The Thorax: An Integrated Approach

MCPA I'CAMT THE THORAX An Integrated Approach DIANE LEE BSR (Honours), FCAMT Wh i te Rock, British Columbia, Canada...

Author: Diane Lee

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MCPA I'CAMT

THE THORAX An Integrated Approach

DIANE LEE BSR (Honours), FCAMT

Wh i te Rock, British Columbia, Canada

Copyright 2003 Diane C. Lee Physiotherapist Corporation

ISBN 0-9732363-0-2

For my momI

will always remember for both of us For my dad and my brother unconditional love

PREFACE, 1ST EDITION In the literature pertaining to back pain, the musculoskeletal components of the thorax have received little attention. The reference list at the end of this text reRects the paucity of research available for review. And yet, clinicians are presented daily with the challenge of treating both acute and chronic thoracic pain. It was this challenge which initiated the clinical work presented in this text. A biomechanical approach to treatment of the thorax requires an understanding of its normal behaviour. Without a working model, the clinician is limited to using unreliable symptoms for direction and treatment planning. If the optimal behavior of the thorax is understood, then this knowledge can be applied to the examination of the painful thorax. A systematic examination of mobility/stability of the associated bones and joints can then be done. Since function is related to structure, an understanding of the anatomy is required. The clinical investigation began in J990 when Jan Lowcock presented a paper on stability testing of the thorax to the Canadian Orthopaedic Manipulative Physiotherapists. I am indebted to her, and many others, for the subsequent academic and clinical discussions which lead to the evolution of the bio mechanical model presented here. Much of this material remains empirical and requires validation through research. The First chapter reviews the anatomy of the thorax as it pertains to the biomechanical model. The emphasis has been placed on osseous and articular anatomy although the muscular and neural con tribution to function is acknowledged. Chapter two describes the biomechanical model and chapters three to five the clinical application of this model to examination and treatment of the thorax. The purpose of this text is to provide the clinician with the ability to assess and treat articular dysfunction of the thor
PREFACE & ACKNOWLEDGEMENTS, 2ND EDITION It's been nine years since the first edition of this text was published and while there is still a paucity of research in the thoracic spine, there have been some significant clinical developments that warrant another look at this topic. For the most part, the biomechanical model has been accepted as written and incorporated into several schools of manual therapy instruction. The most Significant change is perhaps the long held view that a restriction of articular motion implies that the joint is at fault. This change has come from a clearer understanding of what can affect the neutral zone of motion and the development of an integrated model of function which considers the role of both the mind and body

on human performance. This model was developed in conjunction with Dr. Andry Vleeming (Lee & Vleeming 1998, 2002) and has been applied to the thorax in this edition, the principles of lhis model are described in Chapter 2. Chapter 3, biomechanics of the thorax, has been updated lo include research since the first edition was published. Chapter 4 has been updated with video clips on a CDROM to demonstrate the aClive and passive mobility and stability techniques previously described in the first edition. In addition, new techniques are presented which analyse the force closure mechanism (dynamic stability) of a thoracic segmenl. The classification of dysfunction within the thorax has been changed to follow the integraled model of function. Chapter6 has been updated with video clips on a CDROM lo demonstrate the passive and aClive mobilization and manipulation techniques for the thorax. Chapter 7 is brand new for this edition and contains vital information for an exercise program aimed al stabilization of the thorax. Some of the exercises are illustrated via still photos while olhers can be seen on the CDROM. The information is still empirical since research is lacking in this area and comes primarily from clinical experience. This chapter reviews some of the concepts of load transfer through the body, the analomy and function of the lumbopelvic core (Lee D G, 1999) and the application of lhis protocol {'or stabilization of the thorax. Chapter 7 is written by Linda-Joy Lee (BScPT,FCAMT) and demonstrates her phenomenal ability to integrate concepts from many models. She is a superb clinician, excited by clinical and educational challenges and I thank her for laking on lhis one. A project such as this does not come together through individual effort and 1 would like to acknowl edge the production team whose ideas and guidance have resulted in an educational producl that goes beyond my original intent. Edi Osghian from DV Media Inc. co-ordinated the project and was instru mental in putting it all together, thank you Edi and yes you were righl- a make-up artisl was a greal ideal The still photos were taken by a superb photographer, Goran l3asaric whose attenlion to detail and lighting drove us crazy for two days but in the end - I was impressed with what a little bil of light in the righl place could dol Steve Sara filmed the video clips with a camera that was almost as big as he was. No rewinds or reviews were possible - "trust me, [ got it right" - and he did. And none of the photos or video clips would have been possible without the assistance or our model, Melanie Coffey, Thanks Mel For saying "Sure, J can do that." Little did she know all that we would expect from her.1 have collaborated on several projects with artist Frank Crymble; and once again he came lo my rescue redrawing the complicated, combined biomechanics of the thorax meeting my demands for visual sim plicity, yet accuracy. His patience for my persistence has always impressed me, thank you Frank. And last, but certai nIy not least, thank you to Laura Galloway for designing the layoul for aII of this materiaI in such a visually pleasing and easy to read format. There are many people who have contributed to my educational and personal growth that has ulti mately allowed me to give this material to you, the clinician. J would like to acknowledge my heartfelt appreciation to Dr. Andry Vleeming, who challenged me to let go of my biases and see the human expe rience from a different perspective and to Karen Angelucci, who taught me to explore a different way of living in my own body through exercise in the method of Pilates. As always, I am especially grateful for my family, Tom, Michael and Chelsea who allow me the time, and provide the encouragement, so necessary to continue along lhis path of enquiry. British Columbia, 2003 D.L.

CONTENTS

CHAPTER 1 ...13

ANATOMY OF THE THORAX

..........1 4

OSTEOLOGy ....

....1 4

Vertebromanubrial Region. Vertebrosternal Region .

....16

. .

Vertebrochondral Region

.......... 18

Thoracolumbar Region ...

..........20

ARTHROLOGy ................... Costal Joints.. .................... Intervertebral Disc

..........20

.

Zygapophyseal Joints . .. .

. .

.

.

. .

.

. .

...........20

.

.....21

.

..

..

.

.

MYOLOGY . .. ...................................

.

.....22

.

.....22 .....22

Local System - Classification Global System - Classification................ Local System - Anatomy................... Global System - Anatomy ................

.....22

.

.

.....22

.

.....25

CHAPTER 2 PRINCIPLES OF THE INTEGRATED MODEL OF FUNCTION . . 29 .

. .

...30

INTRODUCTION.

...... 31

FIRST COMPONENT - FORM CLOSURE . SECOND COMPONENT - FORCE CLOSURE ................

......32

.

.......33

Lumbopelvic Stabilization - The Research Reviewed The inner unit - Local system - The core ..

......33

The outer unit - The global system - The slings ........... ... . .

.......36

THIRD COMPONENT - MOTOR CONTROL .. ... .....................

.....38

.

FOURTH COMPONENT - EMOTIONS & AWARENESS

.......38

CONCLUSION

.......39

. . .

. . . . . . .

. . . . . .

. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .

CHAPTER 3 ... .... 41

BIOMECHANICS OF THE THORAX .. TERMINOLOGY. LITERATURE REVIEW

..

... ..... ....... 42 .... 42

..

CONTENTS

......... 43

FUNCTIONAL MOVEMENTS Vertebrosternal Region ......................... F lexion ..................... .

......... 43

.

. ... ... 43

.

Extension.. . ...........

........ 46

.

........ 48

Lateral bending

.......5 1

Rotation... . ... .... . . . .

......53

Vertebrochondral Region

......5 4

Flexion/extension Lateral bending

....5 4

Rotation

..... 55

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . ..

...55

Vertebromanubrial and Thoracolumbar Region F lexion/extension .................................................. . Lateral bending... ....... ...

.

.....55 . ..56

.

............ 56

Rotation ...

...........57

RESPIRATION

...................57

SUMMARY

CHAPTER 4 DIAGNOSING THE THORACIC DYSFUNCTION

........... 59

SUBJECTIVE EXAMINATION

......... .60 .......60 ......... 60

Pain/Dysaesthesia Sleep ..

..... ...60

Occupation/Leisure activities/Sports

.... .....60

General Information .....................................

...........60 ...........60

OBJECTIVE EXAMINATION

........60

Postural Analysis .

.....63

Functional Movement Tests - Regional Tests Forward and backward bending .. ................

.....63

.

64

Lateral bending..........................................

...6 4

Axial rotation Respiration ................................................................

........6 4

Functional Movement Tests - Segmental Tests Forward bending.

.

.

.

. .

.

.

.

.......6 4

. .

..

.. .

....6 4

Backward bending

........65

Lateral bending........... ........ .. .. .... .............

.........66

Rotation .................... . Respiration

..67 . . . . .

67

CONTENTS

.......67

Articular Function - Form Closure.... ......... .....

... ...67

Passive mobility tests of ost.eokinematic function

. . ... 68

Passive mobility tests of arthrokinematic function .

Zygapophysea/ joints.

..

.

. . . . .

.

..

. . . . . . . .

.

.

..............69

. .

....70,71

Costotransverse joints

...............72

Lateral translation.

........73

Passive stability t.ests of arthrobnetic function Vertical (traction!compression) ................................... .

..73

.

Anterior translation - spinal

74

Posterior translation - spinal

.........74 ........ 75

Transverse rotation - spinal ........................ . .

Anterior translation - posterior costal............ ..............

........76

..

.........76

Anterior/Posterior translation - anterior costal ............... . .

Lat.eral translation.

.

. .

.

.

..

. .

. . . . . . . .

. . .

.........76

.

......... 77

Neuromyofascial Function - Force Closure and Motor Control

.........77

Palpation of the segmental local st.abilizers . �une ann /� ...................

.

.

.

.

. . .

.

.

. .

...

. . . . . .

.........78

Test for the integrity of the active force closure mechan:isrn

.........78

Neural Conduction and Mobility. Adjunctive Tests......................................

.........77

.........79

.

CHAPTER 5 .........81

CLASSIFYING THE THORACIC DYSFUNCTION INTEGRATED MODEL OF FUNCTION CLASSIFICATION .

Excessive Articular Compression with an Underlying Instability Insufficient Articular Compression.

. . . . . . . . .

.. .............................. .

Excessive Articular Compression ...

. . . .

.

. . . . .

83 83

.........83 ..........83

CHAPTER 6 RESTORING FORM CLOSURE OF THE THORAX

..........85

EXCESSIVE ARTICULAR COMPRESSION - STIFF JOINT

.

Bilateral Restriction of Flexion

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Vertebromanubrial regi.on .................................. Vertebrosternal/vertebrochondral region Unilateral Restriction of Flexion................................... Verlebromanubrial region

.........88 .......88 ..... 89 .

....90 ..90

..

m

CONTENTS

Vertebrosternal/vertebrochondral region Thoracolumbar region

..........90

........

. ........ 91

Bilateral Restriction of Extension

......... 91

Vertebrornanubrial regiol1

......... 91

Unilateral Restriction ofExtension Vertebrornanubrial region. .

................. 91 . .

.

.

. .

.. .

. . . . . .

.

. .

. .

. ..

. ........ 92

.

Vertebrosternal/vertebrochol1dral region

. ......... 92

T horacoluntbar region .........................................

....... 92

.

Unilateral Restriction of Rotation - Rib.............................. ............................

. ....... 93

.

Vertebromanubrial region - restricted anterior rotatiol1. .. . .

.....93

Vertebrol1lanubrial region - restricted posterior rotatiOIl

. .... 93 .

Vertebrosternal/vertebrochondral regiol1s.....................................................

.

.......9-+

.

EXCESSIVE ARTICULAR COMPRESSION - COMPRESSED JOINT

94

. .. . .. .....95

Unilateral Restriction of Flexion/Right Sideflexion/Right Rotation. Unilateral Restriction of Inspiration

....... 96

.

Unilateral Restriction of Expiration . . . . .... .... .. .. . . . . .. . . . .. . . . . . . . . . . . . . . . .... . .... 96 .

. .

. . . .

.

.

.

.

.

.

.

. . .

.

.

.

.

. . .

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

. . 96

EXCESSIVE COMPRESSION WITH AN UNDERLY ING INSTABILITy

.

Fixation ofthe Costotransverse/Costovertebral Joint ............................................ Vertebro",wl1ubrial region

. ..

.

.

...... 9 7

.

..

....9 7

Vertebrosternal/vertebrochondral region

...... 97

'n1.oracolumbar region .........................................

. ...... 98

.

Fixation of the 'Ring' .................... .

....... 99

CHAPTER 7 RESTORING FORCE CLOSURE IMOTOR CONTROL OF THE THORAX

. . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

.......... 103

INTRODUCTION ................................................... .

..10-+

.

CONCEPTS OF LOAD TRANSFER ........................ .

..105

.

Optimal Load Transfer Through the Thorax................ .

.. 105

Dysfunctional Load Transfer Through the Thorax

.. 106

DEVELOPING THE EXERCISE PROGRAM

. 10 7

THE EXERCISE PROGRAM.

108

Introduction to Stabilization Exercises for the Lumbopelvic Region. Pelvic floor.

. . . .

.

. . . . . . . . . . . . . . . . . . . . . . . .

Transversus abdo'

. . . . . . .

. .

.. .

. . . . . .

.

.

. . . . . . . . . . . . . . . .

. . . . . . . . . . . .

.

. . . .

..108

. . .. .

.

....109

.....109

Deep fibres

.111

Stabilization of the Thorax Breath.ing .........................

.....

..

.

112

... I j 3

CONTENTS

Neutral spine.

Exercise Progression - Adding the Global Muscles........................ Trunl�-arm dissociation.

. . .. . .. .

. .

.

. .

.....125

.....131

[niraihoracic .................. ........ . ..................... . .

....124

.131

Moving out: of neutral spine

Integrated u f nctional

.....120

.....129

Trunk-leg dissociation

T horacopelvic

.

.

...125

Maintaining neutral spine while adding load

REFERENCES

.....11 4

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .. . . . . . . . . . . . ..

Isolation of the local thoracic segmental stabilizers.................

.

. .

. .

....133 ... .134

....137

..

I

ANATOMY OF THE THORAX

A biomechanical approach to treatment of the thorax requires an understanding of its normal behavior. Without a working model, the clinician is limited to using unreliable symptoms for direction and treatment planning. If the optimal behavior of the thorax is understood, then this knowledge can be applied to the examination of the painful thorax. A systematic examination of mobility-stability of the associated bones and joints can then be done. Since function is related to structure, an understanding of the anatomy is required.

I!I

C I I APTER I

ANATOMY OF TH E THORAX

INTRODUCT ION

The thorax can be divided into four regions (Fig. ] . 1) according to anatomical and biomechanical difFerences. The vertebromanubrial region (upper thorax) includes the first two thoracic vertebrae, ribs one and two and the manubrium. The ver tebrosternal region (middle thorax) includes T3 to T7, the third to seventh ribs and the sternum. T8, T9 and T 10 together with the eighth, ninth and tenth ribs form the vertebrochondral region (middle/lower thorax). The lowest region is the thoracolumbar region which includes the T J J and TI2 vertebrae and the eleventh and twelfth ribs. The regional anatomy pertinent to the bio mechanical model will be described in this chapter and comes From the following sources - Cray's

Anatomy (3 7th edition), Clinical Anatomy of the Lumbar Spine and Sacrum by likolai Bogduk, Clinical Anatomy and Management of Thoracic Spine Pain (cds. LCF Giles and KP Singer) and Primal Pictu res 3 D J nteractive Series.

OSTEOLOGY

Vertebromanubrial Region The first thoracic vertebra is atypical (Figs. 1.2, 1.3. 1.4). I t has a large, nonbifid spinous process, clublike at its end. The superior aspect of the spinous process tends to lie in the same trans verse plane as the Tl-2 zygapophyseal joints. The facets on the superior articular processes lie in the coronal body plane while those on the inferior articular process present a gentle curve in both the transverse and sagittal planes. The transverse processes are long and thicle They are located betvveen the superior and inFerior alticular processes at the dorsal aspect of the pedicle and are ideally situated For palpation of intervertebral motion. On the ventral aspect or the transverse process there is a deep, concave Facet which articulates with a convex racet on the first rib to rorm the costotransverse joint. In the normal upright posture, the orientation of this joint is anteroinrerior.

Figure 1.1. Four regions of the thorax - vertebromanubrial,

Figure 1.2. The superior aspect of the first thoracic vertebra.

vertebrosternal, vertebrochondral and thoracolumbar.

The zygapophyseal joints lie in the coronal plane.

ANATOMY OF THE THOIv\x CHAPTER I

Figure 1.3. The inferior aspect of the f irst thoracic vertebra.

Figure 1.4. Anterolateral view of the first thoracic vertebra.

The zygapophyseal joints are gently convex in both the

The uncinate process at each posterolateral corner creates a

transverse and sagittal planes. The ventral aspect of the

concavity on the superior aspect ofthe vertebral body. There

transverse process contains a concave facet for articulation

is a full facet at the superolateral aspect ofthe vertebral body

with the first rib.

for the head of the first rib. A demi-facet on the inferolateral aspect articulates with the head of the second rib in the second decade of life. Note the concave facet on the transverse process for articulation with the f irst rib.

The superior aspecl of the vertebral body of T] is concave in the coronal plane. This concavity is formed by the uncinate process at each postero lateral corner. These processes articulate with the inferior aspecl of the body of C7 to form the non synovial, uncovertebral joint (Ha yashi & Yabuki 1985). There are lwo ovoid facets on either side or the vertebral body for articulation with the head of the fll'Sl rib. The inferior aspect of the vertebral body of TI is flat and contains a small facet at each poslerola leral corner for articulation with the head or the second rib. This articulation is incomplete unlil early adolescence when a secondary ossificalion cenlre appears to complete the formation of the head of the rib (Penning & Wilmink 1987, Williams et aI 1989). In children, the head of the second rib only articulates with T2.

the shortesl and lhis, together with the fibrous sternochondral joinl, contributes to the stability of the firsl ring. The convex head of the first rib articulates with the body of T 1 at the costover tebral joint. The neck of the rib is located between the head and the tubercle. The articular portion of the tubercle is convex and directed postero superiorly "vhen the head and neck are in l he

The firsl rib (Fig. 1.5) is the shortest of the twelve and the broadesl at its anterior end. The first ster nochondral joinl is unique in that it is fibrous rather lhan synovial. The first costocartilage is Figure 1.5. Superior aspect ofthe first rib.

m

CIIAPTER I

ANATOMY OF THE THORAX

The manubriosternal symphysis remains separate throughout life although ossification can occur (Fig. 1.7).

Vertebrosternal Region The vertebrae in this region (T3 to T7) have long, thin, overla p ping spinous processes. The tip of the spinous process can be three finger widths inferior to the transverse p rocess of the sa me vertebra and frequently deviates from the midline. Consequently, it is an unreliable point for palpating intervertebral motion. Figure 1.6. The manubrium.

normal upright posture. The second rib is a bout twice as long as the first and its features are similar to the vertebrosternal region described below. Anteriorly, the cartilage of the second ring artic ulates with both the manubrium and the sternum at the manubriosternal symphysis. The manubrium (Fig. 1.6) is a broad triangular sha ped bone which articulates with the clavicle and the costocartilage of the First and second ribs.

The face ts on both the superior a n d inferior articular processes present a gentle curve in both the transverse and sagittal planes (Davis 1959, Singer & Goh 2000) (Fig. 1.8). 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. 1.9). The top bowl ca n rotate forward, ba ckwa rd, sideways and around the bottom bowl. Translation of the top bowl meets immediate resistance. The coronal orienta tion of the superior a rticula r processes resists posteroanterior translation of the superior vertebra.

Figure 1.8. The superior aspect of the fourth thoracic vertebra. The zygapophyseal joint is gently convex in both the transverse and sagittal planes. The ventral aspect of the

Figure 1.7. The manubriostemal symphysis is usually

transverse process contains a concave facet for articulation

maintained through life, however ossification can occur.

with the fourth rib.

ANATOMY OF THE THORAX CHAPTER I

-

Figure 1.9. Two mixing bowls model the potential

Figure 1.10. Anterolateral view of the fourth thoracic

biomechanics of the zygapophyseal joints in the thorax.

vertebra. Note the concave facet on the transverse process for articulation with the fourth rib as well as the two demi-facets on the lateral aspect of the vertebral body for articulation with the heads of the fourth and fifth ribs.

The transverse processes, located at the dorsal aspect or the pedicle between the superior and inferior articular processes, are ideally situated

for palpation of intervertebral joint Illotion. The ventral aspect of the transverse process (Fig. 1.10) contains a deep , concave facet for articulation

Figure 1.11. Posterolateral view of the articulated thorax, vertebrosternal region. Note the curvature of the fifth costotransverse joint (arrow).

..

CIIAPTER 1 ANATOMY OFTHE THORAX

Figure 1.12. The fourth rib.

Figure 1.13. The sternum.

with the rib of the same num ber. This curvature (Fig. 1. 11) influences the conjunct rotation that occurs when the rib glides in a superoinferior direction (see Chapter 3 biomechanics). In the normal upright posture, the orientation of the facet on the transverse process is anterolateral.

of ribs three to six. Superiorly, the second rib artic ulates with the sternum at a demi-facet; inferi orly, the seventh rib articulates with both the xiphoid and the sternum.

-

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. Development of the superior cos tovertebral joint is delayed until early adolescence (Penning & Wilmink 1987, Wil liams et a1 1989) accounting for the flexibility of the young thorax. The shaft of the rib is long and thin and twists to a variable degree at the posterior angle (Fig. 1. 12). Tl1e sternum (Figs. 1.7, 1. 13) has eight full concave facets which articulate with the costocartilages

Vertebrochondral Region The vertebrae in this region (Fig. 1. 14) (T8, 9, 10) differ from the vertebrosternal region in the following aspects. The spinous process is shorter, although still c1irected 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 ( F ig. 1. 15) . Therefore, when the tubercle of the rib glides superiorly, it also glides posteromeclially with minimal conjunct rotation. When the tubercle of the rib glides inferiorly, it also glides antero laterall y following the plane of the costotrans-

ANATOMY OFTHE THORAX C I I APTER I

Figure 1.14. Anterolateral view ofthe eighth thoracic vertebra.

