . The r e s p o n s e to t h e s e c o m b i n e d m ov e m e nt s c a n be charted o n t h e l e tter 1 . The fo rward/b ackward b e n d i ng com po n e n t o f t h e m o t i o n i s d e n o ted b a n d o f t h e I and the bending com p o n e n t b a n d . W h e n a n a b n or m m o v e m e n t p attern is p l ac e d on t h e ' abn orm a l pattern . For t h e I w h i c h m arl! when a z y g a po p h y s e a l restricted i n s u perior g l i d i n g t h e l e ft, a n a b n orm a l m o v e m e n t p a ttern w i l l b e detected o n for w ard b e n d i n g co m b ined w i t h r i g h t l ateral bendi n g . Th i s i s c harted b y p l ac i n g an X o v e r t h e r i g h t t o p h orizo n t a l b a n d o f t h e l etter I . The patient i s then i nstructed to : 4 . right l ateral h e ad/tru n k . 5 . l e ft l a tera l b e n d h e a d/tru n k .

a n d t h e n forward b e n d

a n d t h e n forw ard b e n d

6 . right l ateral b e n d the h e a d/tr u n k a n d t h e n backw ard b e n d t h e

h e a d/tr u n k .

68

-


7 . left lateral bend the head/tru nk and then b ackward bend the he ad/trunk. Any restriction to movement or kinks i n the curve are noted . The response to these combined movements can be charted on the let ter H. The forwardlbackward bending component of the motion is denoted by the vertical band of the H and the lateral bending com ponent by the horizontal band. When an abnormal movement pat tern is detected, an X is placed o n the ' arm ' of the H which mani fested the abnormal pattern . For example, when a zygapophyseal j oint is restricted in superior gl iding on the left, an abnorm a l move ment pattern will be detected on right lateral bending combined with forward bending. This is charted by placing an X over the right top vertical band of the letter H. A hypomobile j o i nt is consistent in that an abnormal movement pattern i s detected i n the same ' arm ' of the H and I tests . It does not matter which movement is induced first, lateral bending or for ward bending, the abnormal motion shows u p i n both . Hypermobile j oints are inconsistent in the pattern they present. An abnormal movement pattern may occur when forward bending occurs first but not when lateral bending is the initial motion . Unila tera l elevation of the arm

Unilateral elevation of the arm is useful i n evaluating the com bined movements of the vertebromanubrial region . The upper tho rax should rotate and sideflex to the side of the elevat ing arm and thus produce a very local ized C curve concave towards the elevat ing arm . The first two ribs should posteriorly rotate on the same side and anteriorly rotate on the opposite. Articular functi on

When a mobility abnormality is detected during the habitual move ment tests, further examination is required to determine the etiolo gy. The specific segmental tests of osteokinematic and arthrokine matic function are used to differentiate an intra-articular from a myofasci al cause for the abnormal motion noted . They include active physiological mobil ity tests, passive physiological mobility tests and passive accessory mobil ity tests. The active physio logical mobility tests exam ine the osteokinematics of a functional spinal and costal unit which includes two adj acent thoracic vertebrae, the two ribs which attach to these vertebrae and the manubrium/ster num. The passive physiological mobil ity tests prov ide further information on the end feel of motion. The passive accessory


-

69

Figure 74. Active

m ob i l i t y

o s t e o ki n e m a t i c

t e s ts fu n c t i o n

of

points of p a l p a t ion for T l -2.

-

Figure 75. Ac t i v e

mob i l i t y

tests

of

o steoki n em a t i c fu nct i o n - pal

p a t i o n for flexion of T l - 2 .

70

-


Figure 76. Act i v e

mobility

o s t e o k i nem a t i c

t e s ts fun c t i o n

of

po ints of p a l p a t i o n for TS -6.

-

mobility tests examine the arthrokinematic fu nction of the zygapophyseal joints, the costotransverse and costovertebral j o ints and help to differentiate the cause of the abnormal motion noted on the habitual movement tests. By correlating the findings from these tests, the therapist can determine if the abnorm al movement pattern is due to a hypomobile j oint or an outside influence (myofascial, neural). Further tests are required to detect a hypermobile or unsta ble joint. A ctive mobility tests of osteokinematic function Forward bending (Figs. 74, 75, 76, 77, 78, 79) . The fol lowing test is used to determ ine the osteoki nem atic function of two adj acent thoracic vertebrae during forward bending of the head/trunk. The transverse processes of two adj acent vertebrae are palpated with the index finger and thumb of both hands . The patient is i nstructed to forward bend the head/trunk and the quantity of motion as well as the sym metry of motion i s noted during flexion of the thoracic segment. Both index fingers should travel superiorly an equal dis tance . When interpreting the mobility findings , the position of the joint at the beginning of the test should be correlated w ith the sub sequent mobility noted, since alterations in j oint mob ility m ay merely be a reflection of an a ltered starting pos ition. To determ ine the position of the superior vertebra, the dorsoventral relationship of the transverse processes to the coronal body plane is noted and compared with the level above and below. If the left transverse process of the superior vertebra is more dorsal than the left trans verse process of the inferior vertebra then the segment is left rotat-

Manual Therapy For Th e Thorax - 7 1

Figure 77.

Active mob i l i ty tests of osteokinematic function - pal pation for flexion o f TS - 6 .

ed. If the left transverse process of the superior vertebra is less dor sal than the left transverse process of the inferior vertebra but more dorsal than the right transverse process of the superior vertebra, then the superior vertebra is relatively right rotated compared to the level below but left rotated when compared to the coronal body plane . Thi s is a typical compensatory pattern seen when a superior segment is derotating or unwinding a primary rotation at a lower level. The fol lowing test is used to determine the osteokinematic func tion of a rib rel at ive to the vertebra of the same n umber during for-

72

Figure 78. Act i v e

mobi lity

o s t eo k i n e m a t i c

tests fu n c t i o n

of -

points of pal pation for T9 - 1 0 .

Figure 79. Active

m o b i l i ty

tests

of

osteoki n e m a t i c fu nction - pal pation for flexion of T9- 1 0 .

-



-

73

Figure 80.

Active m o b i l i ty tests of osteoki n e m a t i c fu n c t i o n points of palpation for T l first rib .

Figure 81 .

Active m o b i l i t y tests of osteokinematic fu nction - pal pation for flexion of the first costotransverse j o i n t .

ward bending of the head/trunk (Figs . 80, 8 1 , 82, 83). The trans verse process is palpated with the thumb of one hand. The rib is palpated j ust lateral to the tubercle and m ed ial to the angle with the thumb of the other hand. The index finger of this hand rests along the shaft o f the rib . The patient i s instructed to forward bend the head/trunk and the relative motion between the transverse process and the rib is noted. In the mobile thorax, the rib should anteriorly rotate and the tuber-

74

-


Figure 82 . Active

m ob i l i ty

oste o k i n e m a t i c

tests

of

fu n c t i o n

points of palpatio n fo r T9

-

ninth rib.

Figure 83 . Active

mobility

tests

of

osteo k i n e m a t i c fu nction - p a l pation for fl e x ion of t h e n i n t h costotransverse j oi n t .

cle of the rib travel fu rther su p eriorly than the transverse process. In the stiffer thorax, the rib should anteriorly rotate and the tuber cle of the rib stop before ful l thoracic flexion is achieved such that the transverse process travels further superiorly than the rib When the relative mobility between the thoracic vertebra and the rib is the same, no motion is p al pated between the vertebra and the r ib during forward bending. To determine the patient's normal move ment pattern it is cr i tical to evaluate levels above, below and con tralateral to t h e tested segment.

Manu a l Therapy For The Thorax

-

75

Figure 84. Active

m ob i l i t y

tests

of

osteokinem a t i c function - pal pation for exte n s i o n o f T9- 1 O . Figure 85. Active

m ob i l i t y

tests

of

osteo k i n e m a t i c fu nction - p a l p a t i o n fo r extension o f T l -2 .

Backward bending. The fo l lowing test is used to determ i n e the osteo k i n e m a t i c function of two adj acent thoracic v ertebrae during b ackw ard bending of the h e ad/trunk. The transverse processes of two adj acent vertebrae are palpated with t h e index finger and thumb of both h ands (Figs . 74,

76, 78).

The patient i s i nstructed to

b ackw ard bend the trunk and the quan t i ty of m o t i o n as w e l l as the s y m m etry of motion i s noted d u r i ng extens i o n of the thoracic seg ment (Fi g .

8 4)

.

B ackward bending of the upper thorax i s achi eved

b y aski n g the patient to elev ate both arms (Fi g .

85).

Both index fin

gers should travel inferiorly an equal d i stance . When i nterpret i n g t h e m o b i l i ty findings, the position of the j oi nt at the beg i n n ing of the test should be correlated with the subsequent mobility noted, since a l terations i n j oi n t m o b i l ity may merely be a reflect i o n of a n altered starting pos i t i o n . The fo l l ow i ng test i s used to determ ine the osteo ki nem at i c fu nc tion of a rib and the vertebra of the same n umber during b ackward bending of the h ead/tru n k . The transverse process i s palp ated w i t h t h e t h u m b o f one h a n d . T h e r ib is palpated j ust l ateral to the tuber cl e and medial to the angle w i t h the thumb of the other hand (Figs .

80, 82).

The index finger of t h i s hand rests along t h e s haft of t h e

r i b . T h e p a t i e n t i s i n stru cted to backward b e n d the trunk and the relative m o t i o n between the transverse process and the rib i s noted (Fi g .

8 6)

.

Backward bending of the upper thorax i s ach ieved b y

ask i n g t h e p a t i e n t to elevate b o t h a r m s (Fi g .

87).

76

-


Figure 86. Active

mob i l i t y

tests

of

osteo k i nematic function - p a l p a t i o n for extension

of t h e

n i n t h costotransverse j o i n t .

Figure 8 7. Active

mob i l ity

tests

osteo k i nematic fu nction pation

for e x t e n s i o n

-

of

pal

of the

first costotra nsverse j o i n t .

In the mobile th orax , the rib should posteri orly rotate and the tubercle of the rib travel fu rther i nferiorly than the transverse proces s . I n the stiffer thorax, the rib should posteriorly rotate and the tubercle of the rib stop before fu ll thoracic exte n s i o n is achieved such that the transverse process travels further inferi orly than the rib . When the relative mobil ity between the thoracic ver tebra and the rib i s the same, no motion is palpated between the vertebra and the rib during backward bending. To dete r m i n e the patient 's normal movement pattern i t i s critical to evaluate lev e l s a b o v e , b e l o w a n d contralateral to t h e tested segm ent. I n the upper thorax, the stiff pattern is normal both i n the m o b i l e and stiff tho rax.

Latera l bending. T h e fo llowing t e s t i s u s e d to determ i n e t h e osteokinematic function o f t w o adj acent thoracic vertebrae d u r i n g lateral b e n d i n g o f t h e head/trunk. T h e transverse processes of two adj acent ve rtebrae are palpated with the index finger and thumb of both hands (Figs.

74, 76, 78) .

The patient is i n structed to lateral

bend the head/trunk and the quantity and d i rection of motion is noted. I n the upper thorax , the superior thoracic vertebra shou l d l ateral bend a n d rotate t o the same s i d e such t h a t t h e superior trans verse process on the side of the concav ity moves dorsa l l y and i nfe riorly (Fig.

88) .

Below T3 , the superior thoracic vertebra sho uld

l ateral bend i n the pu re coronal plane until the l ast few degrees of movement. At this p o i n t , t h e superi o r vertebra shou l d rotate c o n tral ateral to the di rection of the l ateral bend . T h e s u peri o r trans-


-

77

Figure 88. A c t ive

m ob i l i t y

tests

of

osteo k i n e m a t i c function - p a l p a t i o n fo r r i g h t l a teral be nd i n g of Tl-2.

Figure 89. Active

m ob i l i t y

tests

of

osteo k i n e m a t i c function - p a l pation for r i g h t l a teral b e n d ing

of

t h e fi f t h

verse j o i n t .

verse process o n the side of the concavity should move inferiorly and ventrally. Below T7 , the direction of motion coupling depends o n the apex of the curve (Chapter 2). The direction of rotation should be congru ent with the levels above and bel ow. The following test is used to determine the osteoki nematic func tion of a rib and the vertebra of the same number during lateral bending of the head/trunk. The transverse process is palpated with the thumb of one hand. The rib is palpated j ust lateral to the tuber cle and medial to the angle with the thumb of the other hand (Figs . 80, 82) . The mdex finger of this hand rests along the shaft of the rib. The patient is instructed to lateral bend the head/trunk and the relative m otion between the transverse process and the rib is noted (Fig. 89) . Rota tion. The following test is used to determine the osteokine

matic function of two adj acent thoraci c vertebrae during rotation of the head/trunk. The transverse processes of two adj acent verte brae are palpated with the index finger and thumb of both hands (Figs . 74, 76, 78) . The patient is instructed to rotate the head/trunk and the quantity and directi on of motion is noted. In the upper tho rax (vertebrom anubrial) and the vertebrosternal regions, the supe rior thoracic vertebra should l ateral bend and rotate to the same side such that the superior transverse process on the side of the

costotrans

78

-


Figure 90.

Active mob i l i ty tests of osteokinema tic fu nction - pal pation for right rotation of T5 -6. Figure 91 .

Active mobility tests of osteokinematic fu nction - pal pation for right rotation of the fift h costotransverse j oint.

concavity moves dorsally and inferiorly (Fig. 9 0) Below T7, the direction of the conj unct lateral bend is variable. It may be either to the same side as the rotation or to the opposite side. .

The fol lowing test is used to determi ne the osteokinematic func tion of a rib and the vertebra of the same number during rotation of the head/trunk. The transverse process is palpated with the thumb of one hand. The rib is palpated j ust lateral to the tubercle and medial to the angle w ith the thumb of the other hand (Figs . 80, 82) . The index fi nger of this hand rests along the s haft of the rib. The patient is instructed to rotate the head/trunk and the relative motion between the transverse process and the rib is noted (Fig. 91). Respiration . The fol lowing test is used to determine the osteokine matic function of a rib relative to the vertebra of the same number during respiration. The transverse process is palpated with the thumb of one hand. The rib is palpated j ust lateral to the tubercle and medial to the angle with the thumb of the other hand (Figs. 80, 82) . The index fi nger of this hand rests along the shaft of the rib . The p atient is i nstructed t o breathe i n fully a n d the rel ative motion between the transverse process and the rib is noted. The patient is then instructed to breathe out fully and the relative motion between the transverse process and the rib is noted (Fig . 92).

Ma nual Therapy For The Thorax

-

79

Figure 92. Active

m ob i l i t y

tests

of

osteoki nematic fu nct i o n - p a l pat i o n for respira tion o f the n in th costotransverse j o i n t .

Passive physiologica l mobility tests Passive p h y s i o l o g i ca l m o b i l i t y tests are used to confirm the level of the abnorm a l movement pa t t e rn noted on active m ob i l i t y test i n g . In add i t i o n , the q u a l i t y o f the end fee l of motio n is determined during these tests . Wi th the patient s i t t i n g and the arms crossed to the opposite s h o u l ders for t h e verteb ro manubrial and vertebrosternal reg i o n s , t h e transverse processes o f the superior vertebra a r e palpated . In t h e thoraco l umbar reg i o n , the i n terspinous space i s palpate d . The head/trunk is pass i v e l y flexed, extended, l aterall y flexed and rotat ed. The q u a n t i t y of motion and the qual ity o f the end fee l i s noted and co m p ared to the levels above and below.

80

-


Figure 93 .

Passive m ob i l i t y tests of arthroki n e m a t i c function points of palpation for superi or glide of the right T4-5 zygapophyseal j o i n t .

Figure 94.