Figure 1.15. Posterolateral view of the articulated thorax,

Note the planar facet on the transverse process for articulation

vertebrochondral region. Note the planar nature ofthe ninth

with the eighth rib as well as the large superior demi-facet for

costotransverse joint (arrow).

articulation with the head of the eighth rib and the small demi facet for articulation with the head of the ninth rib.

verse joint (see Chapter 3 biomechanics) . The orientation of the facet for the costotransverse joint changes to accommodate greater l oading from the upper limb and thorax (Ciles & Singer 2000). At T2, the facet on the transverse process faces anteroinferiorly when the thorax is viewed in a normal upright posture. At TlO, the facet on the transverse process faces superolaterally such that the rib rests on top of the transverse process. -

T8 and T9 have four demiFacets for articulation with the head of the eighth and ninth ribs. TlO is variable. Often, there is onl y a small articula tion between the superior aspect of the head of the tenth rib and the inferior aspect of the vertebral body ofT9. Occasional ly, the tenth rib will artic ulate onl y with TIO at the base of the pedicle via an unmodified ovoid joint.

Anteriorl y, the eighth, ninth and tenth ribs artic ulate indirectly with the sternum via a series of cartilaginous bars which blend with the seventh costocarlilage (Fig. 1. 16). There are a variable number of synovial joints between the costocar tilages (interchondral joints) . This arrangement permits greater flexibility. Figure 1.16. Anterior view of the articulated thorax.

m

CHAPTER I

ANATOMY OF THE THORAX

Thoracolumbar Region

Figure 1.17. The eleventh and twelfth thoracic and the first lumbar vertebrae. Note the orientation ofthe zygapophyseal joints.

Figure 1.18. Lateral view of the twelfth thoracic vertebra. Note the change in direction of the facets on the superior and inferior articular processes. There is one facet on the lateral aspect of the vertebral body for articulation with the head of the twelfth rib. There is no facet on the small transverse process, there is no costotransverse joint.

The spinous processes ofT! 1 and TI2 are short, stout and contained entirely within the lamina of their own vertebra (Figs. 1.17).The facets on the articular processes of TIl (Fig. 1. j 8) resemble those of both the vertebrosternal and vertebro chondral 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 TIl- 12 does not restrict axial rotation. Laterally, the transverse processes are small tubercles (Fig. 1.19), the mamillary processes are larger and more superficial. The spinous process is a more reliable point for palpating interverte bral motion in this region. The heads of the eleventh and twelfth ribs artic ulate only with the vertebral body at the base of the pedicle via an unmodified ovoid joint (Fig. 1.20). There is no costotransverse joint in this region. The ribs do not have a neck and do not twist significantly. They remain detached from the rest of the thorax anteriorly (Fig. 1.21) and provide attachment for the diaphragm and trunk musculature. The shape of the costovertebral joint facilitates multi-directional movement of the vertebral body even when the large muscles contract and fix the eleventh and twelfth ribs. The eleventh segment (TIl, T12, eleventh rib) is the most flexible in the thorax.

ARTHROLOGY

ZygapophysealJoints

Figure 1.19. The transverse processes of the twelfth thoracic vertebrae are small tubercles (arrow) and cannot be used for palpating inteNertebral motion.

The zygapophyseal joints of the thorax are synovial and, like other synovial joints, contain small intra articular folds comprised of fibrous or fibro-fatty tissue (Giles & Singer 2000). These folds originate medially from within the joint space and extend a variable distance into the joint cavity. The capsule

ANATOMY OF TH E THORAX CHAPTER I

or the zygapophyseaIjoint is supported by the Iig amentum Aavum medially and the rotatores muscle laterally (Bogduk 1997), the deepest fibers of this muscle insert into the capsule.

Costa/Joints The costotransverse joints are synovial and also contain small intra-articular Folds (Giles & Singer 2000). 1l1e lateral costotransverse ligament SUPPOltS the lateral aspect of the joint and is transversely oriented (Fig. 1.22). It attaches to the tip or the transverse process and inserts into the non-articular portion of the tubercle of the rib. The superior

Figure 1.20. Lateral view of the thoracic spine. Note the unmodified ovoid facet (arrow) for the head of the twelfth rib.

EI

costotransverse ligam ent has a variable number of bands that run in a superoinFerior direction from the inferior aspect of the transverse process to the neck of the rib below. The neurovascular elements of the thoracic segment emerge between the bands of this ligament. The second to tenth costovertebral joints are divided into two synovial cavities, each cavity is separated by an intra-articular ligament. The capsule is supported by the radiate ligam ent (Fig. 1.23) which has fibres extending from the head of the rib both anteriorly and posteriorly to blend with the vertebral body of the level above, the intervertebral disc and the vertebral body of the level below. The costotransverse ligament connects the neck of the rib to the ventral aspect of the adjacent transverse process. The first, eleventh and twelth costovertebral joints contain a single Facet located at the base of the pedicle. They are essentially unm odified ovoid in shape.

Figure 1.21. Posterior view of the articulated thorax, thoracolumbar region. Occasionally the spinous processes are bifid.

m

CHAPTER 1 ANATOMY OFTHE THORAX

Figure 1.22. The ligaments of the posterior aspect of the thorax.

Figure 1.23. The costovertebral joint and the ligaments of the

LC= lateral costotransverse ligament

anterior aspect of the thoracic spine.

SC=superior costotransverse ligament

RL=radiate ligament

(Reproduced with permission from Primal Pictures).

(Reproduced with permission from Primal Pictures).

With the exception of the first, the sternocostal joints are synovial, unlike the lateral costochon dral joints which are fibrous, the periosteum and perichondrium continuous.

MYOLOGY

Intervertebral Disc The intervertebral discs of the thoracic spine are narrower than those in the cervical and lumbar regions and constitute approximatel y one-sixth of the length of the thoracic vertebral column. Since the ratio of the height of the disc to the vertebral body is 1:5, motion bet\,yeen the segments of the thorax is small. There is a linear increase in the cross-sectional area of the disc in the lower thorax reflecting an increase in the weight bearing function of these levels.

The muscl es of the thorax can be divided into deep and superficial layers. Functionally, these muscles can be classified into two systems; the local and the global (Bergmark ]989, Richardson et al 1999).

Local System - Classification Functionally, stability is maintained via low force continuous activity of the local musculature. These muscles work in all positions of the joint and during alJ directions of joint molion. This activity increases the stiffness at a segmental level and helps to control excessive physiological and translational motion, especiall y in the neulral joint position where passive support from the ligaments and capsule is minimal. The activity of the local system often increases in anticipalion of impending load or motion, thus provicling joint

ANATOMYOF THETI-IORAX CHAPTER I

IJII

Figure 1.24. The local stabilizers ofthe thorax include the

Figure 1.25. The intercostals are classified as local stabilizers

rotatores (R), levator costarum brevis (LCB) and longus

while spinalus

(LCL) and the deep fibers of multifidus

(M).

(Reproduced

(5), longissimus thoracis (LT) and iliocostalis

thoracis (IT) are global muscles. (Reproduced with

with permission from Primal Pictures).

permission from Primal Pictures).

protection and supp0l1 (80 & Stein 1994, Comerford & iVlottram 200 I, I lodges et al 1997b, Richardson el al 1999).

pelvis and therefore function gl obally. Co-acti vation of diFFerent muscle groups results in flexion, extension, lateral bending and axial rotation of the thorax.

Global System - Classification The primary role of the global system is to generate lorque and provide control of inner and outer range o[joinl motion. These muscles are required to concenlrically shorten into the full physiolog ical inner range position, isometrically hold this position as well as eccentricall y control or decel erate loads against gravity (Comerford & Mottram 200 I, Richardson et al 1999). They are necessary for stability under conditions of high load. I n general , the deeper layers of the spinal mus cul ature arc segmental and are thought to play a significant role in local stabilization of the spine (Bergmark 1989, Hides et ai, 199-+ Mosel ey et al 2002). The superficial muscles of the thorax tend lo span sevcral segments/ribs and function to move the thorax '"Clalive to the lumbar spinc and

Local System - Anatomy SpeCiFically, the local muscles which stabilize the thorax are thought to include the rotatores thoracis, the deep Fibers of multiFidus, the levator costar-um breves and l ongus and the internal and external intercostal muscles. The rotatores thoracis and multiFidus are part of the transversospinalis group. The research has yet to be done to confirm the inclusion of these muscles into this cl assifica tion, they are here based on clinical impression and extrapolation From research done in the lumbar spine and pelvis. The cleven pairs of rotatores thoracis (Fig. 1.2 4 ) arise from the inFerior border and lateral surface of the lamina of the thoracic vertebra and run inferolaterally to insert onto the superoposterior

III

C I I APTER l

ANATOMY OF THE THORAX

superfical fibers span two to four vertebral segments before attaching. In the lumbar spine, these super ficial fibers are known (Moseley et al 2002, Richardson et al 1999) to be phasic in [unction (responsible For angular motion) whereas the deep Fibers have a more tonic function (are non-direction specific and responsible for stabilization) . The research is still lacking for the thorax - however the clinical impression is that the Function is similar. All fascicles arising from the spinous process of a given vertebra are innervated by the medial branch of the dorsal ramus of that segment (Bogduk 1997) regardless of the length or depth of the muscle. The levator costarum breves (Fig. 1.24) are found from C7 to T J J and arise from the tip of the trans verse process. The short fibers pass inferolater ally to insert onto the subjacent rib between the tubercle and the angle. The levator costarum longus is comprised of four muscular slips which arise from the transverse processes oFT7, T8, T9 and Tl 0 (vertebrochondral region only). The fibers are longer than those of levator costarum breves and pass infero laterally to insert between the tubercle and angle or the rib two segments below their origin. Figure 1.26. The global stabilizers and mobilizers of the

thorax connect the thorax to the pelvic girdle and function to control sagittal and transverse plane motion. (Reproduced with permission from DeRosa & Porterfeld 2001.)

aspect of the base of the transverse process of the subjacent segment. These muscle Fibers attach to the capsule of the zygapophyseal joint. The multifidus muscle (Fig. 1.24) overlies the rotatores thoracis and fills the gutter between the spinous processes and the base of the transverse processes. The deepest layers arise from the lateral aspect of the spinous process and pass inferolat erally to attach to the base of the transverse process. The deep Fibers are segmental whereas the more

The intercostal muscles (internal and external) (Fig. 1.25) fill the gap between the ribs and although their action is facilitated with expira tion and inspiration respectively, their main function is to stiffen the chest wall during respiration. In this regard, they are non-direction specific thus meeting the criteria for being loca I sta bi Ii7.ers. The internal intercostal muscle lies deep to the external intercostal muscle and arises From the subcostal groove and costal cartilage and passes inferolateral anteriorly and inferomedial posteri orly. The external intercostal muscle arises From the lower border or the rib passing inrerolateral posteriorly and inferomedial anteriorly until the costochondral joint beyond which it continues to attach to the sternum as the external inter costal membrane.

ANATOMY OF TH E THORAX CHAPTER I

Global System - Anatomy The global muscles of the thorax (Fig. 1.26) include the external and internal oblique abdominals, semispinalis thoracis, erector spinae , rectus abdominis and possibly the upper fibers of trans verses abdominis. All of these muscles generate torque and function to control direction specific movements. The obi iq ue a bdom ina Is con tro I rotation of the thorax relative to the lumbar spine and pelvic girdle concentrically, isometrically and eccentrically. The external oblique is the largest and most super ficial abdominal with eight digitations arising from the external surfaces and inFerior borders of the lower eight ribs. This origin interdigitates with fibers of serratus anterior and latissimus dorsi. The upper attachments of the external oblique arise close to the costochondral joints, the middle attachments to the body of the ribs and the lowest to the tip of the cartilage of the 12th rib. Inferiorly, the posterior fibers descend vertically to attach to the outer lip of the anterior J /2 o[ the iliac crest. The upper and middle fibers end in the anterior abdominal aponeurosis (Fig. J .27) . Rizk (1980) investigated this structure in 41 specimens and discovered that the aponeurosis of the external oblique was bilaminar. The two layers cross the midline to blend with the fascia of the opposite side with the deep layer being continuous with the contralateral internal oblique. The superfi cial l ayer merges with the superficial layer of the contralateral side. The deep and superficial layers produce a cross hatched appearance as their ori entation is 90° to one another. The internal oblique lies between the external oblique and the transversus abdominis and arises from the lateral 2/3 of the inguinal ligament, anterior 2/3 of the intermediate line of the iliac crest and the lateral raphe of the thoracodorsal fascia. The posterior fibers ascend laterally to reach the tips of the 11th and 12th ribs and the J Oth rib ncar the costochondral junction. The

111

anterior fibers arising from the inguinal ligament arch inferomedially to blend with the aponeuro sis of transversus abdominis and aLlach to the pubic crest. The intermediate fibers pass super omedially to insert into a bilaminar aponeurosis (H.izk 1980) blending with the aponeurosis of the external oblique forming a decussating network of fascia across the midline of the body. Semispinalis thoracis is part of the transver sospinalis group and is superficial to multifidus and deep to spinalis thoracis (part of the erector spinae group). It arises from tendinous slips [Tom the transverse processes of T6 - TI 0 and inserts cranially into the l ateral aspect of the spinous processes of C6-T4. Spinalis thoracis (Fig. 1.25) (medial part of the erector spinae group) lies medial to the thoracic component of longissimus thoracis (Fig. 1.25) and posterior to the thoracic component of semi spinalis. Tt arises From the lateral aspect of the spinous process from TII-L2. From these 4 slips it forms a small muscle which inserts cranially into the lateral aspect of the spinous process of Tl-T8. The thoracic component of l ongissimus thoracis (Fig. J .25) is the largest part of the erector spinae group in the thoracic spine and forms the bul k of the paravertebral muscle mass adjacent to the spine. It arises from the ribs and transverse processes ofTI - T12 and descends to attach via the aponeurosis of the erector spinae to the spinous processes of the lumbar spine and sacrum. Each fascicle descends a variable length with those from the upper thorax reaching to L3 while the lower fascicles bridge the lumbar spine com pletely. Iliocostalis thoracis (Fig. 1.25) (lateral part of the erector spinae) lies lateral to longissimus and medial to the thoracic component of iliocostalis lumborum. It arises from the superior border of

m

C I IAPTER 1

ANATOMY OF TH E THO RAX

Figure 1.27. The anterior fibers of the external oblique muscle

Figure 1.28. Transversus abdominis. (Reproduced with

insert into the abdominal fascia strongly connecting to the

permission from DeRosa & Porterfield 2001).

interdigitations separating the rectus abdominis. (Reproduced with permission from DeRosa & Porterfield 2001).

the a ngle 0 [" ribs seven to twelve inserting inlo the superior border of the angl e of ribs one to six and lhe transverse process of C7. This Ill uscle is conlained enlirely within the thorax. The thoracic component of iliocoslalis lumborum ( B ogduk 1997) is large and the Illost laleral part of the ereclor spinae Illuscle group. Fascicles from lhe inferior borders or the a ngles or the l ower seven to eighl ribs originate lateral to the attach menl o[ iliocoslalis thoracis and descend to auach to the i l ium a nd sacrulll with the l horacic

cOIllPonent of the longissimus thoracis lo form the aponeurosis of ereclor spinae. These thoracic fascicles have no altachlllenl to the lumbar vertebra bridging the gap between the thorax and the pelvis. Since the thoracic component of iliocoslalis l umborum lies lateral lo the axis of spinal rOlalion a nd the distance between the rib cage and lhe pelvis is greatly increa sed during c onlra l a leral rotation, Bogduk ( 1997) suggests that this muscle can serve to derotale the thoracic cage and thus could also qualify as a global muscle [or this region.

ANATOMY OF THE THORAX CHAPTER I

liectus abdominis (Fig. 1. 27) lies posterior t o the anterior abdominal Fascia separated from its coun terpart by the linea alba. I L is divided by three tendinous intersections which are connected to the extern al oblique laterally ( Deliosa 200 J ). It arises From the f-irth to seventh ribs and the xyphoid process and descends to attach to the pubic crest and tubercle. Transversus abdominis (Fig. J . 28) is the deepest abdominal and arises from the l ateral 1/3 of the inguinal ligament, the anterior 2/3 of the inner l ip or the iliac c rest, the lateral raphe of the tho racodorsal Fasc i a and the internal aspec t of the lower six cost al cartilages interdigit ating with the costal fibers or the diaphragm. From this broad attachment, the muscle runs transversely around the trunk where its upper and middle fibres blend with the fascial envelope or t he rectus abdominis reaching the linea alba in the midline. Inferiorly, the muscle blends with the insertion of the internal oblique musc le to reac h the p ubic c rest. The lower fibers of transversus abdominis are known (H odges et al J 997a, b) to locally stabil ize the l umbopelvic region. U rquhart et al (200 1 ) noted that t he upper and middle Fibers of transverses abdominis lend to be more direction specific with respect to rotation or the thorax. I t is possible that these fi bers are part of the global system.

III

The Integrated Model of Function

FUNCTION

P

2 PRINCIPLES OF THE INTEGRATED MODEL OF FUNCTION

The following text is taken in part from material jointly written by the author and Dr. Andry Vleeming (Lee & Vleeming 2002). The integrated model of function was developed from scientific and clinical studies on the anatomy and function of the lumbopelvic region and has been adapted for the thorax by D GLee.

m

CIIAPTER 2 PRINCIPLES OFTHE INTEGRATED MODEL OF FUNCTION

INTRO DUCTION

Scientific research has led to the dcvelopment of models that en ha nce our knowledge, facilitate communication and foster a unified approach to futurc rcsca rch. The i n t e n t io n of thc biome cha nical model presen t ed in the f-irst edition of this tcxt was t o focus o n how the joi nts of the thorax behaved n ormally a n d how dysfu n ction could be assessed and treated to alJeviate symptoms. Whilc t his model d i d a d d ress t he a rtic u l a r componcnt of the patient's problem, it has become cvident that two other factors c a n have an equal impact on rccovery. These components are neu romyofascial and emotional. The integratcd model (Fig. 2 . 1) has four compo nents - three tha t are physical • •

•

form closure (structure), force closure (forces produced by myofascial action) and motor c o n t ro l (specific timing of muscle action/i naction du ri ng loadi ng)

culoskcletal in naturc or due to thc thoracic \nsccra.

According to Panjabi ( J99 2) stabi I ity is achicvcd when thc passivc, activc and control systcms work togcther. Vlccming ct al (l99 0a ,b) believc that the passive, activc and con t rol systems produce approximation of' thc joint surfaccs; essential if stability is to bc insurcd. The amount of approx imation required is variable and difficult to quantify since it is cssentially dependent on a n individ ual's structure (form closurc) and the forces they need to control (force closure). The term "adequate" (Lee & Vlecming J998) has been used to describc how much approximation is necessary and rcflects t he n on-qua ntitative aspect o f this mcasu re . Essentially, it mcans " not too much" and "not too little", in other words just e n ough to suil thc existing situation. Consequen tly, the ability to effectively transfe r load through the thorax is dynamic and depends on: 1.

optimal function of the boncs, join ts and ligamcnts (form closure or joint congruency)

2.

optimal function of the musc lcs and f'ascia (forcc closure)

3.

appropriate neural Function (motor control, emotional state)

a nd onc that is psychological •

emotions.

The proposal is that join t mechanics ca n be in Au enced by multiple factors (articular, neuromus cular and cmotional) and that management requires atten tion to all. Living on earth requires a constant response to gravity. Our upright posture requires that the grav itational force be t ransferred through thc thorax, low back, a n d pelvis to the legs. H ow well this load is tra nsferred over a lifetime, dictates how efficient fun ction will be. Impairmcnt implies that the individual has lost the ability to perform and this loss is usually associated with symptoms significant enough to motivate them to seek help. Thoracic impairmen t , therefore, can be dcfined as an inability to perform due to problems within the thorax. This impairment may be neuromus-

For every individual, there a re ma ny st rategies available to achievc stability. These are based on

The Integrated Model of Function

t7� �tJ FUNCTION

Figure 2.1. The integrated model offunction - Lee & Vleeming

2002.

PHINCIPLES OFTHE INTEGHATED MODEL OF FUNCTION CHAPTEH 2

the individual's anatomicallbiomechanical factors (i.e. connective tissue extensibility, muscle strength, body weight, joint s u rface shape, motor control patterns), psyc hosocial Factors and the loads t hey need to cont rol. Stability is not only about how much a joint is moving (qu antity of motion) o r how resistant stru ctu res are that restrict it, but abou t motion control which allows load to be transferred smoothly. When mot ion control is inadequate, t he re may be too m u c h , or too little, approximation of t h e joint su rFaces. Too much compression over a long pe riod of time will wear out t he joint s and c an lead to osteoarth ritis. Too litt l e compression leads to episodes of givi ng way and coll apse. E ac h component of t h e integrated model contribu tes to functional stability.

..

pression before lateral instability occu rred. Form clos u re of t h e t horax, t herefore, depends on an intact rib cage. There h ave been few in vivo s t udies of t horacic spin al motion a n d most of t h e biomechanics described in this text a re a clinical extrapolation from Panjabi, Brand and White's in vitro inves ti gation ( 1976) of t he t horacic spine (see Chapter 3). T h i s research addressed t he q ue stion h ow much does the thoracic spinal segment move and which motions are coupled? The answer - it moves a little bit and is always coupled. Since t his study was published, Willems et al ( 1996) investigated in vivo the direction of motion coupling and found it to be consistent for flexion/extension and variable for lateral bending and rotation. They fou n d t his to be true t h roughout alJ four regions of the t horax.

This t e rm was coined by Vleeming & S n ijders (Vleeming et aI 1990a,b, Snijders et al 1993) and is used to describe how t he joi nt's structu re, ori e n t a t ion and s h ape cont ribu te to s t abilit y. All joints have a variable amount of form clos u re and the individual's in herent anatomy will dictate how much additional Force is needed to ensure s tabi lization when loads are inc reased. The "form" of the thorax (the bones, joints and ligaments) has been described in detail in Chapter 1.

To date, no manual diagnost i c tests h ave s hown inter-tester reliability for determining h ow much t h e joints of the ve rtebral column a n d/or pelvis are moving i n e i t h e r sympt omatic or asympto matic subjects (Carmichael 1987, Dreyfuss et al 1994, Dreyfuss et al 1996, He rzog et al 1989, Laslet t & Williams 1994). Given t h e wide indi vidual variation and t h e limited potential ra nge of motion, i t is no wonder we have not been able to demonstrate reliabil i t y wit h manual testing when amplit ude is considered. And yet, h ow can a diagnosis of hypomobility or hypermobil ity/insta b ility be made wit ho u t clinically reliable passive mot i on tests of mobility? Subsequent research has helped to clarify t his dilemma.

The thorax transfers large loads, generated primarily from the upper extremity, and its overall shape is well adapted to t his task. This is mai nly due to the rib cage and the effec t it has on motion of the spinal segments. Andriacch i et al (1974) noted that the rib cage increased the bending s tiffness of the spine by a factor of two in extension. He fou nd that when t he rib cage was left intact , t h e spine could support t h ree t imes the load i n com-

Buyruk et al (1995a) establis hed that t h e Ec ho Dopple r could be u se d to measure s tiffness of the Sl]. Subsequent research (Buyruk et al 1995b, 1997, 1999) u sing t his methodology on subjects wit h and w i t h out pelvic pain, revealed the h igh degree of individual variance in t h e s tiffness of the SI] . Wit hin the same s u bject, t he asympto matic indivi d u al demonst ra ted similar values for both SI]s, whereas t h e symptomatic individual

FI RST COM paNENT FORM CLOSURE

..

CHAPTER 2 PRINCIPLES OFTHE INTEGRATED IVlODELOF FUNCTION

demon st rated diFfere nt stiffness values For the left a nd right Sl]. In other words, asymmetry of stiFfness correlated with the symptomatic indi vid u al . Cli n i c a lly, t h e re appears to be a wide variation in the amo u n t of resista nce or stiFfness within the thorax both between individ u als of the same age and also within the same individu al as a result of i ncreasing age. In keeping with this researc h , the emphasis of manu al motion testing should Foc u s less on how much a joint is movin g and more on the symmetry, or asymmetry of t h e motion palpated. A clinical reasoning approach which considers all of the Fi ndings from the exam ination is req uired to determine if the amplit ude of motion is less, or more, than optimal for that individual. Form closure analysis requ i res an eval uation of both the neutral zone and elastic zone of motion (Fig. 2. 2 ) (Panjabi 1992). The ne u tral zone is a small range of movement near the joint's ne utral position where minimal resistance is given by the osteoligame ntou s stru ctures. The clastic zone is the part of the motion I'Tom the end of the neutral zo ne up to the joint's physiological limit. Panjabi ( 1 992) fou nd that the size of the neutral zo ne i n c reased with i nju ry, a rtic ular dege ne ra tion a n d/or weakness of the stabilizing m u scula-

Load R2 .' .

.

. . . . . .

.

'

Elastic zone .

o

.

. '

. .

.

R1

Range of motion Panjabi 1992

Displacement

Figure 2.2. The zones of articular motion - the neutral zone (O-R1) and the elastic zone (R1-R2) (Panjabi 1992).

t u re and that t h i s was a more sensitive indicator than a ngular range of motion for detecting in sta bility. Lee & Vleeming ( 1998) suggest that the neutral zone is not only a ffected quantitatively, but also qualitatively when compression is applied (or reduced) across the joint. This compression c a n a Ffect t h e stiFfness of t h e neutral zon e of motion . To explain this fu rther we need to under stand what compresses the thorax, in other words what p rovides force clos u re.

SECON D COM PONENT FORCE CLOSURE ]J the artic ular su rfaces 01' the thorax were con

sta ntly a n d completely compressed, mobil ity would not be possible. I l0wever, compression d u ring loading is variable and thereFore motion is possible a n d stabilization req uired. This is ac hieved by increasing compression across the joi nt s u rFace at the moment of loading - force closure (Vleeming et al 1 990, Snijders et al 1993). The a n atomical structu res responsible for t h i s a rc the ligaments, muscles a n d fascia . Several ligaments, muscles and fascial systems contribute to Corce closure of the thorax. When working el'F i cien tly, the shear Forces between the vertebrae and ribs are adequately controlled and loads can be t ra n s ferred between the tru n k, pelvis a rms and legs. Pa njabi et al (J 981) tested t h e stability of the thoracic spinal u nit by loading it to failure in both flexion a n d exte n sion . Fail u re was defined as complete separation of the two vertebrae or more than 10 mm of tra nslation or 45 degrees or rotation. The ligaments were then cut sequentially and the contribution of the various ligaments to stability was noted. In flexion , they fou nd that the u nit remained stable u ntil the costovertebral joint was c ut. The integrity of the posterior one-third of the disc a n d t h e costovertebral joints is c ritical to anterior tra nslation stability in the thorax.

PRINCIPLES OF T HEINTEGRATED MODEL OF FUNCTION

Panjabi et al ( 198 1) then seq uentially c u t t h e a n terior longit udinal ligament, the anterior h alf of t he intervertebral disc, t he costovertebral joints and the posterior h alf of t h e intervertebral disc and noted t he contribu tion of each to stability in extension. In extension, t hey found t ha t t he unit remained stable u ntil the posterior longitudinal ligament was cut. All of the ligaments anterior to and including the posterior longit udinal ligament limit extension of the thoracic spinal u ni t . W i t h respect to the neuromyofascial system, sta bilization of the t horax requires bot h segmental ( Ioca I) and globa I control. Segmentally, t he local muscles ( deep fibers of mul ti fid u s, rot at ores breves, levator costarum and t he intercostals) are important. Globally, t he thorax is part of a larger system whose stabilization begins with t he lum bopelvic core. To understand t he exercise program in Chapter 7 it is essential to review how stability is ach ieved in the entire trunk and t h e research that has led to the proposals presented later in this text for stabilization of the thorax. Lumbopelvic Stabilization The Research Reviewed

There are two important groups of muscles that contribute to stability of the trunk. Collectively they have been called t he inner unit (Richardson et al 1999) or local syst em (Be rgmark 1989, Comerford & Mottram 200 1)) and t he outer unit (Ri. chardson J989, Comerford & M ottram 200 1 ). The local stabilizers of t he lumbopelvic region consist of t h e muscles of t h e pelvic floor, t h e tra nsversus abdominis, t he deep fibers of m ul t i fidus, t he diaphragm and possibly t he posterior fibers of psoas (Gibbons 2002). The ou ter unit or global system consists of several slings or systems of muscles t h at are a n at omically connect e d and fu nctionally related ( M eyers 200 1, Vleeming e t a l 1995b).

CHAPTER 2

The Inner Unit - Local System The Core

The function of t h e local muscles is t o apply adequ a te compression such t h a t t h e system is stabilized in preparation for t he addition of external loads. Research h as shown ( B o & Stei n 1994, Constantinou & Govan 1982, Hodges 199 7b, Hodges & Gandevia 2000, Sapsford et al 200 1) t h a t the local muscle system is anticipatory when f u n c t io n ing opt ima lly. In o t her wor d s , t hese muscles work at low levels at all times and increase their action before any further loading or motion occurs. Hodges & Richardson ( 1996, 1997a) have shown t h a t t ra nsversus abdominis is an anticipa t ory muscle for stabilization of the low back and pelvis. Alt h ough i t doesn't directly cross t he SIJ, it h as an impact on compression of the pelvis (Richardson et al 2002) t hrough, in part, its direct pull on t he large attachment to the middle layer and the deep lamina of the posterior layer of the t h oracodor sal fascia (TDF) ( Barker & Briggs 1999, Vleeming e t al 1995a) (Fig. 2. 3a,b). As an anticipat ory m uscle, it is recruited prior to t he initiation of any movement of t h e upper or lower extremity (Hodges & Richardson 1996). I n a study of patients with chronic low back pain, a timing delay was found in w h ic h t ransversus abdominis failed t o anticipate t he initiation of arm and/or leg motion ( Hodges & R.ichardson 1997a). Delayed activation of transversus abdominis mean s t h a t t h e TOF is not p retensed a n d t h e pelvis is therefore not compressed in preparation for extern al loading. Therefore, it is potentially vulnerable to t h e loss of intrinsic s tabilization. M ul tifidus also plays a crucial role i n stabiliza tion of t he pelvic girdle. This muscle is contained between the lamina of t he vertebrae/dorsal aspect of the sacrum and t he deep layers of t h e t hora codorsal fascia. W hen it contracts, it broadens and therefore increases the tension of t he t hora-

III

CIIAPTER 2

PRINCIPLES OFTHEINTECRATED MODEL OF FUNCTI ON

Figure 2.3Q. The superficial fibers of the thoracodorsal fascia

Figure 2.3b. The deep fibers ofthe thoracodorsal fascia form a

bridge the pelvis connecting the latissimus dorsi and the

roof over the sacral multifidus and directly connect the

gluteus maximus muscles. (Reproduced with permission

sacrotuberous ligament to the aponeurosis of the erector spinae

from Andry Vleeming).

muscle. (Reproduced with permission from Andry Vleeming).

codorsal fascia (Fig. 2.4a,b). This creates a "pumping up" (hydraulic amplification) (Gracovetsky 1990, Vleeming et al 1995a) effect which tenses the thoracodorsal fascia and t h e refore compresses the posterior pelvis (Richardson et aI 2002).

the stiFfness of the S I J, facilitating the Force closure mechanism of the pelvis. Further study is necessary to analyze which other muscles co-contract besides the multifidus and transversus abdominis and influence compression of the S I J.

The Echo Dopp l e r has been used to measure stiFFness, or compression, of the S I ] under valying conditions (13uyruk et al 1995a,b, 1997 , 1999). I �ecently, the impact of the activation of the local muscle system on compre ssion of t h e S I J has been studied (Richardson et aI2002). The results of this research supports w h at is clinically noted in well trained individuals, that is - co-activation of transversus abdominis and multifidus increases

Hides et al ( 1994), O'Sullivan (2000) and Danneels et al (2000) have studied the response of multi fidus in low back and pelvic pain patients and note that multifidus becomes inhibited and reduced in size in these individuals. The normal " pump up" effect of multifidus on the TDF, and thereFore its ability to compress the pelvis posteriorly, is lost when the size or Function of this muscle is impaired. Rehabilitation requires both retraining

PRINCIPLES OF THE iNTEGRATED MODEL OF FUNCTiON CHAPTER 2

(Hides et al 1996, O'Sull ivan et al 1997) and hypertrophy or the muscle ( Danneels et al 2001) for the restoration or proper Force closure of the lumbopelvic region. Togeth e r, multifidus and transversus abdominis form a corset o f support For the lumbopelvic region. The "roof and Aoor·' of t h is cannister are supported by the muscles of the pe lvic Aoor and the respiratory diaph ragm. The muscles or the pelvic Aoor play a critical role in bot h stabilization of t h e pelvic girdle as well as urinary and fecal continence (Ashton-Miller et al 200 1, 130 & Ste in 1 994, Constantinou & Govan 1982, SapsFord et al 200 1). Contstantinou & Govan (] 982) measured the intra-urethral and intra-bladder p ressures in h ealthy continent women during coughing and valsalva (bearing down) and found that during a cough the intra urethral pressure increases approximately 250ms before any pressure increase is detected in the bladder. This suggests an anticipatory reflex. The increase in u rethral pressure occurred s imulta neously with t h e increase in bladder p ressu re during a valsalva. They suggest the difference may be due to the role of the pelvic Aoor during a cough (cont raction) ve rsus a valsalva ( relax ation).

m

Sapsford et al. ( 2001 ) investigated t h e co-acti vation pattern of the p elvic floor and the abdom inals via needle EMG for the abdominals and surface EMG for the pelvic Aoor. They Found that the abdominals contract in response to a pelvic floor contraction command and t h at the pe lvic floor contracts in response to both a 'hollowing' and 'bracing' abdominal command. The results from this research suggest that the pelvic floor can be facilitated by co-activating the abdomi nals and visa versa. When the l ocal muscle system is functioning optimally, it a pplies comp ression to the pelviS (Richardson et al 2002) and thus stabilizes the SIJs, augmenting the form closure and helps to prevent excessive shearing of the S1Js. The pelvis is then prepared to 'accept' additional load from outside the pelvis.

Figure 2.40. The sacral multifidus is contained within an fibro

Figure 2.4b. When the sacral multifidus contracts it

osseus container dorsal to the sacrum. (Reproduced with

broadens posteriorly. (Reproduced with permission from

permission from Lee 2001).

Lee 2001).

III

CHAPTER 2

PRINCIPLES OFTHEINTEGRATED MODEL OF FUNCTION

The Outer Unit - The Global System The Slings

In the past, four muscle systems (slings) which stabilize the pelvis regionally (between the thorax and legs) have been described (Vleeming et al 1995a,b, Snijders et al 1995). The posterior oblique

sling (Fig. 2.5) contains connections between the latissimus dorsi and the gluteus maximus through the thoracodorsal fascia, the anterior oblique sling (Fig. 2.6) contains connections between the external oblique, the anterior abdominal fascia and the contralateral internal oblique and adductors of the thigh, the longitudinal sling (Fig. 2. 7) connects the peroneii, the biceps femoris, sacro tuberous ligament, deep lamina of the thora codorsal fascia and the erector spinae, and the lateral sling which contains the primary stabiliz ers for the hip joint namely the gluteus

Figure 2.5. The posterior oblique sling contains, in part, the

Figure 2.6. The anterior oblique sling contains, in part, the

latissimus dorsi, the thoracodorsal fascia and the

external oblique abdominal and the contralateral adductors

contralateral gluteus maximus muscles. (Reproduced with

of the thigh. (Reproduced with permission from Lee '999

permission from Lee '999 and Churchill Livingstone).

and Churchill Livingstone).

PRINCIPLES OF TI-IEINTEGRATED MODEL OF FUNCTION CHAPTER 2

medius/minimus, tensor fascia lata and the con t ralateral adductors of the thigh. These muscle slings were initially classified to gain a better under standing of how local and global stability of the pelvis could be achieved by specific muscles. It is now recognized that although individual muscles are important for regional stabilization as well as for mobility, it is critica I to understand h ow they connect and function together. A muscle con traction produces a force that spreads beyond the origin and insertion of the active muscle. This force is transmitted to other muscles, tendons,

iii

fasciae, ligaments, capsules and bones t hat lie both in series and in parallel to the active muscle. In th is manner, forces are produced quite distant from the origin of the initial muscle contraction. These integrated l1luscle systems produce slings of forces that assist in the transfer of load. Van Wingerden et al (2001) used the Echo Doppler to analyze the effect of contraction of the biceps femoris, erector spinae, gluteus maxil1lus and latissiumus dorsi on compression of the S I ]. None of these muscles directly crosses the SI] yet each was found to effect compression (increase stiffness) of the SI]. The global system of muscles is essentially an integrated sling system which represents forces and is comprised of several muscles. A muscle may participate in more than one sling and the slings may overlap and interconnect depending on the task being demanded. The hypothesis is that the slings have no beginning or end but rather connect to assist in the t ransference of forces. I t is possible that the slings are all part of one inter connected myofascial system and the particular sling (anterior oblique, posterior oblique, lateral, longitudinal) which is identified during any motion is merely due to the activation of selective parts of the whole sling. The identification and treatment of a specific muscle dysfunction (weakness, inappropriate recruitmen t , t i g h tn e s s ) is impo r tant w h en resto ring global stabilization and mobility (between the t horax and pelvis o r between the pelvis and legs) and for understand ing why parts of a sling may be inextensible (tight) or too flexible (lacking in support).

Figure 2.7. The longitudinal sling connects the peroneii, the biceps femoris, sacrotuberous ligament, deep lamina of the thoracodorsal fascia and the erector spinae. (Reproduced with permission from Lee '999 and Churchill Livingstone).

Ell

CHAPTER 2 P R I N CIPLES OFTHE INTECRATED MODEL OF FUNCTION

TH IR D COM PONENT

FOURTH COM PONENT

M O TOR CONTROL

EMOTIONS & AWARENESS

M otor control pertai n s to patterning of m u scle activation ( Coillerford & Mottram 200 1 , Dan neels et al 200 I , Hichardson et al 1 999, O'Sullivan e t a l 1 997) in other words, t he tillling o f specific m u scle action and inaction. Efficient move ment requ ires coordinated ill u scle actio n , s uc h t hat stability is ensured while motion is controlled and n ot restrained. Wit h respect to the thorax, it is the coo rdina t ed action between the local and global muscle systems that ensu res stability without rigidity of" post u re and without episodes of collapse. Exercises that focu s on seq u encing m u scle acti vation are necessary for restoring motor cont rol ( Lee 200 1 ). The exercises in chapter 7 Focus on balancing tension wit h i n t h e sli n gs of Ill uscle systeill s and invo lve an extensive u se of i magery. I magery has been s h ow n (Yue & Cole 1 992) to be e Ffective in restoring n e u ral patte rning and increasing strength . U s i ng i magery and specific sequencing of Illuscle activation, individual muscles a re strengthe ned, lengthened and appropri ately tillled d u ring Functional tasks.

Fro lll Andry Vleeming E ill otional states can play a sign ifica nt role in h u man functio n, including the Fu nction 0 1" the neuroillusculoskeletal system. Many chronic pain patients present with trau matized lif"e experiences in addition to their f"unctional cOlllplaints. Several of t hese patients adopt motor patterns indicative of defensive posturing which suggest a negative past experience. A negative eillotional state leads to f u rt h e r stress. Stress is a norillal response intended to e nergize our syste lll for q uick right and Right reactions. When this response is sustained, high l evels o f adre naline and cort isol re main in the system ( I- I olstege et al 1996, Sternberg 2000) in part d u e to circ u lati n g s t re s s related ne u ropeptides ( Sapolsky et al 1 997a,b) which are released in anticipation of defensive or ol"fensive behavior. Emotional states (fight, Right or free7.e react ions) are physically expressed through Ill u scle action and when sustained, influence basic muscle tone and patterning ( H olstege et aI 1996). It is illlportant to understand the patient's eillotional state since the detrimental m otor pattern can often only be changed by affecting the eillotional state. Sometillles, i t can be as simple as restoring h ope t h rough education and awareness of the underlying Illechan ical probleill. Other times, proFessional cognitive behavioral therapy is requirecl to ret rain Ill o re positive tho ught patterns. A bas ic requireillent Cor cogn itive and physical learning is Focused, or attentive, training - in other words not being absent-minded . 1eaching an indi vidual to be " mindful" or aware of what is happening in t h eir body d u r i n g tim e s of p hysical a n d/o r emotional loading can reduce su stained, unnec essary m u scle tone and t hereFore joint cOlllpres sion ( M u rphy 1 992).

PH INC I PLES OFT HEINTEC HATED MODEL OF FUNCT I ON CHAPTER 2

CONCLUS ION

It has been long recognized that physical factors impacL jo i nt motion. The model presented here suggests that joi n t mec h a n i cs are in fl uenced by multiple factors, some i n tri nsic to the j o i nt i tself while others are produced by muscle action which in turn is i n fl u enced by t he emotional state. The e ffe ct i ve m a n ageme n t of b a c k pa i n a n d dys fu nction requ i res aLte n t i o n to all fo u r compo nents - form closure, Force closure, motor cont rol and emot ions with t he goal being to guide patients towards a healt hier way to l ive i n t heir body.

m

\" T1

T2

3 BIOMECHANICS OF THE THORAX

Managing dysfunction requires an understanding of function. The biomechanics of the thorax presented in the first edition of this text were derived from clinical observation and influenced primarily by the study of Panjabi, Brand & White (1976). Few studies have added to our knowledge base since. In 1996, Willems, Jull and Ng reported on their in vivo findings of coupled motion in the thorax. The results from this study, and the influence it has had on the original biomechanics, will be discussed in this chapter.

EI

CHAPTER 3 BIOMECHANICS OF THE THORAX

were c u t 3 Clll lateral to the costotransverse joints and the front of the chest was reilloved . The spinal unit was intact, h owever, the costal uni t was not.

TER MINOLOGY To fac ilitate the s u bsequen t d i sc u ss ion, the ter

m inology used requires definition. Osteokinematics (Ma c C ona i l l & B a s m aj i a n 1977) refe rs to the study of motion of bones regard less 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 occ u rs about a coronal axi s , anterior/posterior rotation a b o u t a parac oronal a x i s , s i d e flexi o n (late ral bend ing) abo u t a sagi ttal axis and axial rotat i on a b o u t a ve rti cal axis. Coupled m o t ion refers to the combinat ion of movements which occ u r as a conseq uence of an induced motion.