Passive m ob i l i t y tests o f arthro k i n e m a t i c fu nction superior glide of the right T45 zygapophyseaJ j oint .

Passive mobility tests of arthrokinematic function Zygapophyseal joints - Eg. T4 -5 to test the superior glide of the righ t zygapophysea l joint (Figs. 93, 94). This test is used to deter m ine the ab i lity of the right inferior articular process of T4 to glide superiorly relative to the superior articular process of T5 . With the patient prone and the thoracic spine i n neutral, the i nferior aspect of the left transverse process of T5 is palpated with the left thumb. The right thumb palpates the inferior aspect of the right transverse


-

81

Figure 95. Passive

tests

mobility

arthrokinematic

fu n c t i o n

of -

p o i n t s of palpation fo r infe r i or

glide

of the

right

zygapophysea\ j o i n t

T4-5

.

Figure 96. Pass i v e

m ob i l i t y

a r t h ro k i n e m a t i c

t es ts

funct i o n

of -

i nferior g l i d e of t h e r i g h t T45 zygapophyseal j o i n t .

process o f T4 . The left thumb fixes T5 and a superoanterior gl ide is applied to T4 with the right thumb. The quantity and end feel of motion is noted and compared to the l e v els above and below. This technique can be used for all thoracic segments. Zygapophyseal joints - Eg. T4-5 to test the inferior glide of the righ t zygapophysea l joint (Figs. 95, 96) . This test is used to deter mine the ability of the right inferior articular process of T4 to gl ide inferiorly relative to the superior articular process of T5 . With the

82

-


Figure 97. Passive

m ob i l i ty

a r t h r ok i ne m a t i c

tests

fu n c t i o n

of -

poin t s of palpation for i n feri or glide of the right fifth cos totra nsverse j o i n t .

Figure 98. Passive

m o b i l i ty

arthro k i n e m a t i c

tests

fu n c t i o n

of -

i nferior gl ide of the right fifth costotransverse j o i n t .

patient prone and the thoracic spine in neutral , the inferior aspect of the transverse process of T5 is palpated with the left thumb . The right thumb palpates the superior aspect of the right transverse process of T4. The left thumb fixes T5 and an inferior glide is appl ied to T4 with the right thumb . The quantity and end feel of motion i s noted and compared to the levels above and bel ow. This technique can be used for all thoracic segments. Costotransverse joints Eg. To test the inferior glide of the right fifth rib at the costotransverse joint (Figs. 97, 98). This test is used -


Figure 99. Passive

mobility

arthrok inematic The

d i rection

t r a n s verse

tests

of

fu n c t i o n

of

the

joint

glide

a n t er o l a t e r o i nfe r i o r

is

at

l evel o f t he n i n t h rib

-

cos to the

( a rrow ) .

Figure 1 00 . Passive

mobility

a r t h r o k i ne m a t i c i n fe r i o r

glide

t e s ts

fu n c t i o n

of

the

-

right

n i n t h costo t r a n sverse j o i n t .

to determ ine the ab i l ity of the right fifth rib to glide inferiorly rel ative to the transverse process of T5 . With the patient prone and the thoracic spine in neutral, the inferior aspect of the right transverse process of T5 is palpated with the left thumb. The right thumb pal pates the superior aspect of the right fifth rib j ust lateral to the tubercle . The left thumb fi xes T5 and an i nferior glide (allowing the conj unct posterior roll to occur) is appl ied to the fifth rib with the right thum b . The quantity and end feel of motion is noted and compared to the levels above and below.

of



mobil ity


tests

of

(b lack box

function

p o i nts of p a J p a t i o n

and wh i t e arrow ) for i n ferior

glIde of the right first costo transverse j o i n t .

Figure 1 02. Passive

m o b i l i ty


tests

fu n c t i o n

of -

inferior glide of the right first costo t r a n sverse j o i n t .


-

85

Figure 103 . Passive

mob i l ity

art hrok i n e m a t i c

of

tests

function

-

points of palpation for superi

or gl ide of the right fifth cos totransverse joint.

Figure 104. Passive

mob i l i t y

a r t h r o k i ne m a t i c

superior

g l ide

te sts

fu n c tion of the

Cos totrans verse join ts - Eg. To test the inferior glide of the right first rib a t the costotransverse join t (Figs. 1 01, 1 02). This test i s

-

right

fi fth cos totransverse joint.

Between T7 and TiD the orientation of the costotransverse j oint changes such that the direction of the g lide is anterolatero inferior. The position of the right hand is modified to facilitate this change in j o i nt direction such that the index finger of the right hand l ies along the shaft of the rib and assists i n gliding th e rib in an antero latero inferi or direction (Figs . 99 , 1 00) .

of



mo b i l i ty

a r t h ro ki n e m a t i c The

tests

fu n c t i o n

of -

d i rection of the costo

transverse j o i n t g l i d e is pos teromed iosuperior at the level

of

the

n int h

rib

and

is

ach ieved b y gli d i n g the trans

verse process of T9 a ntero l atero i n ferior

(a rrow) .

used to determine the ability of the right first rib to g l ide inferior ly relative to the transverse process of T l . The patient lies supine with the head and neck comfortably supported on a pillow. Wi th the lateral aspect of the MCP of the index finger of the left hand, the superior aspect of the left transverse process of T l is palpated and fixed. With the lateral aspect of the MCP of the index finger of the right hand, the superior aspect of the right first rib is palpated j ust lateral to the costotransverse j o i nt. The left hand fixes Tl and an inferoanterior glide (allowing the conj unct posterior rotation to occur) is applied. The quantity and end feel of motion is noted and compared to the opposite side. Cos totrans verse joints - Eg. To test the superior glide of the right fifth rib a t the costotransverse join t (Figs. 1 03, 1 04) . This test is

used to determ ine the ab il ity of the right fifth rib to glide superior ly relative to the transverse process of T5 . With the patient prone and the thoracic spine i n neutral , the superior aspect of the trans verse process of T5 is palpated with the right thumb . The left thumb palpates the inferior aspect of the right fifth rib j ust lateral to the tubercle. The right thumb fixes T5 and a superior glide (allowing the conj unct anterior rol l to occur) is applied to the fifth rib with the left thumb . The quantity and end feel of motion is noted and compared to the levels above and below. Between T7 and T 1 D the orientat ion of the costotransverse j o i nt changes such that the glide is posterom ediosuperior. The position of the right hand is modified to facil itate this change in joint direc tion such that the index finger of the right hand l ies along the shaft

Manual Therapy For The Tho rax

-

87


mob i l i t y


tests

fu nc t i o n

posteromed iosuperior

of -

glide

o f t h e r i g h t n i n t h costotrans verse j o i n t .

of the rib. The right hand fixes the rib and the transverse process is glided anterolateroi nferior thus producing a relative posteromedio superior gl ide of the rib at the costotransverse joint (Figs. 1 0 5 , 1 06) . Costotransverse joints - Eg. To test the superior glide of the righ t first rib a t th e costotransverse joint (Figs. 1 0 7, 1 08) .

Thi s test i s used to determine t h e ab il ity of t h e right fi r s t r i b to glide superior iy relative to the transverse process of Tl . The patient lies supine with the head and neck comfortably supported on a pillow. The superior aspect of the right transverse process of T1 is palpated with the right thumb . The index and middle fingers of the right hand palpate the inferior aspect of the right first rib . The right index and m i ddle fingers fix the first rib and a postero inferior glide (allowing the conj unct anterior rotation to occur) is applied to the transverse process of T 1 thus producing a relative superior glide of the first rib at the costotransverse joint. The quantity and end feel of motion is noted and compared to the opposite side.

Mediolatera l transla tion - Eg. To test th e ability of TS and the right and left sixth ribs to glide transversely to the right on the

T6 ver

tebra (Figs. 1 09, 11 0) . This motion is necessary for full left rota tion/l eft si deftexion to occur. I t requires the left sixth rib to glide anteromedially relative to the left transverse process of T6 and the right sixth rib to glide posterolaterall y relative to the right trans verse process of T6. The patient is sitting with the arms crossed to opposite shoulders . With the right hand/arm, palpate the thorax such that the fifth finger of the right hand l ies along the sixth rib . Wi th the left hand, fix the transverse processes of T6. With the

88

-


Figure 1 0 7.

Passive m o b i l i t y tests of arthrok i n e m a t i c function points of palpation (two white arrows) for superior glide of the right first costotransverse j oi n t .

Figure 1 08.

Passive mobility tests of arthrok i n e m a t i c fu n c t i o n superior glide of the right first costotransverse j o i n t .

right hand/arm translate the T5 vertebra and the ribs PURELY to the right in the transverse plane. The quantity and i n particular the endfeel of motion is noted and compared to the levels above and below. Passive stability tests of arthrokinetic function 21 Vertical (traction/compression) . Th is test stresses the anatom ical structures which resist vertical forces . A positive response is the


-

89

Figure 1 09. P a s s i ve

mobility

arthrokinematic p oint s

of

tests

of

fu n c t i o n

-

p a l pation for righ t

mediolateral tran s l a t i on g l i d e of T 5 a n d the s ix t h r i b s .

Figure 1 1 0 .

mo b i l i t y t e s t s of arth roki n e m a t i c fu n c t i o n

Passive

-

right m e d i o l a teral tra n s l a t ion test of T5 a n d the sixth r i b s .

reproduction of the patient's pain as opposed to a sense of increased osteoarticu lar motion. The patient is sitting with the arms crossed to opposite shoulders such that the arm closest to the chest grasps the scapula. The other arm rests on top of the contralateral shoulder. The thoracic spine is i n neutral. Traction i s applied to the middle and lower thorax by applying a vertical force through the patient's crossed arms (Fig. 1 1 1) . Traction is applied to the upper thorax b y app l y i n g a vertical force through the cran ium .

90

Figure 1 1 1 . Passive

s t a b i l i ty

tests

of

a rt h rokinetic function - trac tion of the m iddle and lower thorax.

Figure 112. Passive

stab i l i t y

tests

of

art hrokinetic fu nction - com pres s i o n of the m iddle lower thorax.

and

-


Manu a l Therapy For The Thorax

-

91


stability

tests

of

arthro k inetic fu nction - po i n ts of

p a l p a t i on

fo r

anterior

translation (spinal).

Figure 1 1 4. Passive

s t ab i l i t y

te s t s

of

arthrokinetic fu nction - a n te rior t ransl a t i o n

Compression i s applied t o the m iddle and l ower thorax b y app l y ing a vertical fo rce throu gh t h e top of t h e patient 's shou lders (Fig. I n) . Com pres s i o n is applied to the upper tho rax b y appl y i n g a vertical force through the cran i u m . A n terior transla tion - spina l. Th is test stresses the anato m i ca l structures which resi st anter ior trans l ation of a segmental spinal u n i t . A p o s i t i v e response i s the reproduct i o n of the patie n t ' s symp toms together w i t h an i n crease i n the quantity of motion and a

(spinal).

For The Thorax

decrease i n the resistance at the end of the range of moti o n . With the patient prone l y i ng, the transverse processes of the superior vertebra arc palpated. With the other hand, the transverse process of the i nferior vertebra are (Figs. 1 1 3 , A posteroan� while fixing applied through superior terior force the i nferior vertebra. The quantity of motion, the reproduction of any symptoms and the endfeel of motion i s noted and compared to the levels above and below. The findings fro m th i s test should be correl ated those of the translation to determine i nstab i l i ty. Excessive anterior translation of the the level of vertebra coul d due to either anterior instah i of T4�5 or posterior instab i l i ty of T3 �4. spina l. Th i s test stresses the anatom ical resist posterior translation of segmental spinal structures unit. A positive response i s t h e reproduction of patient 's syrnpan i n crease the quanti toms together motion and decrease i n the resistance at the end of the range of motion . The patient is s i tting with the arms crossed to opposite shoulders . The thorax is stab i lized with one hand/arm u nder/over (depending on crossed and the contralateral s capul a the level) grasped. transverse o f the vertebra fixed w i t h the dorsal hand. Static stab i l ity i s tested b y applying an anteroposterior force to the superior vertebra through the thorax w h i l e fixing the i nferior vertebra (Figs. 1 1 5 , 1 1 6) . The quantity of symptom s and the endfeel of motion, the reproduction of levels above and below. and compared motion is t1ndings from test should correl ated with of the anterior translation test to determine the level of the instab i l i ty.

Posterior tra nsla tion

�

Dynamic stabil ity can be tested by resisting elevation of the crossed arms. If the segmental muscul ature to control translation, posterior w i l l be is dynam stable. Transverse rota tion - spina l. Thi s test stresses the anato m i cal structures w h i ch resist rotation of a segmental spinal unit. A posireproduction the patient's sym ptom s togethtive response with an i n the of motion decrease in motion. Wi th patient end of the resistance l y i ng , the transverse process of the superior vertebra i s palpated. With the other hand, the contral ateral transverse process of the inferior vertebra is fixed. A transverse plane rotation force is by apply i ng u n i l ateral appl i ed (Figs . leroanterior while the inferior 1 1 8) . The quantity of motion, reproduction

Man u a l Therapy For The Thorax

-

93


stability

tests

of

arthrokinetic fu nction - po ints of

palpation

fo r

posterior

transla t i o n (sp i n a l ) .


stab ility

tests

of

arthrokinetic function - poste rior transla t i o n (spi n a l ) .

and the endfeel of m o t i o n i s noted and compared to the levels above and b e l ow. A n terior

transla tion

- posterior costa l.

This

test

stresses

the

anatomical structures w h i c h res ist an terior tran s l a t i o n o f the poste rior aspect of t h e r i b relative to t h e thoracic vertebrae to w h i ch it attach es . A positive response i s the reproduct i o n o f the p a ti e n t 's

94

-



stab ility

tests

of

arthrokinetic fu nction - p o i n t s of p a l p a t i o n f o r l e f t ro tation (sp i n a l ) .


stability

arthro kinetic

tests

fu nction

-

of left

rota tion (spinal).

symptoms together with an increase in the quantity of motion and a decrease in the resistance at the end of the range of motion. With the patient prone lying, the contralateral transverse processes of the thoracic vertebrae to which the rib is attached are palpated . For example, when testing the r ight seventh rib the left transverse processes of T6 and T7 are palpated . With the other hand, the rib is palpated j ust lateral to the tubercle (Fig. 1 1 9) . A posteroanterior force is applied to the rib while fixing the thoracic vertebrae (Fig . 1 20) . The quantity of motion, the reproduction of any symptoms


-

95


s t ab i l i t y

tests

of

arthrokine tic function - p o i n t s of

palpation

fo r

anterior

translation (posterior cost a l ) .

Figure 120. Passive

stab i l i t y

tests

of

arthroki n e t i c fu nction - ante rior

translation

costa l ) .

(posterior

96

-


Figure 121 . Passive

s t a b i l i ty

tests

arthrok i n e t i c fu nction

-

of

points

of palpation for i n ferior trans l a t i o n (pos terior cos t a l ) .


s t ab i l i t y

tests

arthro k i n e t i c fu nct i o n or

tra n s l a t i o n

-

of

inferi

(pos t e r i o r

costal).

and the endfeel of motion is noted and compared to the levels above and below. Inferior translation - posterior costa l. This test stresses the anatomical structures which resist inferior translat ion of the rib rel ative to the thoracic vertebrae to which it attaches . A positive response is the reproduction of the patient's symptoms together with an increase in the quantity of motion and a decrease in the resistance at the end of the range of motion. With the patient prone

w[anual Therapy For

Thorax

-

97

t h e c o n t r a l a te r a l transverse process of the t h o r a c i c v e rte � bra a t t h e s a me l e v e l as the rib i s p a l p ated. With the s a m e h a n d , t h e i p s il a teral transverse process o f t h e thoracic vertebr a a t t h e the super i �

t h e other

l e v e l a b o v e t h e r i h i s p a l p a ted .

o r aspect of t h e r i b j us t l at e r a l to t h e tubercl e i s p al p a te d . An i n fe r i o r force i s a p p l i e d through the r i b w h i l e fi x i n g t h e t h o r a c i c T h e q u a n t i t y of motion, t h e repro�

vertebr a e (Figs .

duction o f a n y s ymptoms and t h e endfe e l of m o t i on i s n o t e d and com p a r e d t o t h e l e v e l s ahove a n d h e l ow. Anterior/Posterior translation - anterior costa l. This test stress es the a n a t o m i c a l s t r uctures w h i c h r e s i s t transl a t i o n o f

cos

toca r t i l age r e l a t iv e to the ster n u m ; a n d t h e r i b r e l a t i v e to t h e costocartil a g e .