In 1996, W i l l e llls , Ju ll and Ng Illeasu red t h e pril l in an in v ivo s t u dy. Sixty s u bjects bet ween the ages of l 8 and 24 were stud ied us ing a 3 S PAC E Fastrak Systeill. The subjects were sc reened and excluded jf they had a c u rrent or past history of thoracic pain, long terlll respi ratory d i sorder or a significant scoliosis. An exaillinat ion of the thoracic spine for segillental Function was not done prior to the study. Sensors were attached to one spinous process in each of three regions of the thora'(, one between T l -T4, a second between T4-T8 and the t h i rd b e t ween T8-Tl2 . Ea ch s u bj e c t was seated, the pelv i s and thighs secu red and the lumbar spine s upported . W i th t h e i r arills folded a c ross t he i r chests, each s u bjec t was asked to Illove to t he i r Illax extension, axial rotation and lateral Aexion. Each motion was carefully taught to ensure the Illot ion

Linear, or translatoric, motions are named according to the axis along which the bone t ranslates. Lateral t ranslation occur s along a coronal axis, anterome d ial/posterolateral translation along a paracoronal axis, t ract ionlcompression along a vertical axis, and anteroposterior t ranslation along a sagittal axis. Arth rokinematics (MacConaill & Basmajian 1977) refers to the s tudy of motion of joints regardless of the m o t ion of the bone s . These m ove ments a re nailled accord ing t o the d i rection the joint s u rfaces gli de.

y

LITERATURE REV IEW

Panj a b i , B rand and White (1976) investi gated t he pri m a ry and co upled Il in an in v i t ro st udy of several cadavers ranging i n age (before death) from 19-59 years. Three hundred and n i ne t y s i x load d i s placeillent c u rves were obtained for s i x degrees of Illot ion; three t rans l a t i ons and three rotations a long and abo u t the X, Yancl Z axes ( Fig. 3.1) for each of the eleven Illotion seOl l l ent b the posterior zygapophyseal joints and the costovertebral and costotransverse joints. The ribs

z

Figure 3.11n an in vitro study by Panjabi, Brand and White (1976), 396 load displacement curves were obtained for 6 degrees of motion at each thoracic segment noting both amplitude and coupling of motion for each.

BIOMECHANICS OF THE THOHAX CHAPTEB 3

desired was aCLually occ u rring in Lhe thorax. "fhe Fastrak is an elecLromagnetic sy stem which t racks Lhe motion in 3D and sends t he i nFormation to a com p uter w h ose softw a re i n Le rp re t s t h e d a t a "a l low ing t h e calcu lation o f L h e pos i t ion o f each sensor in space" (Willems et al J 996). The methods and results from L h i s study have been carefu l l y considered w i L h res pec t to t h e b i o m ec ha n i c a l model o f Lhoracic mOLion a n d w i l l b e d i sc ussed . Accord i ng Lo m a L h e m a t i c a l (Sa m a u rez J 986, Andriacchi eL al 1 974, Ben-Ha i m & Saidel J 990) a n d t heoret ica I (Lee 1 993 , 1 994 ) m o d e l s , t he Lhorax is capable of six degrees of motion along a n d abouL t h e L h ree cardinal axes of t h e body; however, it is known t h a t no movement occ u rs i n i so l a t i o n ( Pa nja b i et a l 1 9 7 6 , W ille m s et a l 1 996) . All angular motion ( rot aLion) i s coupled wiLh a l i near mot ion ( t ranslaLion) a n d visa versa. As t h e thorax moves to meet it s biomec h a n ical demands, iL Illust accommodate Lhe requiremenLs of respiraLion. To do t h i s , it needs flex i b i l i t y i n mot ion patLerni ng.

Flexion

FU NCTIO NAL MOVE ME NTS Vertebrosternal Region Flexion

Flexion of the t horacic vertebrae occ u rs d u ring forward bending of the t ru nk. Panjabi eL aJ (1976) found that forward sagittal rotation (nexion) around the X axis cou pled with anterior t ranslation along the Z a x i s (.5 111111 ) a n d very s l ighL d i stract i o n ( Fig.3.2). W h e n an terior translat ion along the Z axi s was ind uced, forward sagittal rOLation arou nd the X axis and very slight compression also occurred. I n the in vivo study of Wi llems et al ( J 996), sagittal p lane motion was the pu rest and showed the leasL i nc idence of coup led illotion. No axial rotation or laLeral Aexion should occur d u ring sagitLal plane Illat ion of the thorax. The oSLeok i ne m a t ic Illot i o n o f t h e r i b s w h i c h oc c u rs d ur i n g flex ion of the thora c i c verteb rae was not noted i n either study ( Pa njabi et aJ 1976, Willems et al 1996). Sauillarez (1986) noted thaL

Anterior Translation

I

VI

y

z -

-----

Figure 3.2. Flexion around the 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 rotation around the X axis and slight compression along the Y axis ( Panjabi et aI1976).

m

CHAPTER 3

BIOMECHANICS OF THE THORAX

...... .. .. . ' . .' .... .....

............ .. .. .. .. .. ....

Flexion

.... .... . .. ...... .

Figure 3.3. The osteokinematic and arthrokinematic motion proposed to occur in the mobile thorax during forward bending - vertebrosternal region.

con s i d e r a b l e i n d e p e n d e n t m o ve m e n t o f t h e ste rn u m and t he spine i s possible, "th us allowing mob i l ity of the spi n e without forcing concomi tant movements of (the) rib cage". T h i s i s supported cl i n ica lly i n t h at th ree move m e n t patterns a re apparent i n t h is region of t h e t horax and depend on the relative flexibility between the spinal column and t he rib cage. [n t he very you n g, (less t han 12 years of age) the head of t h e rib does not fu lly art iculate with the i n ferior aspect of t h e s uperior vertebra (Wi l liams et al 1 989) . In other words, the superior costovertebral joint is not com pletely developed prior to puberty. The secondary ossi fica t i o n centres for the head of the r i b d o n o t deve lop u ntil puberty; therefore, the you ng chest

i s m u c h more mobi le. I n the s keleta l l y mature, the superior costovertebral joi n ts I imit t he degree of rotat ion possi ble in a l l t h ree planes. I n old age, t h e costal cart i l ages tend to oss i fy su perficia l ly and decrease the pliabil ity and relative flexibility of the t horax. This change i n re lal ive flex i b i l ity is a p p a re n t when exa m i n i n g t h e spec i fi c cos t a l osteokinematics du ring forward/backward bending of t r u n k . 1 . D u r i n g flexion of t h e mobile t horax ( Fig. 3.3),

flexion o f the s u perior verte b ra occurs . The ribs a nt eriorly rotate about a paracorDnal axis along the l i ne o f the neck of t he rib such that the a nterior aspect trave ls i nferiorly while the posterior aspect trave ls superiorly. At the i m it

!

BIOME CHAN I CS OF THE THORAX CHAPTER 3

_

Figure 3.4. The osteokinematic and arthrokinematic motion proposed to occur in the stiffer thorax during forward bending - vertebrosternal region.

of forward bend i ng, the vertebrae stop and the ribs conti nue to anteriorly rotate relative to the vertebrae. Art h rokinemal ical ly, the inFerior facets of t h e su perior t horacic vertebra glide su peroanteri orly at t he 7,ygapop hyseal joi n t s . The su perior art icu lar proce sses of t h e inferior t h oracic vertebra present a gentle curve convex posterior in bot h t he sagi t t a l a n d coro n a l p l a ne. The superior motion of t he inferior art icular processes fo l lows t h e curve o f t h i s convex i t y a n d t h e res ult is a su peroanterior g l i d e . T h e anterior rotat ion of t h e r i b res u lts in a s u perior glide cou pl ed w i t h an anterior rol l of t he tu bercle at t he costotransverse joi nt.

2. I n the stiFf t horax ( F ig. 3.4), the r i bs are less Rexible t han the spinal col u m n. During rlexion, the anterior as pect of the rib trave ls i nFeriorly w h i le the poster ior aspect trave l s s u periorly. Once the range of mot i o n of the r i b cage is exhau sted , t h e t horac ic vertebrae con t inue to Rex on t he now stationary ribs. The arthroki ne matics of the zygapophyseal j o i n t s re main a s u peroa n terior gl ide. At t he costotra n sverse joi n t s , t h e a rthrokinematics are d i ffere n t . As the thoracic vertebrae cont i nue to forward Rex, the concave facets on the transverse processes travel su periorly relative to the t u bercle of t he ribs. The result is a relative inferior glide cou pled with a posterior rol l of the t u bercle of t he rib at the costotran sverse joi n t .

CI-IAPTER 3

B IOMECHANICS OF THE THORAX

3. The third m ovement pattern occurs when the relat ive flex i bil ity between the spi nal col u m n a n d the r i b cage i s the same. During flexion o f the thora,'(, the quantity o f movement is reduced a n d there is no apparen t m ovement between t he t horacic ver t e b rae a n d t h e rib s . S o m e superoanterior gliding occurs a t the zygapophy seal j o i n t s , however very l i t t l e , i f a ny, costo t ransverse joint motion can be fel t . Extension

Extension of the thoracic vertebra occu rs during backward bending of the trunk and during b ilateral eleva t ion of the arms. Panjabi et al ( 1 976) fou n d that ext e n s ion a ro u n d the X a x i s c o u pl e d w i th pos t e r i or t ra n s l a t i o n a l o n g the Z axi s a n d very sl ight distraction (Fig. 3.5) . When backward trans lat ion along the Z axis was i n duced in the exper i m e n t a l mode l , exten sion a ro u n d the X axis and very s l ight com pression a l so occu r red.

Extension

The osteo k i n e m a t i c Illo t i o n of t he r i bs whic h occurs d u ri ng exte nsion 01' the t h orac ic vertebra was n o t noted in e i t h er st udy by Pa nj a b i et a l ( 1 976) or W i l l e m s e t a l ( 1 996). Cl i n i cal l y, t h e movement patterns obse rved appear once aga i n t o depend o n relative f lexibil ity between the spinal c ol u m n a n d the rib cage . Three patterns have been noted. 1 . During ext e n s i o n 01' t he mobile lhorax ( F ig. 3.6), extension of the superior vertebra occurs. The ribs posteriorly rotate about a paracoro n a l axis along the l i ne of t he neck 01' the rib such that the a n terior aspect trave l s superi o r l y whi l e the posl erior aspect t ravels i n feri o r l y. At the l i m i t of backward b e n d i ng, l he vertebrae stop and the ribs cont i n ue to poste riorly rotate re lat ive to the vertebrae.

Posterior Translation

Figure 3.5. Extension around the X axis induced posterior translation along the Z axis and slight distraction along the Y axis. Posterior translation along the Z axis induced backward sagittal rotation around the X axis and slight compression along the Y axis (Panjabi et aI1976).

BIOMECHANLCS OFTHE THORAX CHAPTER 3

I

' . , . , . , .

.'

.'

. . . . .

. .

.

. .

.

.'

.

.'

.'

-.

n

.. ..

: J:'*

. . . _, f

Figure J.6. The osteokinematic and arthrokinematic motion proposed to occur in the mobile thorax during backward bending - vertebrosternal region.

.

.

.

.. .

...

...

Arthrokineillatically, the i nFerior Facets of the su perior lhoracic vertebra glide i n feroposteri orly at the zyga pophyseal joi nts. The superior articular processes present a gentle cu rve convex posterior in both t he sagittal and coronal plane. The i nFe rior Illol ion of the i n ferior articular processes follows the c u rve of this convexity and the res u l t is an inFcroposterior glide. The posterior rotation of lhe neck of the rib res u lts i n an inrerior glide coup led with a posterior roll of the l u bercle al the costotransverse joint. 2. During exte nsion of the stiff thorax (Fig. 3.7), the ribs are less flexible than the spi nal column.

.. .

'

.

.

.

.

. .

. .

.' . . . . . .

I nitial ly, the a nterior aspect of the rib travels superiorly w h i l e t h e posterior aspect travels i n feriorly. Once t h e range of Illotion of the rib c age is exh a u s te d , t h e t ho ra c i c verte b rae continue to exten d on the now stationary r ibs. The a rt h rokinematics of the zygapophyseaJ joints remain a n i n feroposterior glide. At the costotran sverse joi nts, t he arthroki n eil are different. As the thoracic vertebrae conti n ue to extend, the concave facets on the transverse processes travel i n feriorly relative to the tubercle of t h e r i b s . The resul t is a re lative s u perior glide coupled with an anterior roll of the tubercle of the rib at the costotransverse joint.

III

CHAPTER 3

BIOMECHANICS OF THE THORAX

Figure 3.7. The osteokinematic and arthrokinematic motion proposed to occur in the stiffer thorax during backward bending - vertebrosternal region.

3. The th i rd movement pattern occurs w hen the relative flexi b i l i ty between the spinal column and the rib cage is t h e same. During extension of t h e t h orax, the q u a n tity of m ovement i s reduced a n d there i s no apparent movement between the thoracic vertebrae and the ribs. Some i n feroposte r i o r gl i d i ng oc curs at t h e zy gapoph y seal join ts o n l y , h owever very l ittle, i f any, costotransverse joi nt motion can be felt . T h ese a re the com mo n p a tterns n oted w h e n sagittal p l a n e motion of t h e t h orax is observed . I t is possible for i n dividuals to volu ntarily cha nge their pattern of motion. For example, in the mobile thorax the spi ne can extend i n duc ing a posterior rotation of the ribs in space and t hen while hol d i ng

t his pos i t ion, it is possible to anteriorly rotate t he ribs. Th is flex i b i l i ty a l lows the l horax to accom modate the demands coming From •

respi ration ,

•

movements of the upper ext rem ities and

•

move ments of the head .

Lateral bending

Sideflexion of the thoracic vertebrae occurs during lateral bending or t h e tru n k. Pa njab i et a I ( J 976) foun d t h a t sideflexion, or rot ation around the Z axis, coupled with contra latera l rotat ion arou nd the Yaxis and i psilateral t ranslat ion along the X axis ( F ig. 3.8). Translation along the X axis coupled w i th i psi laleral sidef lexion around the Z axis and contralateral rotation arou nd the Y axis.

BIOMECHANICS OF THE THORAX CHAPTER 3

Right Side Flexion

III

Right Translation

Figure 3.B. Right sideflexion around the Z axis induced left rotation around the Y axis and right translation along the X axis. Right lateral translation along the X axis induced right sideflexion around the Z axis and left rotation around the Y axis (Panjabi et aI1976).

Wi l lems et ai's (I996) fou n d t h at the pattern of c o u p li n g d u ri n g lateral b e n d i n g was v a r i a ble, although an ipsilateral relationsh i p predominated. S i n c e t h e move m e n t of t he s e n s o r was o n l y compared to i ts base l i n e s t a rt i n g pos i t i on, t h e pattern noted i n t h i s s tudy c a n o n l y reflect how t h e s p i n o u s p r o c e s s m oved i n space a n d n o comment can be made o n segmen t a l motion pat tern i ng. In other words, d uring lateral bendi ng of the t r u n k , Wi l le m s et al (1996) noted t h a t t h e vertebra tended to s ideflex a n d rotate i n a n ipsi lateral d i rect i o n . SideFlex and rotate compared to what? No comme n t can be made o n what T4 did relative to T5 because this was not measured. In this study, T4 sideflexed and rotated i n a n i psi lateral direction (compared to its start i ng position) d u ring lateral bending of the thorax. If T5 rotated more than T4, then the resultant segmental motion would, i n fac t , be a contrala teral rotation. It is i nterest i n g to pos t u late o n what p rod uces coupled motion in the t horax. In the m idcervical spine, it is thought ( Pe n n i ng & Wil m i n k 1 9 87) that the oblique orientation of the zygapophyseal

join ts together with the uncinate processes d i rects t he i p s i l a t eral rot a t i o n a n d s id e fl e xi o n w h i c h occurs. In t he l um ba r spine, t h e zygapophyseaJ

Figure 3.9. As the thorax sideflexes to the right, the ribs on the right approximate and the ribs on the left separate at their lateral margins. The costal motion stops first, the thoracic vertebrae then continue to sideflex slightly to the right.

m

CIIAPTER 3 810M ECHANICS OF THE THORAX

joints a lso are known (Bogd uk 1 997) to i n R uence the d i rection of mot ion coupl i ng duri ng rotat ion. However, the facets o f the zygapophyseal joi n t s i n the thoracic s p i n e l ie i n a somewhat coronal plane and wou ld not l imit pure sideRexion during latera l ben d i ng of the tru n k. It is difncult to see how they cou ld be respon s i ble for the rot ation (ipsi lateral or contralateral) found to occur during s i deflexion .

Figure 3.10. Since the tubercle of the rib is convex, as the thoracic vertebra sideflexes to the right it has to move posterior and inferior on the right and anterior and superior on the left. Osteokinematically, this produces a right rotation of the thoracic vertebra relative to its starting position. As T5 sideflexes to the right on the fixed 5th ribs, it rotates to the right (necessitated by the shape of the tubercle of the 5th ribs). T4 follows this motion, however the relative anterior rotation of the right 5th rib and posterior rotation of the left 5th rib limit the amplitude of the right rotation of T4 such that it rotates less to the right than T5 and is therefore relatively left rotated. This only occurs at the limit of lateral bending.

Rotation

Figure 3.11. Panjabi et al (1976) found that right rotation around the Y axis induced left sideflexion around the Z axis and left translation along the X axis.

As t he t r u nk bends latera l l y to the right , a left convex curve is prod uced. The thoracic vertebrae s i d e fl ex to the right a n d the r i b s on t he right approximate whi l e the r i bs on the leFt separate at t he i r l a t e ra l margi n s ( F ig. 3.9 ) . In both the mob i l e thorax and the stifF thorax, the ribs appear to stop moving before the thoracic vertebrae. The thoracic ve rtebrae then con t i n u e to s i deFlex t o the right. This mot ion c a n b e palpated at the cos totra n sverse joi n t . Thi s s l i ght i n c rease i n r ight s i deflex i o n of the thoracic vertebrae against the nxed ribs is proposed to cause the fo l lowing arthroki nematic mot ion . At the costotra nsverse joints, a re lat ive superior glide of the t u bercle of the right rib and a re lative i n ferior gl ide of the tubercle of the left rib occurs as the vertebra conti nues to sideflex to the right aga i n s t the fixed ribs (Fig. 3. 1 0 ) . Si nce the cos totransverse joint is concavoconvex in a sagi ttal p l ane, the superior glide of the right rib produces a relat ive a nterior roll of the neck of the rib with respect to the t ransverse process ( remember that the rib is stationalY and the moving bone is actually the thorac ic vertebra). The i n ferior gl ide of the l e ft r i b produces a posterior roll of t he neck of the r i b relat ive to the transverse process. Aga i n , i t i s import a n t to n o t e that t h e mov i n g b o n e is the thoracic vertebra, not the rib. Since the tubercle of the rib is convex, as the thorac ic vertebra side flexes to the right it has to move posterior a n d i n ferior on the right a n d an terior and superior on the left . Osteokinematical ly, this produces a right rota t i o n o f t he thora c i c vertebra relat i ve to i t s star t i ng posit ion. This is exact ly what Wil lems et

BIOMECHANICS OF THE THORAX CHAPTER 3

..

al ( 1996) found i n their study. However, consider what ha ppens not just in space, but between two thoracic vertebrae. As T5 sideflexes t o the right on the FLxed 5th ribs, it rotates to the right (neces s ita ted by the shape of t he tuberc le o f the 5th ribs). T4 ,"o l l ows this mot ion; however the head of the rib lim its the amplitude of the right rotation oF T4 such that it rotates less to the right than T5 and is there fore relat i vely left rotated. This only occurs at the limit of lateral bendi ng. In summary, dur i ng lateral bend i ng of the verte brosternal region, the vertebrae sideAex and rotate i p s i latera l l y re lat ive to their s t art i n g pos i t i o n . Re l a t ive t o one a n other, the superior ver t e bra rotates less than the level below and therefore is actua lly left rotated i n comparison. This coupling of motion only occurs at the end of the range. [n the m id-pos i t ion , e i ther i p s i lateral or contralat eral coup l i ng can occur. Panjabi et al ( 1 976) found that right lateral trans lation along the X axis occurred during right s i de flexion (Fig. 3.8). The eFfect of this right l ateral translat ion is negated by the left lateral trans la t ion which occurs as the superior vertebra rotates to the leFt. The net effect is m i n i mal, if any, lateral tra nslation of the ribs a long the l i ne of the neck of the rib at the costotransverse joi nts. The c l i n ical i m pression is that n o anteromed i a l or postero lateral sl ide of the ribs occurs during lateral bendi ng of the trunk. At the zyga pophy s e a l joi n t s, t he l e ft i n fer i or art icu lar process of the superior thorac ic vertebra glides superoa nteromed i a l ly and the right glides i nFeropostero lateral ly to fac i l itate r ight sideAex ion and left rot ation of the superior vertebra. Rotati.on

Pa njabi et al ( 1 976) found that rot at ion around the Y axis coupled w i t h c o n t ra l a t eral rota t i o n around the Z a x i s a n d contralateral tra n s l a t ion a long the X axis ( F ig. 3.11). This is not consis tent with c l i n ical observat ion ( F ig. 3. J 2). In the m idthoracic spine, rot ation around the Yaxis has

Figure 3.12. Clinically, the midthorax appears to sidefiex and rotate to the same side during rotation of the trunk.

been found to be coupled with i psilateral rotat ion arou n d the Z axis and contral ateral tra n s l a t ion along the X axis. 1 n other words, when axial rotation is the first m o t i o n i n duced, rot a t i o n a n d s i d e flex i o n appear t o occur to the same side i n the m idthorac ic s p i ne . Willems et ai's ( 1 996) foun d i n tersubjec t variat ion i n motion pat terning when the primary movement was axial rotation, however a n i p s i l a teral re l a t ionshi p was predo m i n a n t . [t m ay be that the thorax must be i n t ac t a n d stable both a n t er i or l y and poster i or l y for this in v i vo coupl i ng of motion to occur. The anterior elements o f the thorax were re moved 3 em lateral t o the costotran sverse jo i n t s i n the study by Pa nja bi et

IjI

CHAPTER 3

BIOMECHANICS OFTHE THORAX

.� "

Figure 3.13Q The costocartilage ofthe left sixth rib was removed

Figure 3.13b. Note the inability of the midthorax to rotate

(arrow points to the incision) in this seventeen year old.

and sideflex to the right during right rotation of the trunk (arrow). Instability prevents the normal biomechanics of ipsilateral sideflexionJ rotation during rotation of the trunk.

a l . When the a nterior e leme n t s of the thorax a re removed s u rg i c a l ly, i ps i l a t e ra l s i d eflexion a n d rot a t i o n c a n n o t oc c u r i n t he m i d thorax. The seve n teen year old y o u th i l l u st rated i n F i gu res 3. 1 3a,b had the costocarti lage of the left s ixth rib removed for cosmetic reasons. Su bseq u e n tly, he p resen ted w i th persi sten t pain i n the mid thorax and on examinat ion of axial rotat ion contralateral si defJexion occu rred at the 6th segmen t . During right rot at ion of the tru n k the fol lowing b i om e c ha n i c s a re proposed t o occ u r i n t he midthorax. The super ior vertebra (eg. T5) rotates to the right and t ra n s lates to the left (Fig. 3. 1 4). The left (6th) rib anteriorly rotates and translates posterolateral re lat ive to the i psilateral t ra nsverse

process of the i n ferior vertebra (T6) and t he right (6th) rib posteriorly roLates and trans laLes antero med ial relative to the ipsi lateral t ransverse process of the i n fe rior vertebra (T6). Whe n the l im i t of this horizontal t ra n s l a t ion i s reached, both the costove rtebral a nd the costo transverse l igamen t s a re tensed. SLabil iLy of the ribs bOLh anteriorly and posteriorly is req u i red for the fol lowing motion to occur. Further righL roLation of the superior verLebra (T5) occurs as the superior ve rtebral body t i l t s to the right (gl ides superiorly along the left s u perior costovert eb ral joint and i n feriorly along the right superior costovertebral j o i n t ). Th is t i l t ca u ses right s i d erl exion of the s uperior vertebra (T5-6 ) d u ring righL rotat ion of the midthoracic segme n t (Fig. 3. 1 5) .

BIOMECHANICS OFTHE THORAX CHAPTER 3

..

Figure 3.14. The osteokinematic and arthrokinematic motion proposed to occur in the vertebrosternal region during right rotation of the trunk.

At t he zyga p o p hysea l j o i n t s, t h e l e f t i n fe r i o r articular process of t h e s u perior vertebra gl i des superolateral ly, the right i nferior art i c u l ar process gl ides i n feromed i a l l y to f ac i l i tate right rota t i o n and right s ideAexion of t h e t horacic vertebra. Vertebrochondral Region

There are significa nt d iffere nces i n the anatomy of t h i s region t h at s u bseq u e n t ly i nf l ue nce t h e b i omec h a n i c s . The facets o n t h e t r a n sverse processes of t he lower thoracic vertebrae are more planar and oriented in a supero lateral di rection ( Wi l l i ams et a l 1 989) . A supero i nferior glide of the rib w i l l t h e re fore n ot necessar i l y be associ ated w i t h t he same degree of a n t eroposterior rotation found i n t he vertebrosternal region. The cost oca rt ilages of t h e ribs seven to ten a re less firmly attached to the sternum. The i nferior demi facet on t he body of T9 for the J Oth rib is small and often absent. The 1 0t h rib articulates wi t h one facet o n t he body of T J 0 a n d often does not at tach to t h e t ransverse process at all.

��

/..

::::::�

:'7

�::: .

6th

{'�.){!.;:::., """

Figure 3.15. At the limit of left lateral translation, the superior vertebra sideflexes to the right along the plane of the pseudo 'u' joint (analogous to the uncovertebral joint of the midcervical spine) formed by the intervertebral disc and the superior costovertebral joints.

ID

C HAPTER 3

BIOMECHANICS OF THE THORAX

motion is necessary at t h e costovertebral joi nts o f ribs 9 and 1 0 s i nce t hey do not have a large attachment to the superior vertebra. The zygapophy seal joints gl i de superiorly d u ring Rexion and i n fe riody i n extension. Facet p lane -+-+----,�

Figure 3.16. The plane of the costotransverse joint in the vertebrochondral region - posteromediosuperior (a glide in this direction occurs during anterior rotation of the rib) and anterolateroinferior (a glide in this direction occurs during posterior rotation of the rib).

Flexion/extension

Flexion of t h e t h o racic vertebrae i n t h i s region oc c u rs d u r i n g forwa rd b e n d i n g of the t r u n k . C l i n ically, i t appears that t h e associated ribs follow t h e sagi t t a l m o t i o n a l t h ough m i n i m al articular

Lateral bending

The biomechanics of the vertebroc hondral region during l ateral bend ing of the t ru n k depend on t he a pex of t h e cur v e p roduced i n s i d eflexio n . For exa m p l e , i f d u r i n g right lat eral bend i ng of t h e tru n k t h e apex of t he sideRexion c u rve i s at the level o f t h e greater t roc h a n t e r o n t h e le ft , then all of the t horacic verte brae will s i deflex to t he righ t , t h e ribs w i l l approxi mate on the r igh t and separate on the left . As the rib cage is compressed on the right and stops movi ng, furt her right side Rexion o f the vertebrochondral region will res u l t i n a su perior glide of t h e r i bs at t he costotrans verse joi n ts on the righ t . G iven the orientation of the a rt ic u l a r s u rfaces ( F ig. 3. 1 6 ) , the gl i de t h at occurs is posteromedios uperior on the right and an terolatero i n ferior on the left with m in i m a l , i f any, rotation of the neck of the r i b . T h e ribs do not appear to d i rect t he s u perior vertebra i n to con t ra l a teral ro t a t i o n a s t h ey do i n t h e verte-

Figure 3.17. The osteokinematic and arthrokinematic

Figure 3.18. The osteokinematic and arthrokinematic

motion proposed to occur in the vertebromanubrial region

motion proposed to occur in the vertebromanubrial region

during forward bending.

during bilateral elevation of the arms.

BIOMECHANICS OFTHE THORAX CHAPTER 3

Figure 3.19. The osteokinematic and arthrokinematic

..

Figure 3.20. The osteokinematic and arthrokinematic

motion proposed to occur in the thoracolumbar region

motion proposed to occur in the thoracolumbar region

during forward bending.

during backward bending.

brosternal region. The vertebrae a re t he n free to fol low t h e rotat ion t h a t i s congru e n t w i t h t h e leve ls above a n d below.

t h e c o s t a l e l e m e n t s . The c o u p l e d m ove m e n t pattern for rotation here c a n b e i p s i latera l side Aexion or contralateral s ideAexio n . The coronally orie nted facets of the zygapophyseal joints do not dictate a coupl i ng of si deAexion when rot ation is i nd uced. The small superior costovertebral joint a n d t h e lack of a d i rect a n terior attac h me n t of t h e assoc i ated r i b s fac i l i tates t h i s flex i b i l i ty i n motion pattern i ng.

I f however t he a pex of t h e sideflex ion c u rve i s within t he t horax, ( i .e. a t T8), then the osteoki ne mat ics of the lowe r t horacic vertebrae appear to be vel)' different. The rib cage remains compressed on the right and separated on t h e left , however, t he t horac ic ve rtebrae s i de Aex to t h e left below the apex of t h e right sideflexion c u rve ( i . e . T9 , T ] O , T I J , T J 2). G i ve n t h e o r i e n t a t i o n o f t h e articular su rfaces of t h e costot ran sverse joi n t s , the gl ide th at occ u rs on t he right is i n an antero lateroi nferior d i rect ion ( posterom ed ios u perior on the left) with m i n imal, i f any, rotat ion of the neck or t he rib . Once aga i n , the ribs do not appear to d i rect t he su perior vertebra t o rot ate i n a sense i nco ngruent to the levels above and below. ,

Rotation

The same Aex.ibility of motion coupling is apparent in the ve rtebroc hondral region when rotat ion i s c o n s i d e re d . T n fac t , t h i s regi o n a p pears t o b e designed t o rot ate w i t h m i n imal restriction from

Vertebromanubria/ and Thoraco/umbar Region Flexion/Extension

The first two r i bs are always less mobile t h a n T 1 o r T2 a n d t h e move m e n t p a t t e rn for fl e x i o n ( F i g. 3. 1 7) and extension ( Fig. 3. 1 8) i n t h e ver tebroman ubrial region is consistent w i t h the stiff t h orax pattern descri bed i n the vertebrosternal section. I n the t horaco l u mbar regio n ( F igs. 3. 1 9, 3.2 0), t h e e leve n t h a n d t we l ft h costove rtebral j o i n t s a re u n m od i fi e d ovo i d i n s h a p e a n d A exion/exte n s ion of t he thorac i c vertebra can be a p u re s p i n ( M acC o n a i l l & Basmaj i a n 1 97 7).

m

C HAPTE R 3

B IOMECHANICS OF T H E THORAX

Lateral bending

Rotation

I n t h e vertebroman u brial regio n , t h e head of t h e first r i b does n o t articulate wit h C7 a n d the super oi nferior glide of t he ribs and the conjunct rotat ion which occ u rs can not i n fl uence t h e d i rection of movement coupling between C 7 and T 1 . C 7-T 1 a n d T l -T2 fo l l ow t h e same p a t t e rn o f m o t i o n coupl i ng a s t h e midcervical spine when the head is bent laterally ( Fig. 3.2 1 ). Sideflexion is coupled w i t h i psi latera l rotation of the s u perior vertebra . T h e u nc i nate processes a t C 7-T l m a y i n fl uence the d i re c t i o n o f motion cou p l i ng h e re. D u ri n g right latera l bend i ng of t h e head/neck t h e t rans verse process gl ides i n feriorly relat ive to t h e rib on t he right and s uperiorly relative to t h e rib o n t he left .

I n t h e vertebromanu brial region, C7 -T J and T J T2 fol l ow t h e same pattern of motion coupling as the m idcervical spine when the head is rotated. Rotation is coup led with ipsi lateral sideflexion of the superior vertebra. The two u ncinate processes at C 7-T 1 may i n fl uence t h e d i rect ion of motion coupling here. During right rotation of the heacVneck t h e t ransverse process gl i des inferiorly relat ive to the rib o n the right and superiorly relat ive to the rib o n the left .

At t h e thoraco l u m ba r j unction, p u re sideflexion can occ u r. The heads of t h e eleventh and twelft h ribs do n o t art i c u late w i t h the vertebra above and t he re is no costotra nsverse joint to consider. The costovertebral joi n t s hape is a n u n mod i fied ovoid a n d t h e refo re p u re side flex i o n of t h e t ho racic verle brae between two fixed ribs can occur.

C o n s i d e ra b l e flex i b i l i t y of m o t i o n cou p l i ng i s a p p a re n t i n t h e t h o ra c o l u m b a r j u n c t i o n . Anatomical ly, t h e lower thoracic levels (T J 0, T I J ) a re designed to rotate wit h m i n i m al resl rict ion from the ri bs. Passively, the T1 J - J 2 segment can b e p u re l y rotated about a vertical axis w i t h no restriction from the zygapophysea l joi n l s or l he ribs. Act i vely, t h e coupled movemenl pat tern for rotation in t h is region can be ipsi lateral s ideflex i o n or co n l ra l a le ra l s i d e fl exion. The coro n a l l y oriented facets of the zyga pophyseal joints do not d ictate a specific cou p l i n g of sideflexion when r o t a t i o n is i n d u c e d . T h e a b s e n c e o f a c o s l o transverse joint and t h e lack of a d i recl anterior attac h m e n t of the assoc iated ribs fac il itates t h is flex i b i l ity i n motion p a t t e rn i n g at t he eleve n t h and twe l ft h segmenls.

Figure 3.21. The osteokinematic and arthrokinematic motion proposed t o occur in the vertebromanubrial region during lateral bending of the head to the right.

BIOMECHANICS OF THE THORAX CHAPTER 3

_

RES P IRATIO N

SU M MARY

The d i a p h ragm is the most effi c ient res p i ratory muscle. Optimally, during inspiration, the d iaphragm descends and pulls t he centra l tendon i n feriorly t h rough t h e fixed t w e l ft h r i bs a n d Ll to L 3 . Osteoki n e m a t i c a l l y, t he l o w e r r i b s posteriorly rotate (art h rokinematic a n terolatero i n fe rior gl i de at the costot ra n sverse joints) c reat ing a latera l , anterior a n d posterior expa n s ion of t h e r i b cage . F u rt h e r i n s p i ra t i o n c au ses t he ve rtebro s t e rn a l ribs to posteriorly rotate (arthrokinematic i n ferior gl ide with a posterior rol l ) furt her increas i ng the ant eroposterior d i m ension o f t he t horax.

The known b i o mec h a n i c s of t h e i n t a c t t ho rax con t i n ues to be far from complete. Willems et al ( 1 996) a c k n ow l e d ge t h a t " a l t e red t e n s i o n i n muscles may change forces on the ribs and vertebrae w h i c h c o u l d i n t u rn i n fl u e n c e t h e p a t t e rn o f coupled motion i n vivo, part i c u l a rl y i n t h e upper t h oracic area" . I nc l usion criteria for st u d ies such as t hese should i nvolve a b iomec h a n ical exa m i nation and not just exc lusion by lack of symptoms or h istory of p roblems s ince " it is not u ncommon to find t ight ness i n m u sc les . . . even in asympto matic persons" (Willems e t aI 1 99 6 ) . Th .is is an excel l e n t study a n d with further refi n e m e n t of the i nc l u s io n criteria (biomechan ical eval uat ion ) a n d met h od o l ogy ( s e n sors o n adj a c e n t l eve l s ) c o u l d y i e l d significant i n formation pert i n e n t t o u n de rstand i n g t h e biomec h a n i c s o f t h e t h orax.

When mot ion of t he lower ribs is I im i ted by over activat ion of the global system (oblique abdom inals and erector spi nae), lateral expansion of the t horax i s l i m i ted a n d abdom i na l b u lging ( b e l ly brea t h i ng) may re s u l t . A l t e rn a t e l y, t h e c h e s t expa n s i o n m ay b e l i m i te d to t he u p per t ho rax (apical brea t h i ng) . These breat h i ng patterns are less opt i m a l . Expirat ion should occur passively a s t he diaphragm relaxes. The ribs anteriorly rotate and this requ i res a posteromed iosu perior glide at t h e costotrans verse joints of the vertebroc hondral region and a superior gl ide/anterior rol l at the cost otransverse joints of the vertebrosternal regio n .

4 DIAGNOSING THE THORACIC DYSFUNCTION

Impaired thoracic function can be defined as an inability to effectively move and/or transfer forces through the thorax. To reach this diagnosis, specific functional tests for mobility and load transfer are required. To understand the underlying cause for the functional impairment, specific tests that examine form closure, force closure, motor control and the effect of negative emotional states are required. The reader is referred to the CD·ROM which accompanies this text to view short video clips of these tests.

m

CHAPTER 4 DIAGNOSING THE THORACIC DYSFUNCTION

SUBJECTIVE EXAMINATION

OBJECTIVE EXAMINATION ----

T he purpose of the subjective examination is to

Impaired thoracic function can be defined as an

establish the nature, irritability and severity of

inability to effectively move ancllor transfer forces

the presenting problem (Table 1) .

through the thorax. To reach this diagnosis, specific functional tests for mobility and load transfer are

Mode of Onset

required. To understand the underlying cause for

Was the onset of symptoms sudden or insidious?

the functional impairment, specific tests that

Was there an element of trauma? If so, was there

examine form closure, force closure, motor control

a major traumatic event over a short period of

and the effect of negative emotional states are

time, such as a motor vehicle accident, or were

required. The impact of the specific impairment

there a series of minor traumatic events over a

is often reflected in the patient's posture and this

long period of time. Is the patient presenting

is where the objective examination begins.

during the acute, subacute or chronic (substrate, fibroblastic or maturation) phase of healing? Is

Postural Analysis

this the first episode requiring treatment or is this

Optimal posture requires the

a recurring problem?

following. In the sagittal plane, a vertical line should pass through

Pain/Dysaesthesia

the external auditory meatus, the

Where is the pain and/or dysaesthesia? Is it localized

bod ies of the cervical vertebrae,

or diffuse? Where does it radiate to and can its

the glenohumeral joint, slightly

quality be described? If there is symptom referral,

anterior to the bodies of the thoracic

does it tend to refer around the chest or through

vertebrae transecting the vertebrae

the chest? What activities, if any, aggravate the

at the thoracolumbar junction, the

symptoms? How long does it take for this activity

bodies of the lumbar vertebrae, the

to produce symptoms? Which activities (including

sacral promontory, slightly posterior

how much) provide relief?

to the hip joint and slightly anterior

Sleep Are the symptoms interfering with sleep? What kind of bed is being slept in and what position is most frequently adopted? Does rest provide relief?

to the talocrural joint and naviculo calcaneo-cuboid joint (Fig. 4 . 1 ) . The prim31y thoracic curve should be maintained i.e. no midthoracic lordosis.

Occupation/Leisure activities/Sports

In the coronal plane, the clavicles

What level of physical activity does the patient

should be hOlizontal, the manubrium

consider their normal and essential for return to

and sternum vertical (and in the

full function? What are the patient's goals from

same plane as the pubic symphysis

therapy?

and anterior superior iliac spines

General Information

of the innominate) and the scapulae

How is the patient's general health? Is any medication being taken for this or any other condition? What are the results of any adjunc tive diagnostic tests (i.e. X-rays, CT scan, MRI, laboratory tests)?

Figure 4.1 Optimal posture.

D IAGNOSING THE THORACIC DYS F U NCTION CHAPTER 4

Age

Name

Dr.

I l""U'Iil",;mr; ro.l'.ili,� Past Treatment

Past History

;/;rr;rJ'..I�'f' ':+Hif:+if' Location

I��IA·

Imm

Surface/Position

fl/, ,

Aggravating Activities

Bowel/bladder symptoms

Effect ofsustained Slump and/or neckjlexion

Status in a.m.

Night Wakening

Medication

Adjunctive Tests

,

Distal paraesthesia

,

Relieving Activities

,

,

Occupation/sport/hobbies

Table 1. Subjective Examination

'*'

CIIAPTER 4 DIAGNOSING THE THORACIC DYSFUNCTION

Figure 4.2 Excessive thoracic kyphosis

Figure 4.3 Excessive midthoracic lordosis

Figure 4.4 Excessive rotoscoliosis

secondary to osteoporosis.

secondary to overactivation of the global

secondary to poliomyelitis and altered

system of the thorax.

neural control of the local and global systems of the thorax.

Figure 4.5 Functional movement testing - regional tests.

Figure 4.6 Functional movement testing- regional tests.

Forward bending of the head.

Forward bending of the trunk.

DIAGNOSING THE THO RACIC DYSFUNCTION CHAPTER -l

Figure 4.7 Functional movement testing- regional tests.

Figure 4.8 Functional movement testing- regional tests.

Backward bending of the vertebromanubrial region occurs

Backward bending of the trunk.

during bilateral elevation of the arms.

shou ld rcst such t hat t he med ial border is par al lel to t he thoracic spine with the inferior angle approx imated to t he chest wal l . Deviations of' t he spinous processes arc common in t he t ho rac i c spi ne and oft en i n sign i f icant . Deviat i on of' t he t horax fro m the t h ree card i nal body pl anes is common ( F igs. 4.2, 4.3, 4.4) and not necessari ly assoc i ated w i t h local sympto m s . I t c a n be c aused by art i c u l ar, n e u ro myofas c i a l and/or emot ional dysfu nctio n .

Forward and backward bending \"'ith the pat ient standing or sitting she is instructed to forward bend the head/tru n k and t he qu ant i t y a n d symmetry o f motion i s observed ( F igs . 4.5, 4.6).

Functional Movement Tests - Regional Tests

Backward bending of the vertebromanu brial region is ac h i eved by aski ng t h e pati e n t to e l evate t heir a r m s b i l at eral l y ( F i g. 4 . 7 ) . When exam i n i n g backward bend ing of the vertebrosternal and ver tebroc hondral regions of t h e t horax ( Fig. 4.8), i t is critical to ensu re t h at the region being exam ined is actu al ly backward bending.

These t est s exam ine the fu nct ional m ovements of' t h e head and t ru nk. The qu ant ity and pat t ern of available mot ion as well as the presence/location of provoked sympt o m s are noted .

Ne i t her rot at i o n n o r s i d cflex i o n s h o u l d oc c u r d u ri ng forward nor backward ben d i n g ( Wi l lems et al 1 996).

m

CHAPTER 4 DIAGNOSING THE THO RACIC DYSFUNCTION

Figure 4.9 Functional movement testing - regional tests.

Figure 4.10 Functional movement testing- regional tests.

Lateral bending of the head.

Lateral bending of the trunk.

Lateral bending

Axial rotation

With the patient standing or sitting she is instructed to laterally bend the head/trunk (Figs. 4.9, 4.10) to either side. The ability of the thorax to produce a smooth regional curve is noted. A flat region or a kink in the curve requires further specific mobility testing to determine the cause.

With the patient standing or sitting she is instructed to rotate the head/trunk (Fig. 4.11) to either side. The ability of the thorax to produce a smooth regionaJ S curve is noted. A lack of movement or a kink in the curve requires Further specific mobility testing to determine the cause.

Respiration With the patient standing or sitting she is instructed to take a deep breath in and a long breath oul. Any asymmetry of chest expansion and release is nOled and when presenl requires further specific mobility testing to determine the cause. Functional Movement Tests Segmental Tests

Forward bending

Figure 4.11 Functional movement testing - regional tests. Rotation of the trunk should produce a smooth 5 curve.