When

the

have been

sternocostal

and/or

a gap and a

costoch o n d r a l

can b e p a l pated at

the j oi nt l i n e . The p o s i t i o n a l fi n d i ngs a rc noted prior to s tr e s s i ng the j oi n t . A p o s i t i v e r e s p o n s e i s t h e repro d u ct i o n o f t h e p a t i e n t 's s ymptoms toge t h e r w i t h a n i ncrease i n t h e qu a n t i t y o f m o t i o n and a decrease i n t h e r e s i s t a n ce at t h e e n d o f t h e r ange of m o ti o n . Wit h o n e thumb, the ante r i o r aspect o f the ster n urn/costocarti l age is p a l p a t e d . Wit h t h e other thumb,

ante

r i o r aspect of t h e costocarti l age/ri b i s palpated. A anteroposte r i o r/poste r o a n t e r i o r

1 24).

fo rce

is

app l i e d

T h e q u an t i ty

to

the

costocart i l age/ri b

moti o n , t h e repro d u c t i o n o f

any s y m p t o m s a n d t h e endfe e l o f m o t i o n i s noted a n d c o m p a red to t h e l ev e l s a b o v e and h e l ow. Superior/Inferior transla tion - a n terior costa l. This test stresses the a n a t o m i c a l structures w h i ch resist s u p e r i o r/infe r i o r t r a ns l a t i o n o f t h e costo c a r t i l agc r e l a t i v e t o t h e stern u m ; a n d t h e r i b rel a t i v e t o the costocarti l age . W h e n the sternocostal a nd/o r costo chondral j o i n ts h a v e b e e n separated, a g a p and a s t e p c a n h e p a l pated a t t h e j oi n t l i n e . The p o s i t i o n a l fi n d i ngs a r e noted p r i o r to stress i ng t h e j o i n t . A p o s i t i v e response i s t h e reprod u c t i o n of t h e patient's

toget h e r w i t h a n i ncrease i n t h e q u a n t i t y o f

motion and a decrease i n t h e r e s i stance a t t h e e n d o f t h e r a ng e o f m o t i o n . Wi t h one t h u m b , t h e a n teri o r aspect o f t h e s t e r n u m/costocarti l age is p a l p a t e d .

t h the o t h e r thumb,

i nfe �

r i o r/su p e r i o r aspect of the costocarti l age/ri b i s p a l p a t e d . A s u p e r i o r/in fe r i o r force

a pp l i e d to t h e costocart i l a ge/ri b (Fi gs .

The qu a n t i ty o f mot i o n ,

1 25 ,

repro d u c t i o n o f a n y s y m p -

to ms and t h e endfeel of m o t i o n is noted and compared to t h e leve l s above a n d h e l ow. Mediolatera l transla t ion . T h i s test stresses t h e a n at o m i ca l structures w h i c h resist horizontal t r a ns l a t i o n h e tween two

ace n t

98

-


Figure 123. Passive

stability

a r t h ro k i n e t i c

tests

of

fu n c t i o n

anteroposterior

transl ation

(anterior sternocost a l ) .

Figure 124. Passive

s t ab i l i t y

a r t h ro k i n e t i c a nteroposterior

tests

of

fu n c t i o n translation

(anterior costochondral).

vertebrae when the ribs between them are fixed . This test is used between the segments T3-4 and T I O- I 1 . The primary structu re being tested is the intervertebral disc. When the ribs are fixed b i laterally there should be very little, if any, mediolateral trans lation between two thoracic vertebrae. A positive response is an i ncrease in the quantity of motion and a decrease in the resis tance at the end of the range . To test the TS - 6 segment, the patient is sitting with the arms crossed to opposite shoulders . With the right hand/arm, the thorax i s palpated such that the


Figure 125. Passive

s t ab i l i t y

tests

of

arthrok inetic fu nction - supe rior translation (anterior ster nocost a l ) .

Figure 126. Passive

s t ab i l i t y

tests

of

arthrokinetic function - i n fe r i or transl a t i o n (anterior ster nocostal ) .

fifth finger of the right hand l i es along the fifth rib . With the left hand, T6 and the s i xth ribs are fixed b i l aterally by compressing the ribs centra lly tow ards the i r costovertebral j oints (Fig. 1 27) . The T5 vertebra is trans lated through the thorax PURELY i n the transverse plane . The quantity of motion, the reproduction of any symptoms and the endfeel of motion is noted and compared to the levels above and below.

1 00

-


Figure 1 2 7.

Passive s t ab i l i t y tests of arthrokinetic function TS - 6 mediolateral translation sta b i l i ty test. -

Muscle function If the specific tests of articular fu nction are norma l , then the m u s c l e s w hi c h c a n influence t h e thorax a r e assessed . H y perto n i c i ty, s e co n dary to s egmental facilitation, m a n i fests as a multiseg mental d y sfu nction (rotoscoli o s i s) d u r i ng t h e h a b i t u a l mov e m e n t s w h i c h requ i r e l e ngthe n i ng of t h e m u s cl e . M u s cl e i m b a l a n c e s due to fau l t y recru i t m e n t p a tterns a l s o p r o d u c e a m u l t i s e g m e n t a l dysfu nc t io n . In b o t h i n s t a n c e s t h e p a s s i v e mob i l i ty tests of a r t h rokinematic function are n o r m a l . M u s c l es w h i c h posture i n a s h o r t e n e d p o s i t i o n w i l l e v e n t u a l l y b e co m e struc t u ra l l y s h o rter. Whe n the m u s c l e i s faci l i t a t e d , a n e u ro p h y s i o l o g i c a l t e c h n i q u e a i me d a t restoring t h e r e s t i n g t o n e of t h e m u s c l e w i l l y i e l d a n i m m e d i a t e c h a n g e i n m o b i l i ty . W h e n t h e m u s c l e i s s tructu r a l l y s horte n e d , stronger s t retch i n g tech n i qu e s a n d m o r e t i m e i s requ ired t o a c h i e v e n o r m a l mob i l i ty. The d i a p h ragm is oft e n i nv o l v e d in p o s t u r a l d y s fu n c t i o n a n d t e n d s to b e a fl e x o r of t h e thorax w h e n i t i s h y p e rto n i c . It h a s b e e n observed22 to p roduce a lordosis a t t h e thoraco l u m b a r j un c t io n . I n a d d i t i o n , i n s u ffi c i e n t re l a x a t i o n of t h e d i ap h ragm c a n lead to overuse of the m i d thoracic s p i n a l e xt e n s o rs c a u s i n g a m i dt h o r a c i c l o r d o s i s ( Fi g .

128).

Thes e c u r v e rev e rs a l s do not


-

101

Figure 128. When

the

d iaphragm

is

h y p e rt o n i c ,

overa c l l v l l y

of

the m i d t horacic spinal exten sors can produce a loc a l ized lordosis .

re s p o n d

to

re q u i re s

re l a x a t i o n

segme ntal

mob i l i z a t i o n

of the

d i a p hragm

tech n i qu e s . and

Corre c t i o n

treatm e n t of the

b r e a th i ng d i s o r d e r. The e mph a s i s of t h i s text is on the i dentification a n d treatment of articu l a r d y s fu n cti o n a n d the r e a d e r i s referred to o t h e r texts fo r e l a b o ra t i o n on postural and m u s c l e d i s o r d e rs 1 7 .

Nerve

function

These tests e x a m i n e the conductivity o f t h e motor and s e n s o r y

1 02

-

Manual Therapy For The Thorax ------

n e rves as w e l l as t h e mob i l i ty o f t h e d u r a a n d the intercostal n e rves i n t h e spinal c a n a l a n d i n te rv e rtebral for a me n . The s e n exami ned by testing

fu n c t i o n o f t h e i ntercostal

sensation i s not

s e n s a t i o n i n the i n te rcostal

p r i m a ry comp l a i n t .

u n c o m m o n a l th o u g h r a re l y

o f n e u ro lo g i c a l

Hyperaesthesia c a n b e o n e

s e n s a t i o n becomes

nte rference a n d tends t o occlIr ( h yp o a e s t he s i a ) .

T h e motor fu n c t i o n of t h e i n terco s t a l nerves i s e x a m i n e d by observ i n g a n d p a l p a t i n g the

i n te rc o s t a l m u s c le s .

S e gm e n t a l

faci l i t a t i o n l e a d s to hy perto n i c i t y o f the i nterco s t a l muscle a n d t h e i n creased t o n e can be p a lp a te d a l o ng t h e i n tercostal s p ace . The t o n e is oft e n associ ated w i t h t e n d e r Reduced m o t o r fu nction

within the musnerves c a u s e s

o f t h e i n te rcosta l muscle s . tests a r e u s e d to detect

upper motor n e u -

l e s i o n s . T h e p l a nt a r response

test fo r c l o n u s

s ho u l d b e d o n e o n every p a t i e n t presenting w i t h p a i n i n t h e t h o rax . The mob i l it y tests for t h e n e u r a l a n d d u ra l tissue i n c l u d e the slump t e s t a n d v a r i a t i o n s t h e reof. The mob i l i ty o f t h e i n trasp i n a l t i s s u e s c a n b e tested b y fu l l y l en g th e n i n g t h e d u ral/neu r a l s y s T h i s i s a c h i eved b y

p a t i e n t fu l l y fl e x t h e and extend the

a n d n e c k , slump t h e w it h the a n k l e dorsiflexed

d u r a i s released

h a v i ng t h e p a t i e n t

and neck. The

i n s y mp t o m response

t h o ra c i c p a i n is

brou g h t o n by fu l l slump a n d r e l i e v e d with e x te n s i o n o f the h e a d a n d neck, i n v o l v e m e n t o f t h e d u r a is suggeste d23 . The i n te rco s t a l nerves c a n be fu rther tensed by

h av i ng t h e

' sl u m p e d ' p a t i e n t twist t h e t h o r a x to t h e l e ft a n d r i g h t (Fig.

1 30) .

Often , the p a t i e n t w i l l present w i th a n o r m a l m o v e m e n t o f re l a t iv e n e u r a l

w h e n r o t a t i o n occurs rel axation and an abnormal

(seg m e n t a l k i nk

t h o r a c i c c u rve) w h e n

in a position of

n e u r a l ten s i o n . I t i s

p o s t u l ate o n t h e e ti o l -

t h e ' ap p a re n t segme n t a l

' in this situation

a n d u n l e s s t h e n e rv o u s sy stem i s a ddress e d , the s y m pt o m s per sist

regardless

of t h e

articular

and

m y ofas c i a l

t r e a tme n t s

e m p l o y e d . The e m p h a s i s o f t h i s t e x t is o n t h e a s sessme n t a n d


-

1 03

Figure 129. The slump test.

Figure 130. Modifica t i o n of the slump test for the detect i o n of segme n t al

neura l dysfu n c t i o n with i n the thorax.

treatment of articu l a r d y sfu nction and the reader i s referred t o Butler 's23 w o r k o n t h i s s u bj e ct fo r fu rther rev i ew.

Adj unctive tests While

X-rays

exclude

serious

bone

d i s e a s e a n d s i g n i fi c a n t

mec h a n i c a l defe c t s , t h e y rare l y p rov ide g u i d a nce fo r m a n u a l t h e r a p y . Asy m metry i s t h e rule i n the thorax a n d dev i a t i o n of the s p in o u s processes is to b e expecte d . For the m a n u a l t h e r a p i s t , the p r i m a r y reason fo r o b ta i n i n g the r e s u l t s of a n y adj u n c -

1 04

-

Manual Therapy For The Tho rax

tive i maging tests is to r u l e o u t s e r i o u s pathology a n d to i d e n t i fy a n a t o m i c al a n o m a l i e s w h i c h may i n fl u e nce t h e i n terpretation o f m ob i l i ty analysis. The fi n d i ngs thorax m u s t be corre l ated e x a m i n a t i o n i f t h e s i g n i fi c ance

o n adj u nctive testing of n o te d o n c l i n i c a l u nde rsto o d .

J\fanual Therapy For

Thoren

-

1 05

5

CLINICAL SYNDROMES chapter will focus on the mechanical syndrom es of

thorax

recognizing that referral of pain to the thorax from the viscera, res piratory syndromes, metabolic, infective and neurological condi tions may coexist. The m odel

classification will follow the

manual therapy model based on the objective findings noted on mobility testing . HYPO M OBILlTY WITH O R WITHOUT PAIN essential objective finding for classification here is decreased osteokinematic motion of either the thoracic vertebrae or the ribs. etiology may be articul ar, myofascial or both and is often the result of excessive bending or rotational force. The arthrokinemat ic tests differentiate the underlying cause of the osteokinematic restriction . The mode of onset may be either insidious or sudden depending the degree

trauma. The irritability of the wounded tissue

dictates the intensity of the pain, the amount of radiation, the degree of physical activity which tends to aggravate it and the amount

rest required

relieve it.

aim

the

examination is to determine the stage and nature of the pathology that treatment

be adjusted accordi ngly (Chapter

The location of the pain may be on the ipsilateral or contralateral of the hypomobility and may radiate around

through to the

anterior aspect of the chest. An acute zygapophyseal j oint sprain tends to produce very localized pain over the involved joint. A chronic restriction of either the vertebra

rib tends to produce

symptoms removed from the source and some of these may be sec ondary to compensation of the adj acent levels. Referral of pain the articulations of

thorax tends

be around the chest

106

-

Man u a l Therapy For

Thorax

opposed to through it. Referral from the intervertebral disc tends to be t h rough the chest. Magnetic i m aging frequency disc di agnosis of Thoraci c discs are no l onger thought to be an uncomm o n cause of thoracic pai n . I n a study by Brown et a1 24 the most common symptom i n patients with confirmed thoracic disc herniations w a s anterior Other included lower extrern ity chest pain (8%) and dysaesthesia gastric pain "The degree of herniation was characterized as mild, m oderate, or severe. A m i l d h e rn i ation consisted of only indentation. Moderate herniation created m in i m a l significant deformation. l i m i ted Severe hern i ations resulted free fragments evi de n ce of cord compression manifested by i ndentation or flat tening of the cord. " 24 The h i ghest incidence h ighest was and T9- 1 O .

t o level was

the second

The sympathetic chain can also refe r symptoms into the upper or lower extre m i ty. These patients commonly report temperature changes, heavy sensations associated with fatigue and nonspecific The upper thorax can i nvolved n u mbness refer p a i n cranium the sympathetic pathway. Hypomobile j o i nts are very consistent in the pattern they present on habitual movement testing. The fi ndings for each j oint restriction w i l l be described below. If j oint i s h ypomobile, myofascia i s restricted. If arthrokinematic glide will also source of restriction, t h e glide will norm a l . Disorders i n t h i s classi fication do not exhibit a l oss of arthrokinetic function. The neural/dural m ob i l i ty tests may be positive i f the mobil ity of by a change position of the sympathetic cha i n is t h e zygapophyseal j o i nt head of the Restrictions i nvolve the neural/dural tissue. The thorax will be divided into the anatom ical regions for further discussion. The obj ective mobil i ty/stabi lity findings, the relevant described. treatment and a exercise w il l


-

1 07

Vertebromanubrial region

Bilateral restriction offlexion

The upper thorax is rarely fixed in a lordotic position , however, a bilateral restriction of flexion is not uncommon at T2-3. Forward bending of the head will reveal a limitation of the superior excur sion of the transverse processes bilaterall y confirmed o n passive physiological mobil ity testing. The superior arthrokinematic glide at the zygapophyseal joint will be restricted bilaterally if the dys function is i ntra-articular. The presence or absence of pain depends upon the stage of the pathology (substrate, fibroblastic, maturation) and the irritability of the surrounding tissue. The grade of the mob il ization techn ique is directed by these factors (Chapter 3). Mob iliza tion techn iqu e . Lo n g i t u d i n a l t r a c t i o n of t h e upper t h o r a x w i l l p r o d u ce a s u p e r i o r gl ide of t h e z y g a p o p h y s e a l j o i n t b i l a t e ra l l y. T h i s t e c h n i q u e m a y b e done with the patient e i ther supine l y ing, sitting o r stand i n g . Wi t h t h e p a t i e n t s u p i n e ( F i g . 1 3 1 ) , g r a d e s 1 a n d 2 t e c h n i q u e s c a n b e a p p l i e d fo r p a i n r e l i ef. W i t h t h e l at e r a l a s p e c t o f t h e M C P o f t h e i nd e x fi n g e r , t h e i n t e rs p i n o u s s p a c e i s p a l p a t e d a t t h e l e v e l t o b e t r a c t i o n e d . W i t h a n o p e n p i n ch gr i p o f t h e o t h e r h a n d , t h e l o w e r cerv i c a l s p i n e is p a l p a t e d as c l o s e to t h e s u p e r i o r v e r t e b r a of t h e l e v e l t o b e t r a ct i o n e d as p o s s i b l e . Lo ca l i z a t i o n i s ach i e v e d b y fl e x i n g/e x t en d i n g t h e d y s fu n c t i o n a l s e g m e n t u n t i l t h e n e u t r a l p o s i t i o n i s

Figure 131 . Vertebrom a n ub r i a l b i l a te r a l

flex i o n

region

-

res t r i c t i o n .