The following test is used to determine lhe osteokinematic Function (active mobility) of two adjacent thoracic vertebrae during forward bending of the head/trunk. The transverse processes of two adjacent vertebrae are palpated with the index fingers and thumbs of both hands (Fig. 4.12a,b). The patient is instructed to forward bend the head/trunk and the quantity/symmetry or motion

DlAGNOSING THE THORAClC DYSFUNCTlON CHAPTER 4

is noted during flexion of the thoracic segment. Both index fingers should travel an equal distance superiorly. When inlerpreting the mobility findings, the position of the joint at the beginning of the tesl should be correlaled with the subsequent mobility noted, since alterations in joint mobility may merely be a reflection of an altered starting position. To determine the posilion of the superior verlebra, the dorsovenlral relationship of the trans verse processes to the coronal body plane is noted and compared with the level above and below. If lhe left lransverse process of the superior vertebra is more dorsal lhan the left transverse process of the inFerior vertebra then the segment is left rotated. If the left transverse process of the superior vertebra is less dorsal 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 righl rotaled compared to the level below but left rotated when compared to the coronal body plane. This is a typical compensatory pattern seen when a superior segment is derotating or unwinding a primary rotation at a lower level.

m

superiorly than the rib at the end of the available range. When the relative mobility between the thoracic vertebra and the rib is the same, no motion is palpated between the vertebra and the rib during forward bending. 10 determine the patient's normal movement pattern it is critical to evaluate levels abo ve, below and contralateral lo the tested segment.

Backward bending The following test is used to determine the osteokinematic function (active mobility) or lWO adjacent thor acic vertebrae during backward bending of the head/trunk. The transverse processes of two adjacent vertebrae are palpated with the index fingers and thumbs o f both hands (Fig. 4.12a,b). The patient is instructed to backward

The following test is used to determine the oSleokinematic Function (active mobility) of a rib relative to the vertebra of the same number during forward bending of the head/trunk. The trans verse process is palpated with the thumb of one hand. The rib is palpated just lateral to the tubercle and medial to the angle with the thumb of the other hand (Fig. 4.13a,b). The index finger of this hand rests along the shaft of the rib. The patient is instructed to Forward bend the head/trunk and the relalive motion between the transverse process and the ri b is noted. In the mobile lhorax, the rib continues to ante riorly rotate and the tubercle of the rib travels further superiorly than the transverse process at the end of the available range. I n the stiffer thorax, the rib anteriorly rotates and the tubercle of the rib stops before full thoracic flexion is achieved such that the transverse process travels further

Figure 4.12a,b. Functional movement testing- segmental tests. Points of palpation for TS-6.

CHAPTER 4 DIAGNOSING THE THORACIC DYSFUNCTION

bend t h e t runk a n d t h e qua n t i t y/symm e t ry of mot ion is noted during extens ion of the t horac i c segment . B ac kward bendi ng of t h e upper t horax is ach ieved by aski ng t h e p a t i ent to elevate bot h a rms. Both i ndex fingers s hould t ravel a n equal d istance i n feriorly. When i nterpreting t h e mobi lity find i ngs, the posi tion of the joint a t the beginni ng

of t h e test should be correlated w i t h t he subse que n t mob i l i t y noted , s i nc e a l t erat i ons i n joint mobil ity may merely be a reflect i on of an a ltered s tarti ng pos i t i o n . Th e follow i ng t e s t is u s e d t o d et erm i n e t h e osteokinemat ic function (act ive mobi l ity) of a rib a n d t h e vert e b ra o f t h e s a m e number dur i n g backward bend i ng of t h e head/t runk. The t rans verse process is pal pated w i t h the thumb of one hand. The rib is palpa ted just lateral to t he tubercle a n d medial to t h e angle w i t h t he t hum b of t he other h and ( Fig. 4.13a,b). The i ndex fi nger of t h is hand rests a long the shaft of t h e ri b. The patient is i nstructed to backward bend the t runk and t h e rel ative motion betwee n t he t ransverse process a nd t h e r i b is noted. B a c kward bend i ng of t h e upper t horax is achieved b y as king the patient to elevate both arm s . I n t h e mobile t horax, the rib conti nues to poste r i o r l y rot a t e a n d t he tubercle of t he r i b t ravels furt her i nferiorly than the tran sverse p rocess at the end of the available range. In the sti ffer thorax, t h e rib posteriorly rot ates and t he tuberc l e of the rib stops before full t horacic extension is achieved such t h a t t h e t ra n sverse process t ravels furt h er i n feriorly t h a n the rib at t he end of the ava i lable range. W hen t h e relat ive mobi l i ty between the thoracic vertebra and t he rib is the same, no motion is palpated between the vertebra and the rib during bac kward ben d i ng. To de term i ne t he pa t i e n t's normal movement pat tern it is crit ical to evaluate levels above, below and contralateral to the tested segment .

Lateral bending

Figure 4. '3a,b. Functional movement testing- segmental tests. Points of palpation forT9- 9th rib.

T h e fo l l ow i ng t e s l i s used t o d et e rm i n e t he osteokinem a t i c function (act ive mobi l i ty) of two adjacent t horacic vertebrae during lateral bend ing of t h e h ead/trunk. The t ra n sverse processes of two adjacent vertebrae are palpated with the index fingers and t h umbs of both hands. The patient is instructed to lateral bend the head/t runk and t he quant i ty and d i rect ion of motion is noted. I n the

DIAGNOSING THE THORACIC DYSFUNCTION CHAPTER 4

upper thorax, the superior thoracic vertebra should lateral bend and rotate to the same side such that the superior t ransverse process on the side of the concavity moves dorsa l l y and i nfe riorly. Below T3, the superior t horac ic vertebra shou l d lateral ben d i n t he pure coronal plane u n t i l t he last few degrees of movemen t . At t h i s point, the superior vertebra should rotate contralateral to t he direction of the l atera l ben d . Below T7, the direction o f motion coupling depends on the apex of t he curve ( Chapter 3). The direction of rotat ion should be congruen t w i t h t he levels above and below. The fo l l ow i n g t e s t i s u s e d to d e t e rm i n e t h e osteoki nema t ic fu nct ion of a rib and t he vertebra of the same n u m ber d u ring lateral ben d ing of the head/t r u n k. The tran sverse process is pa l pated with the t h u m b of one hand . The rib i s pal pated just lateral to the tuberc le and med ial to the angle w i t h the t h u mb of t h e o t h e r h a nd . The i ndex finger of t h i s hand rests a long the shaFt of the rib. Th e pat i e n t is i nstr u c t e d to l a t e r a l be n d t h e head/trunk and the re l a t ive mot ion between the transverse process and t he rib is noted .

Rotation The fo l l ow i n g t e s t i s u s e d t o d e t e rmi n e t h e osteoki nematic function o f two adjacent t horaci c vertebrae d u ring rotation of t he head/tru n k . The tran sverse processes of two a djacent vertebrae are pal pated with t he index finge r a n d t h umb of bot h h a n d s . The patient is i n st ructed to rotate the head/t r u n k and the quant ity and direct io n of motion is noted. 1 n the u pper t horax (vertebro ma n ubri a l ) and th e vertebrosternal regions, the supe rior t h o racic vertebra should l ateral be n d and rotate to t h e same side such that t he superior t ran sverse p rocess on the side of t he concavity move s d o rs a l ly a nd i nfe r i o rly. Be l o w T7, the d irection of the conj unct lateral ben d i s variable. It may be eit her to the same s i de as t he rotat ion or to t he oppos ite side.

•

Th e fo l l ow i n g test i s u s e d t o d e t e rmi n e t h e osteokinematic fun c t i o n of a rib a n d the vertebra of t h e s a m e n u mber d u r i n g ro t a t i o n of t h e head/t r un k . The transverse p rocess i s pal pated with the t h u mb of one h a n d . The rib i s pal pated just l a teral to the tubercle and med i a l to the angle w i t h t h e t h u mb o f t he o t h e r h a n d . The i n dex finger of t h i s hand rests a long t he shaft of the rib. The patie n t is instru cted to rotate the head/t ru n k a n d t h e relative motion between t he transverse p rocess and the rib is noted .

Respiration T h e follow i n g t e s t i s u s e d t o d e t e r m i n e t h e osteoki n e ma t i c fun c t i o n of a r i b relative to t h e vertebra o f t h e same number d u r i n g respi rati on. The transverse process is palpated with the thumb of one hand. The rib is palpated just l ateral to t he t u bercle a n d medial to the angle w i t h t he t h umb of the other h a n d . The index finger of t h is h a n d res t s a l o n g t h e s h a ft of t h e rib. Th e pat i e n t i s in s t r u c t e d t o b re a t h e i n fu l l y a n d t h e r e l a t ive mot i o n between the t ran sverse p rocess a n d t he r i b i s n o t e d . The p a t i e n t i s t h e n i n s t ru c t e d t o breathe out fully and t h e relative mot ion between the t ran sverse p roc ess a n d the rib is n oted . Articular Function - Form Closure

When a mobi l i ty abnormal i ty i s detected d u r i n g the fu n c t io na l moveme n t t e s t s a n d loc a l i zed to a segmen t w i t h the act ive mob i li ty tests, fu rther examin a t i o n is requ i red to d i ffere n t iate t he ro le of the joints ( form c losure) and the muscles ( force c losu re) i n t h is movement aberration . The spec i fic segmental tests of osteokinematic (passive p h ys i ol ogi c a l ) , arthrokinema t i c ( passive accessory ) , a n d arthroki netic (passive stabi l i ty ) fun c t ion a re u sed to differe nt iate t he two.

Passive mobility tests of osteokinematic function Passive physiologi c a l mobi l i ty tests a re used to c o n fi rm the l ev e l o f the abn ormal movement pattem noted on active mobility testing. In addit ion,

m

CHAPTER 4 DIAGNOSING THE THORACIC DYSFUNCTION

the end Feel of motion (analysis of the elastic zone of motion) is determined during these tests. With the patient sitting and the arms crossed to the opposite shoulders for the vertebromanubr ial and vertebrosternal regions, the transverse processes of the superior vertebra are palpated. In the thoracolumbar region, the interspinous space is palpated. The head/trunk is passively flexed, extended, laterally Rexed and rotated (Fig. 4.l4). The quantity of motion and the quality of the end Feel is noted and compared to the levels above and below.

Passive mobility tests of arthrokinematic function Zygapophysea l joi n t s Eg. T4-S to test the superior glide of the right zygapophyseal joint. This test is used to determine the ability of the right inferior articular process or T4 to glide supe riorly relative to the superior articular process of TS. With the patient prone and the thoracic spine in neutral, the inferior aspect of the left trans verse process ofTS is palpated with one thumb. The other thumb palpates the inferior aspect of the right transverse process of T4. Fix TS and apply a superoanterior glide to T4 (Figs. 4.1Sa,b). -

Figure 4.14 Articular function- form closure. Passive mobility tests of osteokinematic function.

Figure 4.1SU,b. Articular function - form closure. Passive mobility test of arthrokinematic function- points of palpation to test the superior glide of the right T4-5 zygapophyseal joint.

DlAGNOSING THE THOHAGIG DYSFUNGTION CHAPTEH 4

PI

Figure 4.16a,b. Articular function- form closure. Passive mobility test of arthrokinematic function - points of palpation to test the inferior glide of the right T4'5 zygapophyseal joint.

The stiffness w ithin the neutral zone and the quality 01' the clastic zone (end feel) is noted and compared to the contralateral side as well as to the levels above and below. This technique can be used for all thoracic segments. Zygapophyseal joints - Eg. T4-5 to test the inferior glide of the right zygapophyseal joint. This test is used to determine the ability of the right inferior articular process oFT4 to glide inferiorly relative to the superior articular process of T5. With the

patient prone and the thoracic spine in neutral, the inrerior aspect of the transverse process or T5 is palpated with one thumb. The other thumb palpates the superior aspect of the right trans verse process ofT4. Fix T5 and apply an inferior glide to T4 (Fig. 4. 16a,b). The stiffness within the neutral zone and the quality of the elastic zone (end feel) is noted and compared to the con tralateral side as well as to the levels above and below. This technique can be used For all thoracic segments.

Figure 4.17a,b. Articular function - form closure. Passive mobility test of arthrokinematic function - points of palpation to test the inferior glide of the right fifth costotransverse joint.

m

CHAPTER 4 DIAGNOSING THE THORACIC DYSFUNCTION

Figure 4.18a,b. Articular function- form closure. Passive mobility test of arthrokinematic function - points of palpation to test the anterolateroinferior (arrow) glide of the right 9th rib.

Costotransverse joints Eg. To test the inferior glide of the right fifth rib at the costotransverse joint. This test is used to determine the ability of the right fifth rib to glide inferiorly relative to the transverse process of T5. \;\Iith the patient prone and the thoracic spine i n neutral, the inferior aspect of the right transverse process of T5 is palpated with one thumb. T he other thumb palpates the superior aspect of the right fifth rib just lateral to the tubercle. Fix T5 and apply an inferior glide (allowing the conjunct posterior roll -

to occur) is applied to the fifth rib (Fig. 4 . 17a, b). The stiFfness within the neutral zone and the quality of the elastic zone (end reel) is noted and compared to thc contralatcral side ClS well ClS to the levels above and b elow .

Between T7 and Tl 0 the orientation of the cos totransverse joint changes such that the direction of the glide is anterolateroinferior. The position of the right hand is modified to facilitate this change injoint direction such that the index finger

Figure 4.19a,b. Articular function- form closure. Passive mobility test of arthrokinematic function - points of palpation to test the inferior glide of the right 1st costotransverse joint.

DIAGNOSING THE THORACIC DYSFUNCTION CHAPTER 4

III

Figure 4.2oa,b. Articular function - form closure. Passive mobility test of arthrokinematic function - points of palpation to test the superior glide of the right fifth costotransverse joint.

lies along the shaft of the rib and assists in gliding the rib in an anterolateroinferior direction (Fig. 4. J 8a,b).

Costotransverse joi n ts Eg. To test the inferior glide of the right first rib at the costotransverse joint. This test is used to determine the ability of the right f i rst rib t o glide inferiorly relative to the transverse process of TJ. The patient lies supine with the head and neck comfortably supported on a pillow. With the lateral aspect of the MCP of the index finger of the left hand, the superior aspect of the left transverse process of 1'1 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 just lateral to the costotransverse joint. The left hand fixes Tl and an inferior glide (allowing the conjunct posterior rotation to occur) is applied (Fig. 4. J9a,b). The stiffness within the neutral zone and the quality of the elastic zone (end feel) is noted and compared to the contralateral side. -

Costotransverse joi nts Eg. To test the superior glide of the right fifth rib at the costotransverse joint. This test is used to determine the ability of the right fifth rib to glide superiorly relative to the transverse process of 1'5. With the patient prone -

and the thoracic spine in neutral, the superior aspect of the transverse process of T5 is palpated with one thumb. The other thumb palpates the inFerior aspect of the right fifth rib just lateral to the tubercle. Fix T5 and apply a superior glide (allowing the conjunct anterior roll to occur) to the fifth rib (Fig. 4. 20a,b). T he stiffness within the neutral zone and the quality of the elastic zone (end feel) is noted and compared to the conlTalateral side as well as to the levels above and below. Between 1'7 and 1'10 the orientation of the cos totransverse joint changes such that the glide is posteromediosuperior. The position of the right hand is modified to facilitate this change in joint d irection such that the index finger of the right hand lies along the shaft of the rib. The left hand fixes the transverse process while the right hand glides the rib posteromediosuperior (Fig. 4.21b). Alternately, the right hand can fix the rib while the transverse process is glided anterolateroin ferior (Fig. 4.21a) thus producing a relative P05teromed iosuperior glide of the rib at the costotransverse joint.

Costotransverse joints Eg. To test the superior glide of the right first rib at the costotransverse joint. This test is L1sed to determine the ability of -

III

CI-IAPTER

Figure 4.210,b. Articular function - form closure. Passive mobility test of arthrokinematic function - points of palpation to test the posteromediosuperior glide ofthe right 9th rib. The T9 transverse process is glided anterolateroinferior.

t he right f i rst rib to gli de superiorly re lat ive to the t ra n sverse process of T 1. The pat ie n t l ies sup i n e w i t h t h e h e a d a n d n e c k c o m fortably s u pported on a pi l low. The superior aspect of the right t rans ve rse process o f T 1 is palpated w i t h t he r i g h t t humb. The i ndex and m iddle fi ngers of the right hand pa lpate the i nferior aspect of t he right first rib. The right i ndex and m iddle f i ngers fix the first r i b a n d a posteroinfer i o r gl i d e is appl i ed to t h e t ransverse process of T1 t h u s prod uci ng a relat ive supe r i o r gl i d e of t h e fi rst r i b at t he cos t o t ra n s-

verse joint (Fig. 4. 22a,b). The s t i ff·ness wit h i n the neut ral zone and t he qua l i t y of t he clas t i c zone (e n d fee l ) is n o t e d a n d c o mpa red to t h e co n t ralateral side. Lateral transl atio n - Eg. To test t h e a b i l ity of T 5 and lhe right and left sixth ribs to gl ide lra ns

versely to t he left on t he T6 vertebra. This motion is n ece s s a ry fo r Ful l r i ght rOlalion lo occu r. I t requ i res t he left sixth rib to glide poslerolalerally relative t o t he lefl t ra nsverse process of T6 and

Figure 4.220,b. Articular function - form closure. Passive mobility test o farthrokinematic function- points o fpalpation t o test the superior glide ofthe right first costotransverse joint.

DIAGNOSING THE THORACIC D YSFUNCTION CHAPTER 4

III

Figure 4.23. Articular function- form closure. Passive

Figure 4.24. Articular function - form closure. Passive

mobility test of arthrokinematic function - points of

stability test of arthrokinetic function - traction midthorax.

palpation to test lateral translation ofTS and the sixth ribs.

the right sixth rib to glide anteromedial ly relative to the right transverse process of T6. The patient is sitting with the arms crossed to opposite shoulders. The therapist is standing at the patient's left side. With the left hand/arm, palpate the thorax such that the fifth finger of the left hand lies along the left sixth rib. With the right hand, palpate the transverse processes of T6. With the left hand/arm translate the T5 vertebra and the ribs P U R E LY to the left in the transverse plane (Fig. 4.23). The stiffness within the n eutral zone and the q uality ofthe elastic zone (end feel) is noted and compared to the contralateral side as wel l as to the l evels above and below.

Passive stability tests of arthrokinetic function Vertical (traction/compression), This test stresses the an atomical s tructures which resist vertical forces. The patient is sitting with the arms crossed to opposite shoulders such that the arm closest to the chest grasps the scapula. T he other arm rests on top of the con tralateral shou Ider. The thoracic spine is in n eutral. Traction is applied to the mid dle a n d lower thorax by applying a vertical force through the patient's crossed arms (Fig. 4.24). Traction is applied to the upper thorax by applying a vertical force through the cranium. C ompression is applied to the middle and lower thorax by applying a vertical force through the top of the patien t's should ers ( F i g . 4. 25 ) .

m

C HAPTER 4 DIAGNOSINC TH E THORACIC DYS F U N CTION

Anterior trans lation - spinal. Th is test st resses the anatomical st ruct ures that resist anterior t rans lat ion of a segmental spi nal u n i t . Wit h t he pat ient prone lyi ng, the t ransverse processes or t he inferior vertebra are fixed. With the other hand , t he t rans verse processes of the superior vertebra are palpated. An poste roa nterior Force is applied t h rough t he superior vertebra while nxing t he inferior vertebra ( Fig. 4 . 26a,b). The s t i ffness w i t h i n t h e n e u t ra l zone and the qua l ity of t he elastic zone ( e n d feel ) i s n o t e d a n d c ompared to the leve ls above and below. The fi n d i ngs from this test should be cor re lated with those of the posterior t ranslat ion test to determ ine t he level of t he instab i l i ty. Excessive a n terior t ra n s l a t i o n of t he T4 vertebra coul d be d u e to e i t her an ant erior i n sta b i l ity or T4- 5 or a posterior i nstab i l i ty of T3-4.

Figure 4.25. Articular function - form closure. Passive stability test of arthrokinetic function- compression midthorax.

C o mpression is applied to t h e upper t h orax by applying a ve rtical fo rce t h rough t h e c ra n i u m . A posit ive response is the reproduction of t he patient's pa i n as opposed to a sense of i n c reased osteoar t i C Ld a r Ill ot i o n .

Posterior t rans lation - spinal . Th is test st resses t h e a n a t o m i c a l s t r u c t u re s t h a t res i s t posterior t ranslat ion of a segmental spi nal u n i t . The pat ient is sitting vvith t he arms crossed to opposite shoulders. T h e t h o ra x i s s t a b i l i ze d w i t h o n e h a n d /a r lll u nder/over ( depe n d i ng on t he level) t he pat ient's c rossed a rlll S . The t ra n sverse processes of' t h e i n ferior verte bra a re fixed w i t h t he dorsal hand. Stab i l i ty is tested by applying an a nteroposterior force to t he s upe rior vertebra t h rough t he t horax

Figure 4.26a,b. Articular function - form closure. Passive stability test for arthrokinetic function - points of palpation to test anterior translation (spinal).

DIAGNOSING THE THO RACIC DYSFUNCTION CHAPTER 4

111

Figure 4.27. Articular function - form closure. Passive

Figure 4.28. Articular function - form closure. Passive

stability test for arthrokinetic function - points of palpation

stability test for arthrokinetic function - points of palpation

to test posterior translation (spinal).

to test left rotation (spinal).

while fixing t he inferior ve rtebra (Fig. 4 . 2 7 ) . The s t i ffness w i t h i n the n e u t ra l zone and t he q u a l i t y o f t he elastic zone (end feci) is noted a n d compared to t he levels above a n d below. The findi ngs from t h i s test shou l d be cor related w i t h t hose of t h e anterior t ra nslat ion t e s t t o determ i ne t he leve l o f t he i nsta b i Iity.

lying, the t ransverse process of the superior vertebra is pa lpated. W i t h t he other h a n d , t he con t ra l a t e ra l t ra n sverse process of t he i n ferior ve rt ebra is fixed. A t ra nsverse plane rotatio n force i s appl ied t h rough the superior verteb ra by applying a u n i lateral posteroa n terior pres s u re w h i le fixing t he i n ferior ve rtebra (Fig. 4 . 2 8 ) . The st iffness w i t h i n t h e ne u t ra l zo ne a n d t he q u a l i ty o f t h e c l a s t i c zone (end fee l) is noted and compared to t he con t ra lateral side a n d t he levels above a n d below.