Longitu d i n a l tract i o n .

1 08

-


Figure 132. Vertebro m a n u bri al b i l atera l

fl e x i o n

region

-

restrictio n .

Long i t u d i n a l tractio n .

a s c e r t a i n e d . G r a d e s 1 to 4 l o n g i t u d i n a l t r a c t i o n i s a p p l i e d b y fi x i n g t h e c a u d a l v e r t e b r a a n d p u l l i n g t h e c r a n i a l v e r t e bra superiorly. Stronger distraction techniques are done with the patient either sit ting or standing with both hands behind the neck, fingers i nterl aced (Fig. 1 32) . The therapist winds both of their arms beneath the p atient's ax i l lae through the tri angu l a r space created by the flexed elbows. The fi ngers are interl aced and p l aced over the p at i e n t ' s hands. T h e thorax is gently gripped by adducting t h e arm s . The patient i s i n structed to look forward and the therapist ensures that the l i gamentum nuchae is not o n fu l l stretch . From this position, a Grade 3 to 5 longitudinal traction techn ique is applied by rocking the patient b ackwards and forwards until a pendul ar type m o t i o n is produced . Gravity provides the distractive fo rce . A h igh v e l ocity, low ampl itude thrust techn ique (Grade

5)

is app l i ed at the apex of

the descent when the patient 's body weight is droppi n g .

Home exercise (Fig. 133) . To m a i n t a i n the m o b i l ity gained, the patient i s i n structed to perform the fo l l o w i ng e xercise fre-


-

109

Figure 133. Vertebro m a n ubrial b i l a teral

flexion

Home exercise.

quently (up to ten t i m e s , ten times per day). Wi th the fingers inter l aced behind the neck and the i ndex fingers i n the appropriate i n ter spi nous space, the patient is in structed to fl ex the he ad/neck. The fin gers m a y assist the motion by app l y i n g a superior pressure to the inferi or aspect of the spinous process of the superior verteb ra. The ampli tude of the exercise should be i n the pai nfree range and should not aggrav ate any sympto m s .

Unila tera l restriction of flexion This i s a com m o n restriction to find in the vertebromanubrial regi o n .

A

u n i l ateral restriction of fl e x ion w i l l produce a segmental

ro tosco l i osis as well as a compensatory m u l t isegmental curv e above a n d b e l o w t h e restricted l ev e l . Act ive fo rward bending o f the head w i l l reveal t h i s asy m m etry.

A u n i l ateral

restriction of fl e x

i o n on the r i g h t at T l - 2 w i l l produce a right rotat i o n/right sideflex ion pos i t i o n of T1 at the l i m i t of forward bending. The left trans verse process of T l w i ll trav el further superiorly than the righ t .

region

-

res t r i c t i o n .

110

- Manua l

Therapy

For

The Thorax

Figure 134.

Vertebromanubrial region unilateral flexion restriction of the right zygapophysea l joint at T l -2. Mobilization technique.

The right transverse process of Tl w i ll be more dorsal than the left. Left rotation and left lateral bending of the head/neck will be restricted in a consistent pattern in both the H and I combined movement tests . Unilateral elevation of the left arm w i l l · produce right sideflexion and left rotation of T l -2. The superior arthrokine m atic glide of the right zygapophyseaJ j o int at T l -2 will be restrict ed if the dysfunction is intra-articular. The presence or absence of pain during these tests depends upon the stage of the pathology (substrate, fibroblastic, maturation ) and the irritability of the surrounding tissue . The grade of the mobi lization technique is directed by these factors ( Chapter 3 ) . Mobi liza tion techniqu e right at Tl -2 (Fig. 1 34) . The

to restore unila teral flexion on th e pat i ent is supine l y i ng with the head

Manu a l Therapy

The Thora),

supported o n a p i l l ow. With the lateral aspect of the i ndex finger, the left transverse process of Tl is palpated. With the other hand, The motion down spine is the then gliding by passively flexing T l -2 er is transverse process of Tl inferomedially C7-Tl is (locked) with the oppos ite hand by sideftexing the C7-Tl s egment to the left and rotating i t to the right. From this position, the right zygapophyseal j oint of T l -2 i s m ob i l i zed into flexion through an LEFT hand. glide inferomedial and s l i ghtly of the will superior slightly anterior at Tl -2. This is an arthrokinematic mobi l ization. By restoring the accessory glide the osteokinematic motion (flexion) w i l l b e restored. The technique c a n b e graded from 1 t o 5 . An active mobilization

(muscle techn i que) a change muscle tone segmentally. When used motion barrier has been localized, the patient is instructed to resist further motion while the therapist applies a gentle sideftexion force to the head/neck . The isometric contraction is held for up to five of complete relaxation . The seconds fol l owed by a taken to new motion the then repeated times and l owed by re-eval uation of m atic function. To the patient i nstructed to left m ob i l i ty to ten frequently arm may Unilateral elevation of lems with repetitive rotation through the craniovertebral and mid cervical regions. The amplitude of the exercise should be in the painfree range and should not aggravate any symptoms. Home exercise for a restriction offlexion on the right a t Tl -2.

B ilatera l restriction of

This restriction is commonly seen when the patient has a forward head posture . B i l ateral elevation of the arms w i l l reveal a l i m ita tion of the inferior excursion of the transverse processes h i l aterally. Rotation and l ateral of the often stops restriction the upper thereby m id cerv ical spine. Unilateral elevation of the arm is markedly restricted on both sides. This restriction places more stress on the clavicular j o ints and the glenohumeral j oint. Passive m ob i lity testing i n ferior dorsal arthrokinematic glide zygapophyseal j o i nt i s restricted b i lateral the dysfunction is depends absence The presence stage of the pathology (substrate, fibroblastic, m aturation) and the

112

-


Figure 1 35. Vertebro m a n ub r i a l

region

-

b i l a t e r a l extension res trict i o n . Mobi l iz a t i o n tech n i q u e .

irritabil ity of the surrounding tissue. The grade of the mobil ization technique is directed by these factors (Chapter 3). Mobiliza tion technique (Fig. 135) . The patient i s supine lying with the head supported on a pil low. With the l ateral aspect of the index finger of one hand, the i nterspinous space is palpated at the level to be treated. The opposite hand supports the l ower cer vical spine as close to the segment as possible. The motion barrier is localized and passively mobilized by dorsally gliding and slight ly extending the superior vertebra. This is an arthroki nematic m obilization. By restoring the accessory glide, the osteoki nematic motion (extension) will be restored. The technique can be graded from 1 to 4.

Manua l Therapy

The ThorfL>(

An active m o b i lization assist (muscle energy tech n ique) m a y be

used to effect a change i n the m uscle tone segmenta l l y. When the i nstru cted ized, the has been therapist reduces the of the neck. The isometric contraction of the deep neck fl exors is held for up to five seconds fol l owed b y a period of complete relaxation. The j oi n t is then passivel y taken to the new motion barrier, the technique repeated three times and fol l owed b y re-eval u ation of osteokinematic fun ction. Home exercise . To m a intain the mobility gained, the patient is instru cted to elevate the arms b i l aterally frequently (up to ten times, ten times per day). The amplitude of the exercise should be range and shou l d not i n the any symptoms. Uni la tera l restriction

t;.'(tens ion

This is another common restriction to find i n the vertebromanubr ial region . B i l ateral elevation of the arms w i l l produce a segmental level rotosco l iosis and a curve and below of restriction . A u n i l ateral restriction of extension on the at Tl -2 produce a left rotation/left positlOn at the l i m i t of extension. The left transverse process of T 1 will travel further inferiorly than the right. The left transverse process of T1 w i l l be more dorsal than the right. Right rotation/s ideflexion of th e head/neck w i l l be restricted. Unilateral of the left s ideflexion and right rotation Tl -2 . The will or arthrokinematic glide of the right zygapophyseal j o in t at T 1 - 2 w i l l be restricted i f t h e dysfunction i s intra-articular. or absence pain during tests depends The the pathology (substrate , the m aturati on) and the of the tissue. grade of the l ization technique is directed by these factors (Chapter 3 ) . Mobiliza tion techn ique t o restore unila tera l extension on

The patient supine lying on a pil With the lateral of the ger, the transverse of T1 is The spine i s supported down to C7 w ith the other hand. The motion barrier i s loca l i zed by passively extending T l -2 and then gliding the r ight transverse process of T 1 inferomedi a l l y o n T2. C7-T1 i s stabi I ocked) w ith opposite h and sideflexing to the right T1 rotating it left . From zygapophyseal j o i nt of T l -2 mobilized into extention, sion through an i nferomedial and s lightl y posterior glide with the TJ -2 (Fig.

1 14

-


Figure 136. Vertebro m a n ubrial u n i l a teral

extension

region

-

restric

tion of t h e right zygapoph y seal

joint

at

T l -2.

Mobi l i z a t i o n t e c h n i qu e .

RIGHT hand . This is an arthrokinematic mob i l ization. By restor ing the accessory glide, the osteokinematic motion (extension) w i l l be restored. The technique can be graded from 1 t o 5 . An act i v e m o b i l i z at i o n a s s i s t ( m u s c l e e n e r g y t e c h n i q u e ) m a y b e u s e d to effe c t a ch ange i n t h e m u s c l e t o n e s e g m e n t a l l y W h e n t h e m o t i o n b ar r i e r h a s b e e n l o ca l i z e d , t h e p a t i e n t i s i n s t r u c t e d t o r e s i s t fu r t h e r m o t i o n w h i l e t h e t h e r a p i s t app l i e s a g e n t l e s i d e fl e x i o n fo rce t o t h e h e a d/n e c k . T h e i s o m e t r i c c o n tract i o n i s h e l d fo r u p to fi v e s e c o n d s fo l l o w e d b y a p e r i o d o f c o m p l e t e re l ax a t i o n . T h e j o i n t i s t h e n p a s s i v e l y t a k e n to th e n ew m o t i o n b a r r i e r, t h e t e c h n i q u e i s r e p e a t e d t h r e e t i m e s a n d fo l l o w e d b y r e - e v a l u a t i o n o f o s teo k i n e m a t i c fu n ct i o n . .

The Thorax Home exerc ise for a restriction of extension on the right a t

To maintain the m obil ity gained, the patient is instructed to times, ten times right head/neck (up elevation right a r m used i f day) . U n i l problems w it h repetitive rotation through craniovertebral and m idcervical regions. The amplitude of the exercise should be i n the painfree range and should not aggravate any symptoms . Tl -2.

Uni la tera l restriction of

rota tion

rib

Thi s dysfunction is seen when the scalene m uscles are hypertonic or tight and hold the anterior aspect of the first rib superiorly o r w h e n t h e superior g l i d e of the first r i b is restricted at t h e costowill restrict u n i lateral This dysfunction arms may involved). articular, rotation and l ateral hending of the head/neck w i l l ited to the s i d e of t h e restricted rib (th is motion requi res a superior glide of the rib at the costotransverse j o i nt) . Full expiration w i l l also reveal asymmetry of r i b motio n . I f t h e restriction i s intra-articul ar, the gl ide first rib at costotransverse wil l be restricted . The presence o r absence of pain during these tests depends upon the stage of the pathology (substrate, fibrobl astic, m aturation) and the irritab ility of the surrounding tissue. The grade of the mobi is directed these factors (Chapter 3). l ization Mobiliza tion techn ique (Fig. 1 3 7) . restore the superior glide of the first rib at the costotransverse j o i nt, the following tech nique is used . The patient is supine l ying with the head supported on a p i llow. The superior of the right transverse process of with the thumb. The and m i ddle Tl is of the hand palpate inferior the right The m i dcervical spine is supported w ith the other hand. 'rhe motion barrier i s l o cali zed and mobili zed by apply ing a posteroi n ferior glide to t h e transverse process of Tl t h u s producing a rel a gl ide of the tive rib at the costotransverse m iddle index fingers right hand inferior This is an arthrokinemat i c i zation restoring the superior gl ide of the first rib at the right costotrans verse j o i nt . B y restoring the accessory glide, the osteokinematic motion (anterior rotation) will be restored . The technique can be to 4. graded

An active mobil ization (muscle technique) used to effect a change in the tone of the scalenus anteri o r and

116

-


Figure 1 3 7.

Vertebromanub rial region un i l ateral anterior rotation restriction of the right first j o in t costotransverse Mob i lization technique . .

Figure 138.

Vertebromanubrial region un il a t e r a l an t e r i or rotation res triction of the r i g h t first cos totransverse j o int. Active mobil ization assis t . Figure 139.

Vertebromanubrial region un i l a teral anterior rot a t i on restriction of t h e right fi rst costotransverse j o in t . Home exercise.

m e d i u s m u s c l e s . T h e h e ad/n e c k i s s i d e fl e x e d t o t h e r i g h t a n d s l i g h t l y fl e x e d w i t h t h e l e ft h a n d w h i l e t h e r i g h t h a n d m o n i t o r s t h e r e s p o n s e i n t h e s c a l e n e m u s cu l a t u r e ( Fi g . 1 3 8 ) . T h e p a t i e n t i s i n s t r u c t e d t o r e s i s t a g e n t l e s i d e fl e x i o n fo rce t o t h e h e a d/neck a pp l i e d w i t h t h e l e ft h a n d . T h e i s o m e t r i c c o n t r a ct i o n i s h e l d fo r u p t o fi v e s e c o n d s fo l l o w e d b y a period of complete relaxation . The j o i nt i s then pas s i v e l y t a k e n t o t h e n e w m o t i o n b ar r i e r , t h e t e ch n i q u e i s


-

117

repeated three t i m es and fo l l o w e d b y r e - e v a l u a t i o n o f o s t e o k i n e m a t i c fu n c t i o n .

of anterior rotation Home exercise the m ob i l ity gained, right firs t rib (Fig. posteroinferior aspect of the patient i s instructed then righ t rotate the first rib with their frequently (up to ten t i mes, ten times per day) . By holding the rib posteriorly, the transverse process of T 1 gl ides inferiorly rel ative to the tubercle of the rib (re lative superior glide of the first rib). The ampli tude . of the exercise should be i n the painfree range and should n o t aggravate any symptoms. Unilatera l restriction

rotation - first rib

This dysfunction posterior aspect of the first held superiorly or glide o f the first rib is ed at the costotransverse dysfunction w i l l restrict s ide, rotation and l ateral l ateral elevation of ing of the head/neck to the opposi te s i de of the restricted rib and ful l inspiration. I f the restriction is i ntra-articular, the i n ferior glide of the first rib at the costotransverse j o i n t will be restricte d . T h e presence or absence of pain during these tests depends upon the stage of the pathology (substrate, fibroblastic, m aturation) and the irritab il i t y o f tissue. The grade of the l ization technique factors (Chapter 3).

1 40) . To restore the Mobilization gl ide of the first rib costotransverse j o int, the fol lowing nique i s used . The patient i s s u p i n e lying with t h e h e a d supported on a p i l l ow. The superior aspect o f the right first rib is palpated with the l ateral aspect of the MCP of the i ndex finger of the right hand. The m idcervical and upper t horacic spine i s supported with the other hand . The spine i s locked by localized sideflexion o f C7, Tl and T2 to the right and rotation to the l eft. The motion barrier of the fi rst costotransverse l o ca l i zed and m ob i l i ze d applying an anteroi nferior tubercle of the rib al the conj unct posterior occur. This i s an arthrokinematic m ob i l i zation aimed i nferior glide o f the fi rst restoring the accessory glide, osteok inematic rotation) will be restored. tech n i qu e can be graded from 1 to 5 . An active mobil ization assist (muscle energy technique) m a y b e

used t o effect a c hange i n the tone o f the segmental muscl es. From

118

-


Figure 140. Vertebro m a nubri al

r eg i o n

u n i l ateral

p o s teri o r

rest riction

o f t h e right

-

ro t a t i o n

cos t o t r a n s v e rs e

first

j oint.

M o b i l iza t i o n technique.

Figure 141 . Vertebro manubrial

region

-

unil ateral

p o s t e r io r

restriction

of the r i g h t first

rotation

costotransve rse j o i n t .

Home

exercise .

the localized motion barrier, the patient is instructed to resist a gen tle sideflexion force to the head/neck applied with the l eft hand. The isometric contraction is held for up to five seconds fol lowed by a period of complete relaxation. The j oint is then passively taken to the new motion barrier, the technique i s repeated three times and fol lowed by re-evaluation of osteokinematic function . Home exercise for a restriction ofposterior rota tion of the right first rib (Fig. 141) . To maintain the mobility gained, the patient i s instructed to fix the posterosuperior aspect of the right first rib with their left hand and to then left rotate the head/neck fre quently (up to ten times, ten times per day). By holdi ng the rib pos teriorly, the transverse process of T1 glides superiorly relative to the tubercle of the rib (relative inferior glide of the first rib) . T he ampl itude of the exercise should be in the painfree range and should not aggravate any symptoms. Vertebrosterna l and vertebrochondral regions

Bila teral restriction of flexion

A lordotic midthoracic region is often indicative of an underlying breathing dysfunction (Fig. 128). Overactivity of the spinal exten sors compensates for a hypertonic diaphragm wh ich tends to flex the thorax . In addition to specifically mob i l izing the m idthorax it is cruci al that the breathi ng pattern be addressed if a more neutral


-

119

Figure 142. Vertebroste rnal a n d vertebro chondral

reg i o n

bila teral

fl e x i o n restriction - longit u d i n a l traction - p o i n ts o f palpa tion for the mob i l iz a t i o n tech n i que.

position o f the spine i s to b e achiev e d . When the m i d thoracic seg ments (v erteb rosternal region) become fixed in extension, active mobility tests of forward bending of the trunk w i l l reveal a l i mita t i o n of the supe r i o r excurs i o n of th e transverse pro cesses b i l ateral ly. Passive mobility test ing of the superior arth rokinematic glide at the zygapophyseal j o i n t w i l l be restricted b i latera l l y if the dys function i s i n tra-articul ar. T h e p r e s e n c e or a b s e n c e of p a i n d e p e n d s u p o n t h e s t a g e o f the pathology (substrate, fibrob l astic, maturation) and the i r r i t a b i l i t y o f t h e s u r r o u n d i n g t i s s u e . T h e g r a d e o f t h e mob i -

120

-


Figure 143. Vertebrosternal and vertebro chondral

region

-

b ilateral

flexion restriction - specific

longi tudinal

trac t i o n .

Mob i l i z a t i o n techniq u e .

lizatio n technique is directed by these factors (Chapter 3). Mobilization technique. Longitudinal traction will produce a superior glide of the zygapophyseal j oint bilaterally. This tech nique may be done with the patient either supine l y ing or sitting. With the patient supine, grades 1 and 2 techniques are b etter con trol led and can be applied for pain rel i ef. The stronger mobil iza tions can be done with the patient either supine or s itting.

The supine technique is performed as fol lows (Figs . 1 42, 1 43). The patient is sidelying, the head supported o n a pillow and the arms crossed to the opposite shoulders . With the tubercle of the scaphoid bone and the flexed PIP j oint of the long finger, the transverse processes of the inferior vertebra are palpated. The other hand/arm lies across the patient's crossed arms to contro l the thorax. Segmental localization is achieved by flexing the j oint to the motion barrier with the hand/arm contro l l i ng the thorax. This local ization is maintained as the patient is rolled supi ne only until contact is made between the table and the dorsal hand. From this position, longitudinal traction is applied through the thorax to pro duce a superior glide of the zygapophyseal joint bilateral ly. This is an arthrokinematic mobil ization. By restoring the accessory glide, the osteokinematic motion will be restored. The technique can be graded from 1 to 5 . An active mobilization ass ist (muscle energy technique) may be

used to effect a change in the muscle tone segmentally. When the motion barrier has been local ized, the patient is inst ructed to gen-


-

121

Figure 1 44.

Vertebrosternal and vertebro chondral region - b i l ateral flexion restriction - general longi t u d i n a l tract i o n . Mob i l ization teCh n ique. Figure 1 45 .

Vertebrosternal and vertebro chondral re gion - b i l ateral flex i o n re striction . Home exercise . t l y elevate their crossed a rms . T h e motion is resisted b y the thera pist and the isometric co n tract i o n i s held for up to five seconds fol lowed b y a period o f co m p l ete relaxat i o n . The j o int is then p a s sively t a k e n to the new m o t i o n barrier, the technique i s repeated three times and fo l lowed b y re-evaluation of osteok inematic fu nc tion. Stro nger d i s tract ive techniques c a n also be d o n e w ith the patien t sitting w i t h the arms crossed to oppos ite shou lders (Fig. 1 44) . A sm a l l towel i s p l aced against the spinous process of t h e caudal ver tebra of the segment to be d i stracted. The towel i s fixed aga inst the therap ist ' s stern u m . Wi t h both arms wrapped around the patient 's trunk, the p at i e n t 's elbow which is cl osest to the chest i s gras p e d . T h e segm e n t i s local ized to ne utral . From t h i s posi t i o n , d istractio n i s appl ied by rock i n g t h e patient b ackwards a n d s i multaneously l ifting the tho rax posterosuperio rly. The towel fixes t h e ca u d a l ver tebra and assists i n localizing the distractive force� to the appro priate segm ent . The technique can be graded fro m 3 to

5.

Home exercise (Fig. 1 45) . To maintain t h e m ob i l i ty gained, the pat i ent i s i n structed to perform specific m idthoracic fl ex i o n fre quentl y (up to ten t i m e s , ten times per day) . The amplitude of the exercise should b e in the p a i nfree range and should not aggravate any s y m p to m s .

1 22

-


Figure 146. Vertebrosternal and vertebro chond ral

region

flex i o n/ex t e n s i o n of

the

l eft

-

u n i l ateral res triction

zygapophyseal

j oi n t a t TS -6. Po ints of palpa tion for the mob i l ization tech n i qu e .

Unila tera l restriction of flexion

A unilateral restri ction of flexion will produce a segmental roto scol iosis as well as a compensatory multisegmental curve above and below the restricted leve l . Active forward bending of the trunk will reveal this asymmetry. A uni l ateral restriction of flexion on the left at TS -6 will produce a l eft rotation/left sideflex ion position of TS at the limit of forward bending. The right transverse process of TS will travel further superiorly than the left . The left transverse process of TS will be more dorsal than the right. Right rotation and right lateral bending of the trunk will be restricted and produce a

Manua l Therapy For The Thorax - 123

Figure 1 4 7. Vertebros tern a l and vertebro chondral

region

- u n i l a teral

flexion restriction of zyga p ophyseal

joint

the

Mob i l i z a t i o n tec h n i q u e .

kink in the m idthoracic curve in a consistent pattern i n both the H and I combined movement tests. The superior arthrokinematic glide of the left zygapophyseal j oint at TS-6 will be restricted i f the dysfu nct i on is intra-articular. The presence or absence of pain during these tests depends upon the stage of the pathology (substrate, fibroblastic, maturation) and the irritability of the surrounding tissue. The grade of the mob i lizat i on technique is directed by these factors (Chapter 3). Mobiliza tion technique to restore unila teral flexion on the Left a t TS-6 (Figs. 1 46, 1 4 7) . The patient is right sidel ying , the head supported on a pil low and the arms crossed to the opposite shoul ders . With the tubercle of the right scapho id bone and the flexed P I P j oint of the right long finger, the left transverse process of T6 and the right transverse process of TS are palpated. The other hand/arm lies across the patient's crossed arms to control the tho rax . Segmental local ization is achieved by flexing the joint to the motion barrier with the hand/arm controlling the thorax . This localization is m aintained as the patient is rolled supine only until conta ct is made between the table and the dorsal hand. From this position , a right sideflexion force is applied through the thorax to produce a superior glide of the left zygapophy seal j oint. This is an arthrokinematic mobil izatio n . By restoring the accessory glide, the osteokinematic motion will be restored. The technique can b e graded from 1 t o S . An

active mobilization assist (muscle energy technique) may b e

left

at TS-6.

1 24

-


Figure 1 48. Vertebrosternal a n d vertebro chondral

re gion

-

un i la teral

flexion restriction of the left zygapophyseal j o i n t at TS -6. Active mobil ization assist.

Figure 1 49. Vertebrosternal and ve rtebro chondral

region

-

u n i l ateral

flexion restriction of the left zygapophyseal j o i n t at TS - 6 . Home exercise.

used to effect a change in the muscle tone segmentally. When the motion barrier has been l ocal ized, the patient is ins tructed to gen t l y elevate t h e i r crossed arm s . The motion i s resisted by the thera pist and the isometric contraction is held for up to five seconds fol l owed b y a period o f co mpl ete re l axation . The j oi n t is then pas sively taken to the new motion barri er, the te c h n iq u e is re p e a te d three times and fol lowed by re-evalu ation of osteokinematic func tion. When the m y o fascia i s t ho u gh t to be the main cause of the osteokinematic restriction the fo llowing technique can be useful (Fig. 1 48). The patient is s itt in g with the a r m s crossed to opposite shoulders . With the dorsal hand the intertransv erse space i s palpat ed. The ventral hand is placed on t he contralateral shoulder. The motion b arrier is localized by flexing and right s i de fl e x i n g the tho rax . From t h i s p o s i ti on the pa t i ent is instructed to hold s t i l l while t he t he r a p i s t appl i es resi stance to the trunk. The dire c t i o n of the appl ied resistance is determined by the neurophysiol ogical effect desired fro m the tech n i que . A hold/relax tec h n i q u e appl ies the principles of autogenic inhibition and is used pr i m a r i l y fo r a con trac t ur ed muscle. The involved muscle i s recruited strongly and then m a x i m a l ly stretched i n the i m m ediate p o s t c ont r ac t i o n re lax ation p h ase . A contract/re lax technique applies the p ri n cip l e s of re c i p rocal i n h i b i t i o n a n d is used p r i m a r i l y for a h y perto n i c muscle. The antagonist m uscle is recr u ited gen tly. The contractio n re s u l t s in reciprocal inhibition of the antago n i s t i c hypertonic mus cle ,

-

.


-

1 25

The isometric contraction i s held for up to 5 seconds fol lowing which the patient is instructed to completely relax. The new flexand the mobilization ion/sideflexion barrier three times.

Home exercise maintain the mobility specific m i dthoracic right the patient i s instructed flexion in s light frequently (up to ten times, ten times per day). The amp l i tude of t h e exercise should be i n the painfree range and shou l d not aggravate any symptoms. Unilatera l restriction of extension will produce a segmental A u n i l ateral restriction of scoliosis as w e l l multisegmental curve and below the Active backward bending unilateral restriction of trunk will reveal sion o n the left at a right rotation/right backward bending. The ion position of transverse process of T5 w i l l travel further inferiorly than the l eft. The right transverse process o f T5 w i l l be m ore dorsal than the right. Left rotation and l eft lateral bending o f the trunk w i l l be restricted and produce a kink i n the m i dthoracic curv e in a consis tent pattern i n both the H and I comb ined movement tests. The i nferior arthro k i n ematic glide of the left zygapophyseal j o i n t a t T5 6 w i l l be restricted is i ntra-articular. during these tests depends The presence or fibroblastic, maturation) the stage of the the irritab i li t y of tissue . The grade of the l i zation tech nique is d irected b y these factors (Chapter 3).

Mobilization technique to restore unilateral extension on the left a t T5-6 (Figs. 1 46, 1 50) . The patient is right sidelying, the head supported o n a pil low and t h e arms crossed to the opposite shoulders. With the tubercle o f the right scapho i d bone and the flexed PIP j oint o f the left transverse o f T6 and the right of T5 are palpated. The crossed arms to control h and/arm l ies across rax. Segmental ach i eved b y extendi ng the the m otion barrier contro l l i n g the thora x . loca l i zation i s is rol l ed supine o n l y contact i s m ade between the table a n d t h e dorsal hand. From th i s position, a left sideflexion force (coupled w i th a sl ight dorsal g l i de) is applied through the thorax to produce an i nferior glide o f the left zygapopbyseal j oi n t . This i s an arthrokinematic mob i l ization. B y

1 26

-


Figure 150. Vertebrostern a l and vertebro chondral

region

extension left

-

u n ilateral

res trict i o n

of the

z y gapophyseal j o i n t

TS-6.

M ob i l i za t i o n

at

tech

n i que.

restoring the accessory glide, the osteokinematic motion will be restored . The technique can be graded from 1 to 5 . An active mob il ization assist (muscle energy technique) m ay be

used to effect a change in the muscle tone segmentally. When the motion barrier has been l ocal ized, the patient is instru cted to gen tly elevate their crossed arms. The motion is resisted by the thera pist and the isometric co ntraction is held for up to five seconds fol lowed by a period of complete relaxation. The j oint is then pas sively taken to the new motion barri er, the technique i s repeated three times and followed by re-evaluation of osteokinematic func tion. When the myofascia i s thought to be the main cause of the osteokinematic restriction the fol lowing technique can be useful (Fig. 1 5 1 ) . The patient i s sitting with the arms crossed to opposite shoulders. With the dorsal hand the intertransverse space IS palpat ed . The ventral hand is placed on the contralateral shoulder. The motion barrier is localized by extending and left sideftexing the thorax. From this position, the patient is instructed to hold sti l l while t h e therapist applies res istance t o t h e trunk. T h e direction o f the applied resistance i s determ ined by the neurophysiological effect desi red from the technique. A hold/relax technique appl ies the principles of autogenic inhibition and is used prim arily for a contractured m uscle. The invo lved muscle is recru ited strongly and then maximall y stretched in the immediate post-contracti on relax ation phase. A contract/rel ax technique applies the principles of reciprocal inhibition and is used primarily for a hypertonic m uscle .