Tra nsverse rotation - s p i n a l . This test s t resses the anatom ica l st ruct u res wh ich resist rota t io n 01' a segmental spi nal u n i t . W i t h t he pat ient prone

Figure 4.29a,b. Articular function - form closure. Passive stability test for arthrokinetic function - points ofpalpation to test anterior translation (posterior costal).

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Figure

CHAPTER 4 DIAGNOSING THE THORACIC DYSFUNCTION

4.30a,b. Articular function - form closure. Passive stability test for arthrokinetic function- points ofpalpation to test

anteroposterior translation (anterior costochondral) .

A n t e rior t ra n s l a t i o n - posterior cost a l . T h i s t e s t st resses t h e a n a t o m i ca l s t r u ct u res w h i c h res ist a n terior t ra n s l a t ion of t he posterior aspect of t h e r i b re l a t i ve to t h e t h oracic vertebrae to w h i c h it a t t a c h e s (Lowcock 1 99 0 ) . Wi t h t h e pat ient prone lyi ng, t h e co n t ra la t e ra l t ra n sverse processes of t he t h oracic vertebrae to wh ich the rib is at t ached are palpa ted . For example, when test ing t he right fifth rib the left t ransverse processes o r T5 and T4 a rc pal pated . With t h e other hand, t he rib is palpated just lateral to the t ubercle (Fig. 4 . 29). A post e roan terior force is appl ied to t h e rib wh i le FIXing t he thoracic vertebrae. The stiffness w i t h i n t h e n e u t ra l zon e a n d t he qu a l i t y of t h e clas t i c zone (e n d fee l ) i s noted a n d compared to t he con t ra l at e ra l side. Anterior/Posterior translation - a nterior costal . This test st resses t h e anatom ical st ruct ures which resist t ra n s l a t i o n of t h e cos tocart i lage re lat ive to t h e s t e rn u m ; a n d t h e r i b r e l a t i ve to t h e costo ca rt i l age . When the s t e rn ocos t a l a n d/or costo chondral joints have been separated , a gap and a step ca n be palpated at the joi n t l i ne. The posi t i o n a l Fi n d i ngs a re n oted p r i o r t o s t ress i ng t h e j o i n l . W i t h one t h u mb, t he a nterior aspect of t h e

sternu m/costoca rt i lage i s palpated. With t he other thumb, the anterior aspect of the costocartilage/rib is pa l pa t e d . An a n t e roposte rior/posteroa nterior Force i s a pp l i ed to t he cos t oca rt i l age/r i b ( F i g. 4 . 3 0 ) . The s t i ffness t h e n e u t ra l zo n e a n d t h e q u a l i t y of t he clast ic zone (end fee l ) is noted and co mpa red to t h e con t ra l ateral side. Lateral translation. Th is test st resses the ,:lI1atom ical struct u res which resist horizontal t ranslat ion between two adjace n t verte b rae when t he ribs between them a re fixed . This test is used between t h e segm e n t s T3-4 a n d T I 0- 1 1 . The pri m a ry struct u re bei ng t ested is t he i n t e rvertebral disc. To test t he T5-6 segm e n t , the pat ient is s i t t i ng with t he arms crossed to opposite shou lders. With t h e l e ft hand/a rm , t he t h o rax is pa lpated s u c h t hat t he fi ft h fi nger of the left h a n d Ii e s a long t he fift h r i b . Wi t h t h e right hand, t he left sixt h rib is compressed ce n t ra l ly towa rd s the costovertebral j o i n t ( F ig. 4 . 3 1 ) . The T5 ve rtebra i s t ra n s lated t h rough t h e t h o rax P U R E LY t o t he left i n t he transverse p l a n e . When t he r i b i s fixed aga i n s t the vertebral body t h e re should b e very l i t t le, i F a n y, l a t e r a l t ra n s l a t i o n b e t we e n t wo t h oracic vertebrae.

D IAGNOSING THE THORACIC DYS F U NCTION CHAPT E R 4

Neuromyofascial Function Force Closure and Motor Control

Palpation of the segmental local stabilizers The local s t a b i l izers for t he t ho rax i n c l u de t h e deep fibers of m u l t i fidus, rotatores b reves, levator cost arum and t he i n tercostals. To date, t he re has been no research t o va l idate t h i s c l as s i fi c a t i o n and t h is hypot hesis comes From knowledge gained from t he resea rc h or t he l u m bopelvic region (see C h apt e r 2 ) . C l i n i c a l l y, it has been noted t h a t at rophy o r t hese deep s m a l l m u sc les occ u rs s u b sequent t o inj u ry to the t horax. Like t he l u m ba r spi ne, t h e a ffect appears t o b e segm e n t a l . The muscles are palpated with the pat ient prone lyi ng, head in neut ral and arms resting com[ortably over t he si des of t he t a b l e . The 'gu t t e r' betwee n t he spi n o u s process a n d t he t ra n sverse process i s pa lpated ( F ig. - L 32). Press f i rm ly, but gent ly, i n to t h e t i s s u e a n d n o t e t h e qu a l i t y o f t h e t i s s u e (Flrlll ness) a n d t he s ize o f t he m uscle. Compa re the f i rm n ess/size t o the con t ra l ateral s i de a n d to leve ls a bove and below.

m ove ; t h i s i s a n o r m a l biom e c h a n i c a l c o ns e quence. Therefore, when i nterpreting t he f i n d i ngs from t h i s t e s t i t i s i m port a n t t o o bse rve w h a t h appe n s i n t h e t h o rax d u r i n g t he m o m e n t t he arm begi ns to l i ft . The provocation of a ny pa i n is also noted a t t h is ti me. The t horax is t he n com pressed pass ively ( F ig. 4 . 3 4 ) by approxi m a t i n g the ribs ( noted t o b e mov i n g d u ring t h e fi rst pa rt

Prone Arm Lift This test was i n i t ia l ly proposed by Li nda-Joy Lee, working toge t h e r w i t h B i l l Lyons in t he deve lop ment of tests ror eva l ua t i ng dyna m ic s t a b i l i t y of t h e t ho rax. I t evo lved from t he Act ive S t ra ight Leg Raise Test (AS L R ) ( M ens e t a l J 997, J 999, 200 1 ) ; a val idated test of load t ra n s fe r/sta b i l i ty of the l u m bopelvic region. The prone pat ient i s asked t o l i rt t he i r a r m off o f t he t a b l e (only a few degrees or l i rt is necessary) ( F ig. 4 . 3 3 ) and to note any d i rre rence in t he efrort requ i red to l i ft t h e left or right arm (does o n e a r m seem heavier o r harder t o l i rt ) . The st rategy used t o stabi l ize t he t horax during t h is task is observed. The arm shou ld Aex at t he glenohu mera l joi n t , t he scapu la should re m a i n u pward ly rot ated a n d stable aga i n s t the chest wa l l , t he t horax shou ld not rotate, sidebend, Aex, ext end or t ranslate. I f the a rm is elevated t o t he end or i t s ava i lable range t hen t he t horax w i l l

Figure 4.3" Articular function - form closure. Passive stability test for arthrokinetic function - T5-6 right lateral translation stability test.

Figure 4.32 Neuromyofascial Function - force closure and motor control. Palpation of the segmental local stabilizers.

C HAPTER 4 D I AGNOSING THE THORACIC DYS F U NCTION

Figure 4.33 The Prone Arm lift is used to evaluate dynamic stability of the thorax during loading.

been veriFieci for t he S I] ( R ichardson et aI 2002 ) . To t e s t t h e s t a t u s o f t h e a c t i ve fo rce c l o s u re mechanism, the pat ient is First inst ructecl to recruit t he local m u sc l e system (see C ha pter 7). This i n s t ru c t i o n may t a ke a few sessions t o master. Once the patient is able to sust 8 i n a tonic co-con t raction of the local musc l e syst e m , t he effect of t h i s contraction on t he n e u t ra l zone is assessed by re pea t i n g t he /"orm c l o s u re tests for a n t e ro posterior an d/or latera l t ra n s l a t ion ( see above). The stiffness should increase and no relat ive inter segm e n t a l or ve r t e b rocos t a l m o t i o n s h o u l d be felt. This means t hat an adequate a mount of com pression of the t horax has occ urred and the force c l o s u re mec h a n i s m is e ffect ive. I f t h e n e u t ra l zone mot ion remains "excessive" compared to the adjacent leve l s a n d t h e local m u s c le system is c o n t racting appropriate l y, t he n t he active force c l os u re mec h a n ism is i ne ffect ive ror control l i ng shear. Thi s i s a poor p rognost ic sign for success fu l re habilitat ion w i t h exerc i se. Neural Conduction and Mobility

Figure 4.34 The impact of manual compression of the thorax through the rib cage is noted on both pain provocation and effort to lift the arm.

of t h i s test) towards the m i d l i n e eit h e r anteriorly or posteriorly. The P rone Ann Lift is repeated and any c hange in effort a nd/or pa i n is noted.

Testfor the integrity of the active force closure mechanism W h e n t h e a c t i ve fo rce c l o s u re m ec h a n i s m i s effect ive, co-c o n t ra c t i o n o f t h e m u s c l e s o f t h e local m u scle system should compress t he t horacic segme n t t h e reby red u c i ng the n e u t ra l zone for both horizo n t a l and vert ical t ranslation. Th is has

These tests exam ine t he conductivity of the motor and sen sory nerves as well as t he mob i l i ty of t he d u ra and t he int ercosta l nerves in t he spinal canal and i ntervertebral foramen. The sensory fu nction o f t he i ntercostal nerves is exa m i ned by test ing s k i n sensat ion i n t he i n te rcost a l spaces. Altered sensation is not u ncommon alt hough rarely reported as a p r i m a ry compl a i n t . H yperaest hesia can be one of the Fi rst s igns of neurological i n terference and tends to occ u r long before sensation becomes red uced ( hypoaesthesia). The motor fu n c t i o n of t h e i n t e rcostal nerves is exa m i ned by observing a n d palpa t i ng the i n ter cost a l m u scles. Segmen t a l fac i l i t a t ion leads to hyperto n i c i t y of the i n tercostal m u scle and the i n c reased tone can be palpated a l ong the i n t er costal space. The tone i s oft e n assoc iated with tender poi nts within t he muscle. Reduced motor fu nction of the i ntercostal nerves cau ses a t rophy of the i n tercostal m u sc les.

DIAGNO SING THE THORACIC D YSFUNCTION CHA PTER 4

Ref lex tests are used to detect spinal cord or upper motor neuron lesions. The p l a n ta r response test and t he test fo r c lonus should be done o n eve ry pat ient present i ng w i t h pa i n i n t he t horax. The mob i l i t y tests for the neura l and d u ra l t issue ( B u t le r 2000) i nc l u de the s l u m p test and varia t i o n s t h e reof. The m o b i l i t y o f t h e i n t ra s p i n a l t i ssues c a n be t es t e d by fu l ly l e n gt h e n i ng t h e d u ra l/neura l system. Th i s is ach ieved b y h aving t he seated pat ient Fu l ly flex t he head a n d neck, s l u m p t he t horaco l u mbar s p i n e a n d exte n d t he knee w i t h t h e a n k l e d o rs i flexe d . The d u ra i s rel eased by t he n having t he pat ie n t ext end the head and neck. The change in symptom response is noted . I f t he t horacic pain is brought on by fu l l s l u m p a n d rel ieved w i t h ext e n s i o n o f t h e h ead and neck, i nvolvement of t he d u ra i s suggested ( B ut ler 2000) . The i n tercostal nerves c a n b e fu rther t en sed by having t he 's l u m ped' pat ient twist t h e t h o rax t o t he lert and righ t . Ofte n , t he patient w i l l prese n t w i t h a norma I movement pa ttern when rot a t i o n occ u rs i n a pos it ion o f re lat ive neura l rel axat io n and an abnormal movement pattern (segmental kink i n t h e t h o ra c i c c u rve) w h e n t he rot a t i o n occ u rs i n a pos i t ion o f re lat ive neura l t e n s i o n . I t is i n terest ing t o post ulate on t he e t i o l ogy o f the 'apparent segmental dysfu nct ion' i n t h i s s i t uation and u n less the nervous system is addressed, the sym ptoms pers ist regardless of t he art i c u l a r and myorasc ial t reatments e m p loyed. The emphasis or t h is text is o n t he assess ment a n d t re a t m e n t o f art ic u l ar a nd myoFasc i a l dysfu nc t i o n and the reader is referred to But ler's work on t h is subject 1'01' furt her review. Adjunctive Tests

W h i l e X- rays exc l ude serious bone d i sease a n d sign i ricant meehanical defects, t hey rarely provide gu idance 1'01' physical t herapy. Asym met ry is t he rule i n t he t h orax a n d devi a t i o n of t he s p i no u s p rocesses i s t o b e expe c t e d . Fo r t h e p h y s i c a l

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t he ra p i s t , the p r i m a ry reason for obt a i n i n g t h e res u l t s of a n y adj u nc t ive i m agi n g tests is t o rule o u t serious pathology a n d to i de n t i fy anatom ical a n o m a l ies which may i nfluence t he i n te rp reta tion of m o b i l ity a n a lysis. The n n d i n gs noted on a dj u n c t ive test i n g of the t horax m u s t be corre l a ted w i t h the fi n d i ngs noted on c l i n ical exa m i n a t i o n i f the sign i ficance i s to b e u n derst ood .

The Integrated Model of Function

FORCE CLOSURE

5 CLASSIFYING THE THORACIC DYSFUNCTION

Functionally, motion of the thorax can become restricted or poorly controlled due to either excessive or insufficient articular compression. In keeping with the integrated model, the causes for the thoracic impairment can be due to dysfunction of •

form closure (structure),

•

force closure (forces produced by myofascial action/inaction) and

•

motor control (specific timing of muscle action/inaction during loading)

In addition, force closure and motor control can be impacted by the emotional state of the patient.

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CHAPTER 5 CLASSIFYING THE THORACIC DYSFUNCTION

CLASSIFYING THE THORACIC DYSFUNCTION CHAPTER 5

INTEGRATED MODEL OF FUNCTION CLASSIFICATION Functionally, motion of the thorax can become restricted or poorly controlled due to either excessive or insufficient articular compression. In keeping with the integrated model , the causes for the thoracic impairment can be due to dysfunction of: •

form closure (structure),

•

force closure (Forces produced by myofascial action/inaction) and

•

m

position of the bones. Repeat analysis of the form closure tests (passive tests for arthrokinematic function, also known as joint play) will now reveal a decrease in stiffness compared to the opposite side. Restoration of the force closure mechanism through an appropriate exercise program must follow. This is an impairment of both form and force closure in that the relationship between the articular surfaces has been disturbed and the muscle response is excessive. Treatment of this individual which focuses on exercise without first addressing the "posture",

molor control (speciFic timing of muscle

"position", alignment" of the thorax:, tends to be

action/inaction during loading)

ineffective and commonly increases symptoms. Conversely, if treatment only includes manual

In add ilion, force closure and motor control can be impacted by the emotional state of the patient.

Excessive Articular Compression Excessive articular compression can result from arlicular pathology (ankylosing spondylitis or diffuse idiopathic skelelal hyperostosis (DISH)), fibrosis of the articu lar capsule or overactivation of muscles. The fused joints cannot be mobilized whereas the fibrosed joinls require specific mobi lization. When the excessive compression is secondary lo muscle imbalance, appropriate motor control training which emphasizes optimal sta bilization strategies (see Chapter 7) \Nill be required.

Excessive Articular Compression with an Underlying Instability When a Force is applied to the joint sufficient to

therapy (mobilization, manipulation or muscle energy) for correction of "posture", "position", "alignment", relief tends to be temporary and dependence on the health care practitioner providing the manual correction is common. This impairment requires a combination of manual therapy, exercise and education for a successfu I outcome.

Insufficient Articular Compression Insufficient articular compression occurs when there is either •

inadequate or inappropriate motor control during movement and loading or

•

overstretching of the ligaments which restrain the end range of the articular motion.

allenuale the articular ligaments , the muscles will respond lo prevent dislocation and further

Treatment requires the restoration of the active

lrauma lo the joinl . The resulting spasm fixes the

force closure mechanism (see Chapter 7) with

joint in an abnormal resting position and marked

specific exercises that initially isolate the muscles

asymmetry of the bones is present. This is an

required for stabilization followed by a program

unslable joinl under excessive compression.

that addresses motor control.

Trealment usually requires a manipulation to distract the joinl. These techniques will reduce lhe arlicular compression and restore the resting

6 RESTORING FORM CLOSURE OF THE THORAX

This chapter will describe the clinical findings of excessive articular compression. Specific articular mobilization techniques for the stiff joint, "muscle release/decompression" techniques for the "compressed" joint and manipulation techniques for the fixated joint will be described.

The reader is referred to the CD-ROM which accompanies this text to view short video clips of these techniques.

m

C HAPTE R 6 R E STORING F O R M C LOS U R E O F T H E T H O RAX

This c hapte r w i l l descri be the c l i n i cal fi n d i n gs of excessive articular compression secondary to either •

•

•

fi b ro s i s o f the zygapop hyseal or c osto transverse j o i n t (stiff j o i nt) or overactivati o n of the segm e n t a l m u sc les which are compress i n g t h e zygapophysea l or constotransverse joint (compressed joint) or a cost o t ra nsve rse joi n t fixat i o n or a fixation of t h e e n t i re thoracic r i n g (excess i ve arti c u l a r c o m p ress i o n w i th a n u n d erly i n g i nsta b i l i ty ) .

Spec ific art i c u l a r mobil ization tec hniques for the sti FF j o i n t , ' musc l e release/decompression' tech n iq ues for t h e 'com p ressed ' j o i n t and m a nip u l a t ion techniques for the fixated joint will be described. The rea d e r is referred to the CD-ROM w h i c h accompan ies th i s text to view short video c lips of t hese tec h n iq ues. Although th is c hapter focuses mainly on excessive c o m p ression thro ugh the posterior j o i n t s of t h e t horax, some mentio n should be made o f thorac ic i ntervetebral d isc herniations. M agnetic resonance i m agi ng ( MRT) has i n c reased the Fre q u e n c y of t h is d i agnosis. Brown e t a l (1992) confirmed t ha t tho rac i c d isc herniations p ro duce a nterior c h est pa i n ( 6 7%) . O t h e r sym p to m s i n c l u d e d l o w e r extre m i ty dysaesthesia a n d weakness (20%), i n ter scapular pa i n (8%) and epigastric p a i n (4%). ''The degree of h e rn iation was c h a racteri ze d as m i ld, moderate, or severe. A m i l d hern i a t i o n consisted of o n ly m i n i ma l dural indentation . M oderate her n iation c reated l i m ited cord p ressure w i t h no sig n ificant deformation . Severe h e rn iations resulted i n free fragm e n ts or evidence of cord c o m p res sion m a n i fested by i n de n tation or fl atte n i n g of t h e cord ." The h i gh est i n c i d e n ce accord i n g to level was T7-8, the seco n d h ighest was T6-7 a n d T9-1 O. The i rritability o f the painfu l tissue d ictates the i n te nsity of t h e pain, t h e amount of rad iat ion,

t h e d egree o f p h ys i c a l a c t i v i t y w h i c h tends to aggravate it a n d the a m o u n t of rest req u i red to relieve it. The intervertebral d isc herniation causes excessive compression of t he thorax due to secondary m usc l e spasm/h ype rt o n i c i t y. Spe c i fi c a n d/or regional d istraction tec h n i q ues as wel l as m usc le release/decompression techniques are often helpful for relievin g pain . In addition, postu ra l education, t aping for support and t i me complete the man age m e n t of this con d i t io n .

EXCESSIVE ARTICULAR COMPRESSION - STIFF JOINT

Fibrosis of the zyga pophysea l a n d/or costot rans verse joint is usua l l y related to a t rau matic eve n t a l t hough h a b i t u a l ly sust a i ned post u res can also l ead to m ultisegmental joint sti ffness. I n t he case of segme n ta l joi n t st i ffness, t he location of pa i n may be on t h e i psilatera l or contra l at eral side o f t h e st i ff j o i n t a n d may rad iate a round or t h rough to t h e a n te r i o r a s p e c t of t h e c h est . An ac u t e zygap o p h yse a l j o i n t s p ra i n t e n d s to p rod u c e local ized pa i n ove r t h e i nvolved j o i n t . A c h ron i c rest r i c t i o n of e i t h e r t h e zyga pop hysea l or cos t ov e r t e b r a l j o i n t te n d s to p rod u c e sy m ptoms removed fro m the so u rce (co n t ralate ral side of the thorax or a t levels above or below). The joi n ts of the thorax ten d to refer p a i n around t he chest whereas t h e i ntervertebral d isc tends to refer pai n th rough t h e c hest . T h e st i ff, fibrotic j o i n t w i l l p rese n t w i t h t h e fol lowi ng objective Find i ngs. 1. Postural analysis.

The i m pa c t of a st i ff joi n t on an i nd ivid ua l's post u re d e p e n d s on w h e t h e r t he fi brosis i s con fined to a si ngle segment o r spans m u ltiple segme nts. A segmenta l , Fi brotic joi nt may not reveal itself through postural analysis. Alternately, i t may stand out as a segmental rotation i n t he

R ESTORING F O R M C LOS U R E OF T H E TH ORAX C H A PT E R 6

m i d s t o f a n o t h e r w i s e n o r m a l c u rve . Mu lli segm e n t a l s t i ffness tends to a l t e r t he primary l horac ic curve and can be exaggerated (kyphosis), reduced (lordos is) or twisted (roto scoliosi s ) .