-

1 27

Figure 1 5 1 . Vertebrostern a l a n d vertebro chondral extension l eft

region

-

u n il a t e r a l

re s t r i c t i o n

of the

zygapo p h y s e a l j o i n t

T5 - 6 .

Act i v e

at

mobil ization

assist.

Figure 152. Vertebrosternal a n d vertebro chondral exte n s i o n l eft

region

-

u n i l a teral

restrict i o n

T5 -6. H o m e exercise.

The antagonist m u s cle is recruited gently. The contraction results in reci proca l in hibition of the antagonistic hypertonic muscle. The isometric contraction i s held for up to 5 seconds following wh ich the patient is instructed to completely relax. The new exten sion/sideftexion barrier i s local ized and the mobilization repe ated three times. Home exercise (Fig. 1 52) . To maintain the mobility gained, the pati ent is i nstructed to perform specific midthoracic left side flexion in slight extension frequently (up to ten times, ten times per day) . The amplitude of the exercise should be in the painfree range and should not aggravate any symptoms. Unilateral restriction of rotation (posterior or anterior) - ribs 3 to 10

seen when the muscles are imbalanced or when arthrokinematic glide of the rib is restricted at the costotrans verse j o int (Figs . 1 5 3 , 1 54) . The clinician m u s t be aware of rela tive flexibil ity between the thoracic vertebrae and the ribs when interpreting the findi ngs on habitual movement tests and passive arthrokinematic m ob i l i ty tests . The di rection of the costotransverse j oint glide can be either superior or inferior during forward and backward bending. The patient 's normal pattern must be ascer tained before the findings can be understood. Respiration produces the most co nsistent movement pattern and is the most rel i able This dysfunct i o n i s

the

of the

zyga p o p h y seal j o i n t

at

1 28

-


Figure 153. Left rotation of the m i d thorax i s fa irly free even i n the pres

ence of a m a rked

scoliosis

secondary to po l i omye l i t i s .

Figure 154. Right rot a t i o n of t h e m id tho rax

is

b l ocked

due

to

the

i n abi l ity o f the r i g h t sixth r i b to posteriorly ro t a t e .

habitual movement to test when evaluat i n g osteo k i nematic func tion o f the ribs. If the d y sfunction is i ntra-articular the arthro k i n e matic g l i de o f t h e costotransverse j o int w i l l b e reduced. Active m o b i l ization techniques are useful when the myofascia is i m b al anced. Respiration m ay produce a s y m metry i n the thorax but the arthro k i n e m atic g l i de of the co stotransverse j o i n t i s n o rm a l . Mobiliza tion techn ique t o restore posterior rotation righ t fifth rib (Fig. 1 55) . When the m y o fasci a is thought to be the m a i r. cause of t h e o s teo ki nematic restrict i o n t h e fo l l owing technique car; be usefu l . The patient is sitting w i t h the a rms crossed to opposite shoulders. With the dorsal hand the fifth rib is palpate d . The ven tral h and i s p l aced o n the pati e n t 's contralateral s h o u lder. The m o t i o n b arrier is localized by left s i deftexing and right rotating the thorax . From this pos i t i o n , the patient is ins tructed to h o l d s t i l l w h i l e t h e therapist app l i e s resistance to t h e tru n k . T h e direction o f the applied res i s tance i s determ ined by the neurophysio logical effect desired fro m the tech n i que . A h o l d/re l a x tech n i que applies the pri nciples o f autoge n i c i n h i b i tion a n d is used prim ari l y fo r a contractured musc l e . The invo lved muscle is recru i ted strongly and then m a x i m a l l y stretched in the immed i ate post-co ntraction rela x a t i o n phase. A contract/relax tech n i que app l i e s t h e principles o f reciprocal i n h i b i t i o n a n d i s used p r i m a r i l y fo r a h y perton i c m uscl e . T h e an tago n i s t m uscle i s recruited gently. T h e co n traction resu l ts in reciprocal i n h i b i t i o n of the an tago n i s t i c h yperto n i c muscle.


-

1 29

Figure 155. Vertebrosternal a n d vertebro chondral

regi o n

- u n i l a teral

restriction of pos t e r i o r rota tion

of

Ac t i v e

the

ri ght

fi ft h

mob i l i zation

rib. tech

nique.

Figure 156. Vertebrosternal and vertebro chondral region

- u n i l ateral

restri c t i o n of a nt e r i o r rota t i o n of t h e right fi f t h rib. Active m o b i l ization tec h n i q u e .

The isometric contraction is held for up to 5 seconds following which the patient is i nstructed to completely relax . The new motion barrier is localized and the mob i l izati on repeated three times. Home exercise. To maintain the mobility gained, the patient is instructed to perform specific midthoracic left sideflexion and right rotation frequently (up to ten times, ten times per day) . The ampl itude of the exercise should be in the painfree range and should not aggrav ate any symptoms. Mobiliza tion technique to restore anterior rota tion righ t fifth rib (Fig. 1 56) . The patient is sitting with the arms crossed to

opposite should ers . Wi th the dorsal hand the fifth rib is palpated. The ventral hand is pl aced on the patient 's contralateral shoulder. The motion barrier is local ized by right sideflex ing and left rotat ing the thorax . From this position, the patient is instructed to hold still while the therapist applies resistance to the tru nk. The di rec tion of the appl ied resistance is determ i ned by the neurophysiolog ical effect desi red from the technique. A ho ld/relax techn ique applies the principles of autogenic inhibition and is used primarily for a contractured muscle. The involved muscle is recruited strong ly and then m aximally stretched in the immediate post-contraction rel axation phase. A contract/relax technique appl ies the principles of reciprocal inhibition and is used primarily for a hypertonic mus cle. The antagonist muscle is recruited gently. The contraction

130

-

Manual Th erapy For The Thorax

Figure 1 5 7.

Vertebrosternal and vertebro chondral region - unilateral restriction of anterior rotation of the right fifth rib. Home exercise . results in reciprocal i nhibition of the antago nistic hypertonic mus cle . The isometric contract i o n is held fo r up to

5

seconds fol l owing

which the patient i s instructed to completel y relax . The new motion b arrier is loca l i zed and the m ob i l i zation repeated th ree times. Home exercise (Fig. 1 5 7) . To m a i n t a i n the m obi l ity gained, the patient i s i nstructed to perform specific m i dthoracic right side flexion and left rotation fre quent l y (up to ten t i m es, ten times per day). The ampl itude o f the exercise s ho u l d be in the painfree range and s h o u l d not aggravate any s y mpto m s .

Thoracolumbar j unction Un ila tera l restriction of flexion

A un ilateral restrict ion of flexion in the thoraco l u m b a r j unction will produce a segmental rotosco l i o s i s as w e l l as a compensatory


-

131

Figure 158. T h o raco l u m b a r

junction

-

u n i lateral restriction of flex

ion of the right zygapop hy seal

joint

at

T 1 1 - 1 2.

Mob i l ization techn ique.

multisegmental curve above and below the restricted l evel . Active forward bending of the trunk will reveal this asym metry. A unilat eral restriction of flexion on the right at Tl l - 1 2 will produce a right rotation/right sideflexion position of T l l at the limit of forward bending . Left rotation and left lateral bending of the trun k w i l l be restricted in a consistent pattern in both the H and I combined movement tests . The superior arthrokinematic glide of the right zygapophyseal j oint at T l l - 1 2 will be restricted if the dysfunction is intra-articular. The presence or absence of pain during these tests depends upon the stage of the pathology (substrate, fibroblasti c, maturation) and the irritabil ity of the surrounding tissue. The grade of the mobi lization tech nique is di rected by these factors (Chapter 3 ) . Mobiliza tion technique t o restore unilateral flexion o n the righ t at Tll - 1 2 (Fig. 158) . With the patient i n left sidelying, hips and knees slightly flexed, the T10-11 interspinous space is palpat ed. The thoracolumbar spine is rotated through the patient's lower arm until ful l rotation of T10- 1 1 is achieved. The Ll -2 interspinous space is palpated and the patient's uppermost hip and knee are flexed until ful l flexion of Ll-2 occurs . The foot of the upper leg rests against the popl iteal fossa of the lower leg. The T l l - 1 2 inter spinous space is palpated and the right zygapophyseal j o int is localized and mobi lized i nto flexion and left sidefl exion through either the thorax or the pelvic girdle . The technique can be graded from 1 to 5 .

132

-


Figure 1 59. T '1 o r a co l u mb a r

j unction

-

u n i l atera l res t r i ct i o n of flex i o n of the right zygap ophy s e a l j o i n t a t T l 1 - 1 2. Home exerc i s e .

An

active mobilization assist (muscle energy technique) may be used to effect a change in the muscle tone segmentally. When the motion barrier has been local ized, the patient is i nstructed to gen tly resist further sideftexion of the trunk. The isometric contraction is held for up to five seconds followed by a period of complete relaxation. The j o int i s then passively taken to the new motion bar rier, the techni que is repeated three times and followed by re-eval uation of osteokinematic fu nction. Home exercise (Fig. 159) . To maintain the mobility gained, the patient is i nstructed to perform specific thoracolumbar flexion and left sideftexion in a four point kneeling position frequently (up to ten times, ten times per day). The ampl itude of the exercise should be in the painfree range and should not aggravate any sympto ms. Unila teral restriction of extension A

u n i lateral restriction of extension in the thoracolumbar j unction will produce a segmental rotoscoliosis as well as a compensatory multisegmental curve above and below the restricted level. Act ive backward bending of the trunk will reveal this asymmetry. A uni lateral restriction of extension on the right at T l l - 1 2 will produce a left rotation/left sideftexion position of Tll at the l im i t of back ward bending. Right rotation and right latera l bending of the trunk w i l l be restricted in a consistent pattern in both th e H and I com bined movement tests (Fig. 160) . The inferior arthrokinematic gl ide of the right zygapophyseal j o i nt at T l l - 1 2 will be restricted


-

133

Figure 1 60. Th orac o l u m b a r

j un c t i o n

-

u n i l a teral restriction of e x t e n s ion of t h e r i g h t zygapo p h y seal j o i n t a t T l l - 1 2 w i l l co m

pletely bl ock t h e form a t i o n o f

t h e S c u rv e d u r i n g rotation of t h e tru n k .

Figure 1 61 . Thoraco l u m b a r

j u nction

-

u n i l a te r a l rest riction of e x t e n s i o n of t h e r i g h t zygapophy seal

joint

at

Tl l- 12.

Mob i l i z a t i o n tech niqu e .

i f the dysfunction is intra-articular. The presence or absence of pain during these tests depends upon the stage of the pathology (substrate, fibroblastic, maturation) and the irritabi l i ty of the surrounding tissue. The grade of the mobi lization technique is d irected by these factors (Chapter 3).

134

-


Mob iliza tion technique to restore unila teral extension on the right at Tll -12 (Fig. 1 61) . With the patient in left sidely ing, h ips and knees slightly flexed, the TlO- l l i nterspinous space is palpated. The thoracolumbar spine is rotated through the patient's lower arm until full rotation of T10- 1 1 is achieved. The Ll-2 inter spinous space is palpated and the patient's upperm ost h i p and knee are flexed until full flexion of Ll-2 occurs . The foot of the upper leg rests against the popliteal fossa of the lower leg. The T 1 1 - 1 2 interspinous space i s palpated and the right zygapophyseal j oint i s local ized and mob i l ized into extension and right sideflexion through either the thorax or the pelvic girdle. The technique can be graded from 1 to 5 .

An active mob i lization ass ist (muscle energy technique) m ay be used to effect a change in the muscle tone segmentally. When the motion barrier has been localized, the pati ent is i nstructed to ge n tly resist further sideflexion of the trunk. The isometric contraction is held for up to five seconds followed by a period of complete relaxation. The j oint is then passively taken to the new motion bar rier, the technique is repeated three times and fol l owed by re-eval uation of osteokinematic function . Hom e exerc ise (Fig. 1 62) . To m a i n ta i n t h e m o b i l i t y g a i n e d , t h e p a t i e n t i s i n s t r u c t e d t o p e r fo r m s p e c i fi c t h o r a c o l u m b a r e x t e n s i o n a n d r i g h t s i d e fl e x i o n i n a fo u r p o i n t k n e e l i n g p o s i t i o n fre q u e n t l y ( u p t o t e n t i m e s , t e n t i m e s p e r day) . The amplitude of the exercise should b e i n the

Figure 1 62 .

Thoraco l u m b a r j u n c t i o n u n i lateral restriction of exten- . sion of the right zygapophy seal j oint a t T l 1 - 1 2 . Home exercise.


-

135

p a i n fr e e r a n g e a n d s h o u l d n o t a g g r a v a t e a n y s y m p t o m s . HYPERMOBILITY WITH O R WITHOUT PAIN Hypermob i l i ty can be t h e r e s u l t of m aj o r trau m a over a short peri od o f time o r m i no r repe t i t i v e traum a over a l o n g period of t i m e . T h e essent i a l obj ective fi n d i n g for class ificat i o n h e r e i s t h e pres ence o f i n creased osteok i n e m a t i c motion o f e i t h e r the thoracic ver tebrae o r ribs. The m o d e of onset may b e either i ns i di o u s o r sudden depen d i n g u p o n t h e degree of trau m a . T h e i r r i t ab i l ity o f the w o u n d e d tissue d i ctates t h e intensity of the pain, the amount o f rad i a t i o n , the degree of p h y s i c a l act i v i ty which tends to aggrav ate i t a n d t h e a m o u n t o f rest requi red to rel ieve i t . T h e a i m o f the subj ec t i v e e x am i n ation i s to determ i ne the s t a g e and nature of the p a t h o l o g y so that treatm e n t m a y be adj usted accord i n g l y (Chapter 3 ) . An acute s u b l u x a t i o n of e ither a rib o r ' a r i n g ' ( s e e b e l ow) tends to produce very l o c a l ized pain over the i n v o l ved j o i n t . I n l o n gstand i n g conditions, the l o cati o n o f t h e p a i n i s p o o r l y l ocal ized t o a spe cific segme n t a n d tends to radiate over a regi o n o f t h e t h o ra x . Referral o f p a i n i s vari ab l e a n d can be e i th e r around the chest o r through i t . If t h e sympathetic c h a i n i s effected by t h e hypermob i l e segme n t , s y m ptom s can b e referred i n to the u p p e r o r lower e x t r e m i ty. T h e s e p a t i e n ts co m m o n l y r e p o r t tem perature Changes, heavy s ens at i o n s assocIated w i t h fatigue and nonspecific n u m b ness of the involved extrem i ty. T h e upper thorax can also refer p a i n i n t o t h e cran i u m thro u g h t h e s y mpathetic pathway. Hy perm o b i l e j o i n t s are very i n c o n s i stent in the pattern t h e y present on hab i tu a l m o v e m e n t test i n g . The active m o b i l i t y tests reveal a n abnorm a l movement p a t t e r n w h i ch i s variable dep e n d i n g u p o n the order in w h i c h the com b i n e d movements are perfor m e d . Sp ec i fi c m ob i l i t y and stab i l i ty test i ng reve a l s the h y p e rm o b i l ity/instab i l i t y s i nce d i s o rders i n t h i s c l a s s i fi c a t i o n e x h i b i t a l o s s o f arthro k i n etic fu nct i o n . The n e u ra l/dural mobility tests may b e p o s itive if t h e mob i l i t y o f the s y m pathe t i c c h a i n i s effected b y a c h a n g e i n p os i t i o n o f t h e head o f t h e r i b . S u b l u xation o f t h e costotransverse a n d costovertebral j oi n ts S u b l u x a t i o n s of t h e costotransverse j o ints are n o t u n c o m m o n a n d o c c u r secondary to rota t i o n a l t r a u m a o r a d i rect b l ow to the che s t .

136


The rib will be either superior or inferior on positional testing and all movements including the arthrokinematic g l i des are blocked . The j o i nt is hypomob ile until the subluxation is reduced. Fol lowing reduction of the sub luxation, the arthrokinetic tests for stabi l ity reveal the underlying h y perm o b i l ity of the rib . Stab i l ization is then requ ired . The treatm e n t techn ique to reduce a subluxed costotrans verse j oint is a grade 5 d istraction tech n ique .

Figure 163. Vertebro m a n u b r i a l

region

u n i l a tera l

subluxa

superior

-

-

Vertebromanubrial region

t i o n of t h e r i g h t fi r s t rib a t t h e c o s t otra n sverse

joint.

Mobi lization technique for a superiorly subluxed righ t first rib

Mob i l i za t i o n tech n i q u e .

at the costotransverse joint (Fig. 1 63) . To restore the i nferior glide of the first rib at the costotransverse j o i nt, the fo llowing technique is used. The patient is supine lying with the head supported on a p i llow. The superior aspect of the right fi rst rib is palpated with the lateral aspect of the MCP of the index finge r of the right hand. The m idcerv ical and upper thoracic spine i s supported with the other hand . The spine is locked by l ocalized sideftex ion of C7, Tl and T2 to the right and rotation to the left. The motion barrier of the first costotransverse j oi n t is localized by apply ing an anteroi nferi or glide to the tubercle of the rib . From th is position a h igh veloc i ty, low ampl i tude thrust is app l ied to the first rib in an anterome dial direction. If

the reduction is successful, the arthrokinematic glide at the cos totransverse j oint will be restored. An active mobi lization tech nique (see hypo mobile classification) may be required to attain myofascial bal ance and optimal osteoki nemati c funct i o n .

Anteriorly, the costochondral a n d sternochondral j o ints can become hypermobile/unstable and a source of localized anterior chest pain. Causes include excessive rotational trauma and/or a direct blow to the anterior chest. There is a palpable step or gap between the rib/cartilage or the cartilage/sternum, the arthrokinet ic test reveals a greater ampl itude of movement and is associated with local tenderness. When the two j oint surfaces are d isplaced or subluxed , reduction is not possible . The acute joint is treated with


-

137

Figu re 1 64.

Vertebrosternal and vertebro chondral region - u n ilateral subluxation of the right fifth rib a t the costotransverse joint. Po i n t of palpation for fixation of t h e rib. Figure 1 65.

Vertebrosternal and vertebro chon dral region - u n i l a teral subluxation of the right fi fth rib at the costotransverse j oi n t . S u p i n e m o b i l i z a t i o n tech nique.

rest, education regarding lim iting t h e use of the shoulder (to avoid further separation of the j oint with contraction of the serratus ante rior and/or pectoralis maj or/m inor muscles), local electrotherapeu tic modalities for pain relief and control of infl ammation and tap ing to limit motion of the thorax .

138

-


Figure 1 66. Vertebrosternal and vertebro chondral

region

-

u n i l ateral

subl uxation of the r i ght fifth rib

at

joint.

the

c o s t o t r a n sv e rse

Prone

m ob i l i z a t i o n

techn i q u e .

Vertebrosternal and vertebrochondra l regions Mobiliza tion technique for th e subluxed right fifth costo transverse joint (Figs. 1 64, 1 65) . The patient is l eft sidelyi ng, the

head supported on a p i l low and the arms crossed to the opposite shoulders. With the proximal phalanx of the l eft thumb, the rib is palpated j ust l ateral to the transverse process of the vertebra to which it attaches. The other hand/arm supports the patient 's thorax . Distraction of the costotransverse j o int i s ach i eved by rolling the patient over the dorsal hand only until contact i s made between the tab l e and the dorsal hand. Further axial rotation of the thorax against the fixed rib will distract the costotransverse j o i nt. A very low amplitude, high velocity thrust applied through the thorax in axial rotation will reduce the subluxatio n . Alternately, t h e technique can be done w i t h t h e patient prone l y i n g (Fig. 1 66) . To distract the righ t fifth rib, the left transverse process es of T4 and T5 are fixed with the left hand . With the other hand, the fifth rib is palpated j ust l ateral to the transverse process of T5 . If the subluxation is superior, the cranial aspect of the rib is pal pated. If the subluxation is i nferior, the caudal aspect of the rib is palpated. The rib is distracted at the costotransverse j o int by apply ing a posteroanterior pressure while fixing the transverse process es of T4 and T5 . A h igh velocity, low amplitude thrust is applied through the rib i n a superior or i nferior direction depending upon the direction of the subluxation. If the reduction is successfu l , the arthrokinematic gl ide

at

the cos-


-

139

totransverse joint will be restored . An active mobilization tech nique (see hypomob ile cl assification) may be required to attain myofascial balance and optimal osteokinematic function. Anteriorly, the costochondral and sternochondral j o ints can also become hypermob ile/unstab le and a source of localized anterior chest pai n . The causes, findings and treatment have been discussed in the vertebrom anubrial section. Thoracolumbar junction

Subluxation of the eleventh or twelfth ribs at the costovertebral joint is not common given the flexibility of the region. A sudden contraction of the ful ly stretched quadratus lumborum muscle (hyperextension from the fully flexed position) can sublux the twelfth rib inferiorly. Excessive rotation of the trunk while ful ly flexed can also sublux these j o i nts. When acute, the patient presents with a lateral shift of the trunk localized to the thoracolumbar j unction. All active movements are blocked at the thoracolumbar j unction. Any attempt to correct the lateral shift meets with resistance and an increase in the patient 's pai n . The lumbar myofascia is hypertonic on the side of the later al sh ift. The subluxed costovertebral joint is extremely tender to local palpation of the soft tissue overly ing the joint. Specific mob ility testing reveals a reduction in the arthrokinematic gl ide of the zygapophyseal j o ints between Tl 1 - 1 2 or T1 2-Ll and a com-

Figure 1 6 7. T h o r a co l u m b a r

j unction

-

u n i l a teral subl u x a t i o n of the right twe l fth rib at the cos t o v e r te b r a l Mob i l ization technique.

joint.

1 40

-

Manual Therapy For

Thorax

plete block of any glide b etween the suhluxed rib and its associat ed vertebra, The treatment technique to red uce a subluxed cosIo transverse j o int is a grade 5 distracti o n technique. Mobiliza tion techn ique to reduce a subluxed right twelfth costovertebral joint (Fig. 1 67) . With the patient i n sidelying,

h i ps and knees slightly flexed, the T 1 2-Ll i n terspinous space is palpated. The thoracolumbar spine i s rotated through the patie n t 's lower arm until ful l rotation of T 1 2-LI is ach ieved . The LI -2 i n terspinous is and patient uppermost and are flexcd u n t i l ful l flcxion of Ll-2 occurs. The foot o f the upper leg rests against the pop liteal fossa of the lower leg. The right side of the spinous process of TI2 i s palpated w i t h t h e therapist's cran i al hanet The twelfth is palpated and fixed w i th of the therapist's left hand. The right costhumb and i ndex tovertebral j o i n t between t h e twelfth rib a n d T 1 2 i s d istracted w i t h a h igh velocity, low amplitude thrust technique by a x i a l l y rotating the spinous process T I 2 away from the fi xed r i b . I f the reduction i s successfu l , t h e arthrokinematic glide a t the cos totransverse j oi n t w i l l be restored . An active m ob i l izati o n techn ique hypomobile classification) be to m y o fascial balance and optimal osteokinematic function. Subluxation of the

' rung'

Thi s subluxation i nvolves the entire ' ring' which i ncludes two adj acen t thoracic vertebrae , the i n tervertebral d i sc , the two ribs and their associated anterior and posterior j o ints and the sternum . Th is subluxation occurs primaril y the vertebrosternal region occasionaHy i n the vertebrochondral region. It can occur when excessive rotation i s appl ied to the unrestrained thorax or when rotation of the thorax i s forced against a fixed rib cage (seat helt i nj u ry). the l im i t right rotati o n in m i dthorax the vertebra has transl ated to the left, the left rib has translated pos tero laterally and the right rib has transl ated anteromedially such that a functional U j o i n t is produced (Chapter 2) . Further right rota tion in right lateral tilt 0 t h e superior v e rtehra . Subluxation of the superior vertebra occurs when the left lateral translation exceeds the physio logical motion barrier and the verte hra i s unable to return to i ts neutral position For the subluxation to occur proposed posteri o r a horizontal cleft through of t h e i n tervertebral d i s c m ust occur (Fig. 1 68). Positionally, the follow i ng findi ngs are noted with a left l ateral ribs), shift subl uxation the sixth (T5 -T6 and the


-

1 41

Ve rt e b ral Body ------...

S u p e ri o r Costove rt e b ra l

R i b ----r-,.,,;.;.�

Figure 1 68.

Anatomy of the lateral shift lesion It is p ro p osed that a c left horizontal occ u rs through the poste r ior 1/3 of the intervertebral disc confl u ent w i t h the s u p e r i o r cos tovertebral j o i nts bilateral l y allowing t h e su p erior vertebra to sublux laterall y . .

I nfe r i o r Costov e rt e b ra l J o i n t H o ri z o n t a l I nt ra-d i scal C l eft -�

Figure 1 69.

This patient sustained a left l ateral s h i ft of T5 and the left and right sixth ribs in a motor vehicle accident one month prior. Note the com p lete block of right rotation a t the subluxed segment.

1 42

-


Figure 1 70. Mobilization tech n ique for a left latera l shift of the sixth ring. Stron g d istraction must be m a i n t a i ned t h roughout the tec h n i que.

T6 is right rotated in hyperflexion, neutral and extension, the right sixth rib is anteromedial posteriorly and the left sixth rib is pos terolateral posteriorly. All active movements produce a ' kink ' at the level of the subluxation, the worst movement i s often rotation (Fig . 169). The passive tests of arthrokinematic funct ion of the zygapophyseal and costotransverse joi nts are reduced but present. The right mediolateral tran slation mobil ity test is completely blocked. Prior to reduction of the subluxation the arthrokinetic tests for sta bility are normal . Subsequent to reductio n, the arthrokinetic tests of anteroposterior costal stabil ity are normal, the right rotational test of TS -T6 is positive and there i s excessive left lateral transla tion of the ring. Mobilization technique for a left lateral shift of the sixth ring (Fig. 1 70)

The patient is in left sidelying, the head supported on a pi llow and the arms crossed to the opposite shoulders. With the left hand, the right seventh rib is palpated posteriorly with the thumb and the left seventh rib is palpated posteriorly with the index or long finger. T6 is fixed by compressing the two seventh ribs towards the m i dline. Care must be taken to avoid fixation of the sixth ribs wh ich must be free to glide relative to the transverse processes of T6 . The other hand/arm lies across the patient's crossed arms to control the tho rax . Segmental local ization is achieved by flexing and extending the joint until a neutral position of the zygapophyseal joints is achieved. This localization is maintained as the patient is rolled


-

1 43

s u p i n e o n ly u n t i l c o n t a c t i s m a d e b e t w e en t h e t a b le a n d th e dors a l h a n d. Fr o m t h i s p o s i t e ft a n d r i g h t s i x t h r i through t h e t h o r ax tra n s l a t e d l at e r a m o t i o n b a r r i e r. n a l d i s tr a ct i o n i s through t h e t h e application of v e l o c ity, l o w The thrust is in a d i re c t i o n i n t h e t r a n s v e r s e p l a n e . T h e g o a l o f t h e t e c h n i q u e i s t o l a t e r a l l y t r a n s l a t e T 5 a n d t h e l e ft a n d r i g h t sixth ribs r e lative to T6. Fo l l o w i n g r e d u c t i o n o f t h e s ub l u x a t i o n , t h e a r t h r o k i n e t i c t e s t s fo r m e d i o l a t e r a l t r a n s l a t i o n w i l l r e v e a l t h e u n d e r l y i n g i n s t ab i l i t y ization is then req S TA B I LI ZAT I O In addi t i o n to the thorax, cum m i cr o t r a u m a c a n lead t o postural changes, a l t e r e d move m e n t p a t t e r n s a n d a s s o c i a t e d fu n ct i o n a l i ns t ab i l i t y . S t ab i li z at i o n t h e rapy i s a concept w h i ch considers t h e i n t e g r a t e d r e l a t i o n s h i p b e tw e e n t h e l e g s , p e l v i c g i r d l e , t r u n k a n d u p p e r e x t re m i t y . T h e c e n t r a l f e a t u r e o f t h i s concept i s t h a t t h e tru n k muscles m u s t h o l d the vertebral column stable ependent upper and extre m i ty m ove a n d a l s o t h a t l o ad m t r a n s fe r r e d fro t r c m i t y t o t h e g r o u n d2 E s s e n t i a l l y, t h e to specifica l l y recru t ru n k m u s c l e s y d then to mainta brace a s t h e y m o v e the u p p e r a n d lower e x trem i t i e s i n d e p e n d e n t l y . I n i t i a l l y, t h e b a s e o f s u p p o r t i s v e r y s t a b l e . T h e p r o g r a m i s p r o g r e s s e d b y i n cr e a s i n g t h e d e g r e e o f d iffi c u l t y b y r e d u c i n g t h e b a s e o f s u p p o r t , b y m a k i n g t h e b a s e m o r e u n s t a b l e a n d/o r b y i n c r e a s i n g t h e l o a d w h i c h must be control led The program is directed by the p at i e n t ' s n e e d s only b y the therap imagination . Th asti c ball s , rol ls , b boards and pu 1 tabi l i za t i o n therapy e ffe c t i v e , f u n allenging. Figures 1 9 1 i l l u s tr a t e rci ses used i n stab i l t h e r a p y . T h e r e a d e r i s r e fe r r e d t o I r i o n 26 a n d S a a 1 27 fo r fu r t h e r i d e a s o n s t a b i l i z a t i o n t r a i n i n g w h i c h i n v o l v e s t h e t o t a l m u scu l o s k e l e t a l s y s te m .

1 44

-


Figure 1 71 . Tru n k bracing - level 1 . Th e patient

is

taught to co-con

tract the a n terior a n d poster i or trunk mu scles isometrical ly without excess ive posterior pelv i c t i l t i ng. When done cor rec t l y t h e lower cos t a l m a r g i n should

be

level

with

the

pelvic gird l e u n l i ke t h e m o d e l i n t h i s i l lustration who is p o s teriorly t i l t i ng h i s pelvic g i r dle

too

much.

A

pressure

b i ofee d b ack u n i t o r a blood press ure cuff p l aced

in

the

lumbar region c a n be a useful tool for e d uca t i o n . Proper co contract i o n o f the trunk mus cles will elevate the pressure i n the cuff 10 to 1 5 points on t he pre s s u re gauge.

Figure 1 72 . T r u n k braci n g - level 2. The p a t i e n t is i n s tructed to m a i n t a i n the co-co ntraction as i n level l a n d t o flex the h i p a n d knee t o 90 d egrees. T h e pres s u re gauge s h o u l d rem a i n at the same level if the co-con tract i o n is m a i n t a i ned proper ly.

N O R M A L M O B I LI T Y W I T H PA I N

P a t i e n t s p r e s e n t i n g w i th p a i n i n t h e t h o r a x w i t h o u t o bj e c ·· t i v e m e c h a n i c a l f i n d i n g s c a n b e a c h a l l e n g e to t r e a t . G i v e n t h e n a t u r e o f v i s c e r a l r e fe r r a l o f p a i n t o t h e t h o r a x , a team appro ach t o t h e p rob l em i s b e s t . I f all m e d i c a : c o n d i t i o n s a r e r u l e d o u t and t h e re i s n o s p e c i f i c a r t i c u l ar, m u s c u l a r , n e u r a l o r d u r a l m o b i l i t y d y s f u n c t i o n t o be fo u n d t h e n a p o s t u r a l a p p r o a c h fo l l o w i n g the p r i n c i p l e s


Figure 1 73. Trunk bracing - level 3 . From the starting pos i t i o n of level 2, the patient i s i n s t ructed to maintain

the

co-cont raction

of the trunk and to bring the opposite h i p and knee to 90 degrees w i t ho u t l o s i n g t runk contro l .

Figure 1 74. Trunk bracing - l evel 4. From the starting p o s i t i o n of level

3 , the patient i s instructed to maintain of

the

t he trunk

co-co n traction and

slowly

extend o n e l e g w i t h o u t l o s i n g trunk con t ro l .

of s t ab i l i z a t i o n t h e r a p y c a n be t r i e d . R e p e t i t i v e o v e r u s e o f t h e a r t i c u l a r a n d m y o fa s c i a l t i s s u e w i l l r e s p o n d t o t h e ap p r o p r i a t e co r r e c t i o n o f r e s t i n g a n d w o r k i n g p o s t u r e s t o g e t h e r w i t h a n e x e r c i s e p ro g r a m a i m e d at b a l a n c i n g t h e trunk musculature and restoring optimal movement pat t e r n s . D i l i g e n c e a n d co m m i t m e n t o n t h e p a r t o f t h e p a t i e n t a n d t h e r a p i s t i s r e q u i r e d t o a c h i e v e s u c c e s s fu l r e h ab i l i t a t i o n .

146

Figure 1 75.

Trunk bracing - level 5. From the starting position of level 4 , the patient is instructed to m a i n t a i n the co-contraction of the t ru n k and s lowly extend both legs without los ing trunk contro l . Figure 1 76.

Trunk control with an unsta ble base. The patient is i nstructed to co-contract the trunk, tighten the b u t tocks (recr u i t the gl uteus max imus), press the inner thighs together (recruit the adduc tors if there is an unstable pubic symphysis) and then to use the hamstrings to l i ft the trunk off of the table. The l ift should occur at the scapular l ev e l and not through the uns table segment. This exer cise is p rogressed by i ncreas i ng the height of the eleva t i o n . O nce fu l l l i ft is achieved, the patient is i nstructed to rol l the ball from s ide to side w i t h contro l .

-



-

1 47 Figure 1 77. Tru n k c o n trol w i t h an u n s t a

I f t h e pa t i e n t

ble

base.

out

r e p ro d u c i n g

is

u na b l e to l i ft the trun k with

symptoms

the b a s e m a y be a l tered b y

placing t h e pa t i e n t o n a 1/2 ro l l . With t h e trunk b raced , a

vari e t y of e x e r c i s es m a y be perform e d such as u n i l ateral

or b i l a teral e l ev a t i o n o f the arms,

u n i l ateral

or

b i l ateral

elev a t i o n of t h e feet or roll ing a ball w i t h o n e or two fee t .

T h e therapist c a n in crease t he c h a l l enge by app l y i n g re sis

tance

to

the

stick

held

between the pa t i e n t s h a n d s . '

The

d i rect i on

tance

is

of

d ic t a t e d

p a t i en t ' s needs.

the

resis

by

the

Figure 1 78. Tru n k control knee l i n g .

in fo ur p o i n t Pro p ri ocep t i o n

from t h e s upport i n g su rface i s

decreased thus i n c r e a s i ng the

diffi c u l t y of the e x e rcise . The pa t i e n t their

is i n s t r u cted to find

n e u t ra l

pos i t i o n .

t h o raco l u m b a r

1 48

Figure 1 79. Tru n k control k n e e l i ng .

in fo u r p o i n t

The

i n structed

to

p at ie nt

ma i ntain

n e u tral t r u n k pos i t i o n

s i t back '

and

w i t h o u t flex i n g

b re a k i n g '

through

is

their to or

their

u n s t able regi o n .

Figure 180. Re-education of the s e g m e n

t a l neutral p o s i t i o n . An u n s t a

b le

s egm e n t

oft e n

re m a i n s

kyphosed w h e n t h e rest o f t h e

col u m n

extends.

Specific e x t e ns i o n

vertebral

exercises

over a ball (ro l l ing fo rward and backward) t o gethe r w i t h a

50 Hz m uscle s t i m u l a t i n g

curre n t over t h e i n volved seg

ment can help to res t o r e the

appropr i a t e m o t i o n .

-



-

1 49

Figure 1 81 . Trunk control with

dent

i ndepen A p ro

arm movemen t .

gression to the above exercise is to i n struct

u n i laterally

the patient to elevate

ab d u c t or

one arm while m a i n taining a stable tru n k

.

Figure 182. Tru n k control w ith

dent

arm

indepen movement. A fur

ther progression to the above exercise

is

to

i n struct

the

p at ient to l ift one arm for

ward,

the other arm backward

s pecifica l l y e x tend the as they roll forward on the bal l . The arm pos i tion is then reversed as t h e y rol l

and to tru n k

back.

150

Figure 183.

Taping

for p roprio cep t ive When the segmental myofascia is unable to control excessive angular or linear motion, tape can be a useful temporary rem i nder as to which movements the p atient s h o u l d avo id . Flexi o n and rotation can be controlled but not preve nted by app l y i ng tape obliquely across t h e unstable region. input.

-

Man u a l Th erapy For Th e Thorax


-

151

Figure 1 84.

Tru nk control with i n d epen dent arm and leg movement. The patient is instructed to maintain their neu tral trunk pos ition and to u n i latera lly elevate one arm and extend the opposite leg.

Figure 1 85 .

Tru nk control with indepen dent a r m and leg movement on a n unstable base. The dif ficulty of the above exe rcise can be increased by decreas ing t he base of support with two 1/2 rolls.

152

Figure 1 86. Tru n k control - s i tting. The p a t i e n t is taught to ach ieve a n e u t r a l t r u n k pos i t i o n while s i t t i n g o n a bal l . The exercise is progressed b y having them move the ball backwards, fo r wards

and

sideways

while

m a i n t a i n i n g t r u n k contro l .

Figure 188. Tru n k control - s t a n d i n g . The patient

is

contract m ove wards,

i n s t ructed the

the

to

trunk

body

co

and

to

w e i g h t for

backwards,

s i d ew a y s

a n d arou n d w h i le s t a n d i n g o n a wobb l e board .

Figure 1 8 7. Tru n k control - si tting. The exercise is progressed b y hav i n g t h e patient s l owly lower the

contro l l ed

supine

t ru n k

s u pp o r t e d

i n to

a

pos i t i o n

fro m t h e seated posi t i o n . Care is

taken

unstable fl e x

to

e n s u re

segment

that

the

does

not

or t r a n s l a te d u r i n g t h i s

exercise.

-



-

153 Figure 1 89. Tru n k con t rol - s t a n d i n g and patient

The

ro t a t i n g .

is

i n s tructed t o co-co n t ract the t r u n k a n d to m o v e t h e body ro t a t i o n

through around

the

by

turning bearing

weight

fem u r . T h i s exercise requi res control o f the t r u n k and t h e h i p rotators . Resista nce m a y be added t hro u g h pu l l ey s o r res i s ti v e tub i n g .

Figure 1 90. Tr u n k control - s t a n d i n g a n d The p a t i e n t

p u s h i n g/pu l l i n g. is

i n s tructed

to

co-con tract

t h e trunk a n d t o push/p u l l a load

by

using

the

l ow e r

extrem i t i e s . Care is taken to ens ure that the u n s t a b l e seg ment does not fl e x or translate d u r i n g t h i s ex erci s e .

Figure 1 9 1 . Trun k contro l - s t a n d i n g . T h e p a t i e n t is i nstructed to s t a n d on a 1 /2 ro l l , to co-contract the t r u n k and then to u n i later ally

and

b i l a t eral l y

e l ev a t e

t h e i r arms. T h e exercise can be

progressed

by

toss i n g

a

ball to the p a t i e n t v a r y i n g t h e speed and t h e d irec t i o n of t h e t h row .

154

-

Manual Therapy For

Thorax

REFERENCES 1 . Hayashi K, Yahuki T 1 985 Origin of the u ncus of Luschka's

j oint in the

spine. JBJS

788-79 1

2. Penning L, Wilmink J T 1 987 Rotation of the cerv ic a l spine - A CT study i n norma l subj ects. Spine 1 2 : 73 2 3 , Wil l iams P, Warwick R, anatomy. 37th Churchi l l 4. Davis P R 1 95 9 The medial inclination of the human thoracic i ntervertebral articular facets. Journa l of Anatomy 93 : 68

v ivo :13

Biomechani cs Journal of

c l i n ical m odel and Man Therapy

6 . Lee D G 1 994 Biomechanics of the thora x . Chapter 3 i n : Physical Therapy of t h e Cervical a n d Thoracic Spine. Ed : Ruth Grant. Church i l l Livingstone, York A A 1 976 Brand R A, Panj abi ties of the human thoracic spine. JBJS 58A:642

proper-

8, Saumarez R C 1 986 An analysis of possible m ovements of human upper cage . Journa l Appl ied 60:678 Saumarez R C 1 986 An analysis of action of intercostal muscles i n h u m an upper rib cage . Journal of Applied Physiology 60:690 1 0 . Andriacch i T, Schultz Bclytschko T, Galante J 1 974 A of mechanical i n teractions model for the hum J. Biomechanics 7 : 497 spine and 1 1 . Ben-Haim S A, Saidel G M 1 990 M athematical model of chest w a l l m echan i cs : A phenomenological approa c h . A n n a l s of Biomedical Engincering 1 8 : 37 1 2 . M acConaill A, Basmaj i an V 1 977 and move ments; a basis for human kinesiology. 2nd edn. Kreiger, New York 1 3 . Panj abi M M, Hausfeld J N, White A A 1 9 8 1 A biomechanical study of the l igamentous of the thoracic spine in man , Acta orthop. 52:3 15


-

155

1 4 . Bogduk N 1 99 1 Contemporary b iomechanics of the cervical spine. In: MPAA 7th Biennial Conference Proceedings, Blue Mountains, New Australi a 1-7 1 5 . Bogduk N , spine. 2nd edn.

Clin ical anatomy o f the Melbourne

1 6 . S tewart S lul l G 1 993 Analysis of thoracic spine m ovement during unilateral arm elevation In: Singer KP (ed) I ntegrating Approaches . Proceed ings of the Eight B iennial Conference of the Manipulative Physiotherapists Association of Australia November 24-27 Perth Western Australi a p 1 03 - 1 05 1 7 . Kendall F P, testi n g and function.

Provance P G 1 993

1 8 . Machida M, Kimura J 1 993 genesis of i diopathi c

Imamura Y, Iwaya T, Yamada i n chi ckens for the 18:12

1 9 . Magu ire J , Madigan R , Wal l ace S , Leppanen R , D raper V 1 993 Intraoperative long-latency rel fex activity i n idiopathic sco l i o s i s demonstrate abnormal central processing: a possible cause of i d i o path i c scol i o s i s . Spine 1 8 : 1 2 20. Peacock E

3 rd edn. W B

London and C l i n i cal Stress Proceed i n g s Orthopaedic Man i p u l a t i v e Physiotherapists, Orthopaedi c D ivision of the Canadian Physiotherapy Association Newsletter November/December 1 99 1 15-19 2 2 . Oldham J 1 993 Personal communication

23 . Butler D S 1 9 9 1 Livingstone , Melhourne 24. Brown C Brugm a n J L 1 992 Spine 1 7 : 6 Supplement

the nervous system .

Akm akj ian J , Donaldson of thoraci c disc herni ation.

25 . S n ij ders C J , Vleem i n g A , S toeckart R 1 993 Tra nsfer of lum bosacral load to il iac bones and legs Part 1 : Biomechani cs o f self bracing of the sacro i l iac j oi nts and its significance for treatment

156

-

Thorax

j\;fallual

and exercise. Part 2 : Loading of the sacroi l iac j oi n ts when l i fting posture , Cli nical B i o mech a n ics 8: 285 - 3 Cll in a 2 6 . Irion J M 1 992 Use of the gym ball i n rehabilitation of spinal dysfunction. Orthopaedic Physical Therapy Cli n ics of North America : 2 27. Saal J A trai n i n g Part

The n e w b ack school prescript ion : stab i l i zation Occupational Med icine 7 : 1 33 -42

1992 II

Manual Therapy for the Thorax: A Biomechanical Approach

The Thorax: An Integrated Approach

The Thorax

The Relaxation Therapy Manual

Manual Therapy for the Peripheral Nerves

Manual Therapy for the Cranial Nerves

Manual Therapy Case Studies: A Problem Based Approach

Functional Neurology for Practitioners of Manual Therapy

Manual Medicine Therapy

Stretching Therapy: For Sport and Manual Therapies

Neuromuscular Therapy Manual

Manual Therapy in Children

Acupuncture in Manual Therapy

Overcoming Depression: A Cognitive Therapy Approach Workbook

NeuroKinetic Therapy: An Innovative Approach to Manual Muscle Testing

Integrative Manual Therapy: For the Upper and Lower Extremities

Integrative Manual Therapy for the Connective Tissue System: Myofascial Release

Manual of Botulinum Toxin Therapy

Manual of Diagnosis and Therapy

Manual of HIV AIDS Therapy

Manual of Botulinum Toxin Therapy

A New Approach to Manual Lymphatic Drainage

Grieve's Modern Manual Therapy: The Vertebral Column

Manual Physical Therapy of the Spine

Manual Physical Therapy of the Spine

The Cleveland Clinic Manual of Headache Therapy

Manual Therapy Masterclasses-The Vertebral Column

Manual Therapy Masterclasses-The Peripheral Joints

Who Calls The Tune?: A Psychodramatic Approach to Child Therapy

Manual Therapy for the Thorax: A Biomechanical Approach

The Thorax: An Integrated Approach

The Thorax

The Relaxation Therapy Manual

Manual Therapy for the Peripheral Nerves

Manual Therapy for the Cranial Nerves

Manual Therapy Case Studies: A Problem Based Approach

Functional Neurology for Practitioners of Manual Therapy

Manual Medicine Therapy

Stretching Therapy: For Sport and Manual Therapies

Neuromuscular Therapy Manual

Manual Therapy in Children

Acupuncture in Manual Therapy

Overcoming Depression: A Cognitive Therapy Approach Workbook

NeuroKinetic Therapy: An Innovative Approach to Manual Muscle Testing

Integrative Manual Therapy: For the Upper and Lower Extremities

Integrative Manual Therapy for the Connective Tissue System: Myofascial Release

Manual of Botulinum Toxin Therapy

Manual of Diagnosis and Therapy

Manual of HIV AIDS Therapy

Manual of Botulinum Toxin Therapy

A New Approach to Manual Lymphatic Drainage

Grieve's Modern Manual Therapy: The Vertebral Column

Manual Physical Therapy of the Spine

Manual Physical Therapy of the Spine

The Cleveland Clinic Manual of Headache Therapy

Manual Therapy Masterclasses-The Vertebral Column

Manual Therapy Masterclasses-The Peripheral Joints

Who Calls The Tune?: A Psychodramatic Approach to Child Therapy

Recommend Documents