3. Articular function - form closure.

Bot h t he segmental s t i ff j o i n t a n d t h e m u l t i segm e n t a l s t i ff region p resent w i t h a consis tent pattern of restriction on segmental passive m o b i l i t y le s t i ng. I n c re a s e d s t i ffn ess i n t h e neutral zone and a harder e n d feel i n t he clastic zone a re noted on passive tests for a rt h rokine matic fu nction. The stiff join t has a solid stop which does not vary w i t h the speed of t he test .

2. Functional movement tests and active mobility

t ests o f osteokinematic function. BOlh t he segmen t a l s t i ff j o i n t a n d t h e m u l ti segmental s t i ff region present w i t h a consis tent p a t t e r n of a s y m m e t r i c mot i o n . If t h e restriclion is bilateral, then a symmetric reduction of movement is noted compared to levels above and below. The uni laterally restricted zygapophy seal joint prese nts w i t h an i psi lateral res tric t ion pattern (sideflexion and rotat ion restricted to t he same s i de ) . The u n i latera l l y rest ricted coslolra n s verse j o i n t p rese n t s w i t h a c o n t ralatera l rest rict ion pattern ( s ideflexion a n d rotalion restricted to opposite side s ) .

iii

4. Neuromyofascial function - force cl osure

and motor control.

The Prone Am Lift test may reveal poor thoracic pos i t i o n control segm e n ta l ly a n d/or m u l t i seg m e n ta l l y. 5. Neural conduction and mobility.

Conduction is normal and neuraJld ural mobility may or may not be restricted.

6.

Adjunctive tests.

X-rays are rarely helpful; they may reveal a roto scoliot ic or kypholorclotic c u rve w h i c h i s a l so evident on post u ra l analysis.

Figure 6.1. Bil ateral fiexion restriction - vertebromanu brial region. Longitudinal traction - supine.

IE'

CHAPTER 6 RESTORING F O R M CLOS U RE OF THE THORAX

art h rokinematic gl ide at the zygapophyseal joint is rest ricted bi latera I ly. Vertehromanuhrial region

Longi t u din a l t ra c t i o n of t h e upper t ho rax w i l l prod uce a superior g l i d e of the zygapop hyseal joint bi l ateral ly. This techn ique is done w i t h the pat i e n t su p i n e lyi ng. Wi t h t h e latera l aspect of t he IVI C P of t he i ndex fi nger, t h e i n t e rsp i nous space is pa lpated at t h e Icve l t o be t ract ioned. With an open pinch grip of t he other hand, the l ower cervi c a l spi n e is palpated as c l ose t o t h e superior vertebra of t he level t o b e t ract ioned as poss i b l e (Fig. 6 . 1) . Loca l i za t i on is ach ieved by Aexin g/extending the dysfunctional segment u n t i l t he n e u t ra l posi t io n i s ascert a i ned. Craclcs 3 to 4 sust a i ned l o n git u d i n a l t ract ion is applied by fixing the caudal vertebra and pu l l i ng t he c ranial ve rtebra superiorly.

Figure 6.2. - Bilateral flexion restriction - vertebromanu brial

region. Longitu d i n a l traction - sitting.

The next sect ion of t h is c hapter will describe/i l l us t ra t e spec ific m o b il iza t i o n t ec h n i q u e s fo r t h e st iff/fibrotic zygapophysea l!costotransverse joints of the t h orax. The restricted motion w i l l be iden t i fi e d a n d t h e relevan t fi n d i ngs on fu n c t i o n a l move m e n t t est i n g a n d a rt h ro k i n e m a t i c t est i ng o u t l i ned.

Bilateral Restriction ofFlexion T h e u pp e r t h o rax i s ra re l y fixed i n a l o rd o t i c posi t ion , however, a b ilateral rest riction o f Aexion is not u ncommon at T2-3 o r t h rough o u t the ver tebrosterna l region genera l ly ( F ig. 4.3). Forward bend i ng of t h e head/t ru n k reveals a l i m itation of t he superior excursion of the t ransverse processes bilate ra l ly and t h is can be confirmed on passive p h ys i o l og i c a l m o b i l i t y t e s t i n g . T h e s u p e r i o r

A l t e r n a t e l y, d i s t rac t i o n c a n be d o n e w i t h t h e pat ient e i t her silt i ng or st and i ng w i t h bot h hands beh i n d t he neck, flllgers i n terlaced. The t herapist w i nds bot h of t he i r arms benea t h t he pat i e n t 's ax i l l ae t h rough t h e t ri a n gu l a r space c reated by t h e Aexed e l bows. The fingers are i nterlaced and p l aced ove r t he pa t i e n t 's h a nds ( F ig. 6.2) . The t h o rax is gen t ly gripped by adduct ing the arms. The pati e n t is i nst ructed to look forward and t he t herapist e nsu res that the l igame n t u m n uc hae is not on fu l l st re t c h . From t h i s posit ion, a Grade 3 to 4 longi t u d i n a l t raction tec h n ique is applied by roc k i n g t h e pat ient bac kwa rds a n d forwards u ntil a pen d u lar type mot ion is prod uced. Gravity provides the dist ract ive force. A h igh ve loc ity, low a m p l i t ude t h rust tec h n i q u e (Grade 5) c a n be a pp l i e d at t h e apex o f t h e desc e n t w h e n t h e pat ient's body weight is d ropping. To m a i n t a i n t he mob i l i t y ga i ned, t he pat ient is inst ructed to perform t he following exercise. With the fi nge rs i n t e rl aced beh i nd t he neck and the i ndex fingers in t he appropriate interspinous space. t h e pa t i e n t is i nstructed to Flex t h e head/neck. The fingers may assist t he motion by applying a

RESTO R I NG FORM CLO S U R E O F THE THORAX C HAPTE R 6

m

s upe r i o r press u re to t he i n fe r i o r aspect of t h e spi n o u s process o f t he s uperior ve r t e b ra . The ampl it ude of' the exercise should be in the pa infree range anc.l should not aggravate any symptoms. Vertebrosternal/vertebrochondral region

Longi tuci inal t ract ion w i l l produce a supcrior glide or the zygapophyseal joint bilaterally. This technique may be done with the pat ient e i t her supi ne l y i ng or s i t t i ng. The supi ne tec h n i q u e is perfo rmed as rol lo\lls. The patient is sidelying, t he head supported on a pil low and t he arms c rossed to t h e opposite shoulders. The therapist stands, rac ing the patient's head with t heir feet/legs in a st ride position. With t he t u berc le of' t he scaphoid bone a nd the Aexed PIP joint or t he long finger, t he t ransverse processes of the i n rerior vertebra a re pa lpated . The o t h e r ha nd/arm l i es across t h e pa t ie n t 's c rossed a r m s to control the t horax ( Fig. 6 . 3 ). Segment a l loca l izat ion i s ach ieved b y Aexing t he joint to t he motion barrier w i t h the hand/a rm contro l l i ng the thorax. This local iza t i o n is m a i n t a i ned as the pat i e n t is rol led supine on ly until contact is made between t he table and the dorsa l hand. From t h i s pos i t ion, fu rther loca l i zat io n is ac h i eved by compressing t he t horax by add u c t i ng the dorsal arm, t he hand of which is stab i l izing t he i n Fe rior vertebra of t he segment to be mobi l ized . Longi t ud i n a l t raction is appl ied t h rough t h e t horax by s h i Ft i ng weight From t h e t h e ra p i s t 's b a c k leg/foot to t he fro n t leg/fool . The t h e ra p i s t 's h a nd/a r m s Foc u s t h e t e c h n i q u e t o t h e spec i fi c segm e n t w h i l e t h e t r u n lJlegs prod uce the m o b i l izat ion force which is graded accord ing to t he needs of the j o i n t . The tec h n i q u e can be graded fro m 3 to 5, t h e s t i ff joi nt w i l l req u i re a sustai ned grade 4 tec h n i q u e . Distraction c a n also b e appl ied w i t h t he pat ient sitting with t he arms c rossed to opposite shou lders. A small towel is placed aga inst t he spi nous process or the caudal vert ebra of t h e segment to be d is t racted . The towel is fixed aga i nst t he t he ra p i st's stern u m . Wi t h both a r m s w rapped a ro u n d t he patient's t runk, the pat ient's elbow which is closest to t h e c hest is grasped (Fig. 6.4). The segment is

Figure 6.3. Bilateral flexion restriction - vertebrosternal and

vertebrochondral region. Specific longitudinal traction - supine.

Figure 6.4. Bilateral flexion restriction - vertebrosternal and

vertebrochondral region. General longitudinal traction - sitting.

C HAPTEH 6 R E STOH I NG F O R M CLOS U RE OF T H E THORAX

be con firm ed on passive physiological mob i l ity testing. The su perior arthrokinematic gl ide at t he zygapophysea l joi n t is res tricted unilateral l y. Vertebromanubrial region restricted flexion right Tl-2

Figure 6.5. Uni lateral fiexion restriction - vertebromanubrial

regio n . Right zygapophyseal joint Tl·2.

The patient is supine lying with t he head supported on a pill ow. Wi t h t h e l ateral aspect of lhe i n dex finger, the left transverse process oF T I is palpated. Wit h t h e o t her h a n d , t h e m i dcervical s p i n e i s supported d o w n t o C 7 . T h e m o t i o n ba rrier i s localized b y passively Aexing T l -2 a n d then gliding the left t ra n sverse process of Tl i n feromed iaJiy on T2 . C7-Tl is stabilized with the opposite hand by s ideAex i ng the C7- T! segment to the left and rot a t i n g i t to the righ t . From th i s pos i t io n , t h e right zygapophyseal joint ofT! -2 is mobil ized i nto fl exi o n t h ro u gh a n i n fero m ed i a l a nd s l i g h t l y poster i or g l i d e wit h t he LEFT h a n d (Fig. 6 .5 ) . Th i s wil l resu l t i n a superior and sl igh t ly an te rior glide of t h e righ t facet at T l - 2 . 'The tech n i que can be graded from 1 to 5, t he stiff joint wiJl require a s u stained grade 4 tech n iqu e . Vertebrosternal/vertebrochondral region restricted flexion left T5-6

Figure 6.6. Unilateral fiexion restriction - vertebrosternal

and vertebrochondral region. Left zygapophyseal joint TS-6.

l oca l ized to n e u t ra l . From t h i s pos i t i o n , distrac tion is appl ied by rocki ng t h e p a t i e n t backwards and s i multaneously lift i ng t h e thorax posterosu periorly. The towel fixes t h e caudal vertebra a n d assists i n loca l iz i n g t h e d i stract ive forces to t h e appropriate segment. The technique can b e graded from 3 to 5 .

Unilateral Restriction of Flexion This is a com mon restriction to find i n a l l regions of t he t h orax. Forward bending of the head/trun k revea ls a l i m i t a t i o n of t h e superior excursion of t he transverse p rocesses u nilatera l ly and t his can

The patient is right sidelying, the head supported on a p i ll ow and the arms crossed to the opposite shoulders. The therapist stands, facing the patient's head with their feetllegs in a stride pos i t ion. Wit h the tubercle of t h e righ t sca p hoid bone and t he Aexed PIP j o i nt of the right long finger, t h e left t ransverse process ofT6 and the righl t ransverse process of T5 are palpated. The other hand/arm lies across t h e pat ie n t 's crossed arms to co ntro l t h e t horax ( Fig. 6 . 6 ) . Segm e nta l loca l iza t i o n i s ach ieved b y flex i ng t he j o i n t to the mot ion barrier w i t h t h e h a nd/arm co n t rol l i n g t h e t h orax. Th i s loca li zat ion is m a i n t a i ned as t h e pa t ient is rol led s u p i ne o n l y u n t i l contact is made betwee n the ta b l e a n d t h e dorsal hand. F rom th i s pos i t io n , fu rther l oca l iza t i o n i s ach ieved b y com press ing the t horax by adduct i ng the dorsal arm , t he h and of w hich is stab i l izing the i n ferior vertebra of t he

R E STORING F O R M C LOSURE OF T H E T H O RAX C HAPTE R 6

..

segme n t to be m o b i l ized. From t h i s pos i t io n , a right sideflexion force is appl ied through t he t horax to produce a s u perior glide of t h e left zyga pophy seal joi n t . The tec h n ique c a n be graded from 1 to 5, t he st i FF j o i n t w i l l requ i re a sustai ned grade 4 tech n ique. Thoracolumbar region restricted flexion right T11-12

With the patient i n left s ide lyi ng, h i ps and knees sl ightly f l exed, the 1' 1 0- 1 1 i n terspi nous space is pal pated. The t horaco l u m bar s p i n e is rotated by p u l l i ng/gu iding t he pat i e n t 's lower arm forward u n t i l fu l l rotat ion of 1'10- 1 1 is a c h ieved. The Ll2 i n terspi nous space is pal pated and the patient's uppermost h i p and knee are flexed until ful l flexion of L 1 -2 occ u rs. The foot of t he u p pe r leg rest s aga i nst t he popl i teal fossa o f t h e lower leg. The 1' 1 1- 1 2 i n ters p i nous space i s p a l pated and t he right zygapophyseal joint is local ized and mob i lized i n t o fl exion a n d l e Ft s i d eflexion t h ro u gh eit h e r t h e t h o rax o r t h e p e l v i c gi rdle ( F i g. 6 . 7 ) . The tec h n iq u e c a n be graded from 1 t o 5, t he stiff joint w i l l requ i re a susta i ned grade 4 tec h n iq u e .

Figure 6.7 Unilateral flexion restriction - thoracolumbar

region. Right zygapophyseal joi n t Tl1-12.

Bilateral Restriction of Extension Th is restriction is commonly seen when t he patient has a forward head pos t u re a n d/or a col l a psed, kyp hot i c t horacic pos t u re . B i l at eral elevat ion of the arms or extension of the mid thorax w i l l reveal a l i m i tat ion or the i n ferior exc u rsion of the t rans verse processes bilateral ly. The inferior arthrokine matic gl ide at the zygapophyseal joi n t is rest ri cted b i l aterally.

Figure 6.8. Bilateral extension restriction

vertebromanubrial region.

s ligh t l y e x t e n di n g t h e s u pe r i o r v e r t e b r a . T h e techn i que c a n be graded from 1 to 4 .

Unilateral Restriction of Extension Vertebromanubrial region

The patient is supine lying with the head supported on a p i l low. Wi t h t he l a teral aspect of t h e i ndex f inger of one hand, the interspinous space is palpated at the level to be treated. The opposite hand SUppOLts the lower cervical s p i ne as c lose to the segment as possible (Fig. 6.8). The motion barrier is localized and passively m o b i l ized by dors a l l y gl i d i n g a n d

T h i s i s another common rest r ic t io n to f i n d i n a l l regions o f t h e t horax . B il at e r a l e l evation of t h e arms or backward b e n d i n g o f t h e t r u n k reveals a l i m i ta t ion of the i n ferior exc u rs ion of t h e trans verse process u n ilaterally and this can be confirmed on pass i ve p hy s i o l ogi c a l m o b i l i ty t e s t i ng. The i n ferior arthroki n e m a t i c gl i de a t t h e zygapophy seal joi n t is restri c ted u n i la teral l y.

..

CI-IAPT E R 6 R E STOR I NG FORM CLOS U R E OF T H E T H ORAX

pos i t io n , t h e right zygapophysea l jo i nt or T 1 -2 is m ob i l ized into extension t h rough a posLero i n rer omedial glide with the RIG HT hand. The technique can be graded from I to 5, the stiFrjoint will requ ire a sustai ned grade 4 tec h n i q ue. Vertebrosternal/vertebrochondral region restricted extension left TS-6

Figure 6.9. Uni lateral extension restriction -

vertebromanubrial regio n . Right zygapophyseal joint Tl-2.

Figure 6.10. Unilateral extension restriction - vertebrosternal

and vertebrochondral region. Left zygapophyseal joint at TS- 6.

Vertebromanubrial region -

The pat ient is right sidelyi ng, t he head su pported on a p i l low and t he arms c rossed to t he oppos i t e shoulders. The t herapist stands, facing t he pat ient's head w i th their feet/legs i n a st ride posit ion. With t he t u bercle of t he right scaphoid bone and t he f lexed P I P j o i n t of t he right long r-inger, t he left t ransverse process of T6 and t h e right t ransverse p rocess oF T5 are palpated . The other ha nd/arm l i e s across t h e patient's c rossed arms to con t rol t h e t h o rax ( F ig. 6 . 1 0) . Segllle n t a l loca lizat ion i s a c h i eved by ext e n d i n g t he j o i n t t o t h e mot ion barrier w i t h t h e hand/a rm contro l l i ng t h e t horax. Th i s loca l izat ion i s m a i n t a i ned as the pat ient is ro l led s u p i ne only u n t i l contact is made between the table and t he dorsal hancl. From t h is posit ion , fu rther local izat ion is ach ieved by compress i ng t h e t horax by add u c t i n g t he dorsal arm, t he hand of which i s stabil izing t h e i n rerior vertebra of the segm e n t t o be m o b i l ized. From t h i s pos i t i o n , a left sidef l exion force (cou pled w i t h a sl ight dorsal g l i d e ) is a p p l ied t h rough t he t h orax to prod uce a n i n rerior glide of t he left zygapop hysea l joi n t . The Lec h n iq u e can be graded [rom J t o 5 , t he stirF joi n t w i l l req u i re a s u s t a i ned grade 4 tec h n iq u e .

restricted extension right Tl-2

Thoracolumbar region -

The patient is supine lying with the head supported on a p i l low. Wi t h t h e l ateral aspect of t he i nd ex f i nger, t he right t ransverse process of T l is palpated . The m i dcervical s p i n e i s s u p ported down t o C7 with the ot her hand. The mOLion barrier is localized by pass ively ext e n d i n g T l -2 a n d t he n gliding t he right t ra nsverse p rocess of T l postero i n ferome d i a l l y on T2 ( F ig. 6.9). C 7-T l i s s t a b i l ized w i t h t he opposite hand by sideAexing t he C7-T J segment to t he right a n d rot a t i ng it to t h e left . From t h i s

restricted extension right T J J - J 2

Wi t h t he pa t i e n t left s i delyi ng, h i ps a nd knees s l ight ly f l exed , t he T] 0- 1 1 i n t e rsp i nous space is p a l pated. The t h oraco l u m bar spine i s rotated by ge n t ly p u l l i n g/gu i d i ng t h e pat i e n t's lower arm forward u n t il fu l l rotation of T] 0- 1 1 i s ach ieved. The LJ-2 i n ters p i nous space i s palpated and t he patient 's u ppermost h i p and knee arc f l exed u n t i l fu l l flexion of L 1 -2 occ u rs . The root of t h e u pper l eg rest s aga i n s t the p o p l i teal rossa or t he lower

R E STORING FOR M GLOS U R E OF T H E T H O R AX C HA PT E R 6

m

l eg. The T J 1- J 2 i n ters p i nous space is p a l pated and t h e righ t zygapop hyseal joint i s localized and m o b i l ized i n t o ext e n s i o n a n d r i g h t s ideflexi o n t h rough e it her t he t horax or t he pelvic girdle ( F ig. 6.11). The tec h n i q ue can be graded from 1 to 5, t h e st iEr j o i n t w i l l req u i re a s u s t a i ned grade 4 tec h n iq ue .

Unilateral Restriction ofRotation - Rib Vertebromanubrial region restricted anterior rotation right 1 st rib

Th i s dysfu nct ion w i l l res t ri c t exte n s i o n of t h e head/neck. Rota t i o n a n d lateral bend i ng o f t h e head/neck will be limited to the side o f t he restricted rib ( t h i s mot ion req u i res a su perior gl ide of t h e r i b a t t h e cost otran sverse jo i n t ) . F u l l expi ra t i o n w i l l a l so revea l asy m m e t ry of r i b m o t i o n . The superior glide of t h e fi rst r i b at t h e costotrans verse joint is rest ricted . The patient is s upine lying with t he head supported on a p i l low. The superior aspect of the r ight t rans verse p rocess 0[T1 is p a l p a t e d w i t h t h e r i gh t t h u m b . The i ndex and middle fingers of t h e right hand palpate t he i n Ferior aspect of t h e right first rib. The m idcervical s p i ne i s su p po rted w i t h t h e ot her hand. T h e m o t i o n barrier i s loca l i zed a n d mobil ized b y a pplyi ng a postero i n ferior glide t o t h e tra n sverse p rocess of T] ( F i g . 6.12) t h u s prod u c i ng a relat ive s u perior gl ide o f t he first rib at t he costotransverse joi n t . The m iddle and index fi ngers or the right hand fix the i n ferior aspect of the first-rib. The tec h n iq u e can be graded from I to 4, t he stiff joint w i l l req u i re a sustai ned grade 4 tec h n ique. Vertebromanubrial region restricted posterior rotation right 1 st rib

Th i s d y s Fu n c t i o n w i l l re s t r i c t flex i o n of t h e head/nec k . Rot a t ion a n d lateral be n d i n g o f t he head/neck to t he opposite s ide of t h e rest r i c ted rib and fu l l i n s p i ra t i o n w i l l a lso be l i m i ted . The i n ferior glide of the first rib at t he costotransverse j o i n t w i l l be restricted.

Figure 6.11. Unilateral extension restriction - thoracolumbar

region. Right zygapophyseal joint Tl1-12.

Figure 6.12. Unilateral anterior rotation restriction of the

right first rib.

The patient is supine lying 'vvith the head supported on a p i l low. The s u perior aspect of t h e right first rib is palpated with the lateral aspect of t he MC P of t h e i ndex finger of t h e r i g h t h a nd . The m id cerv i c a l a n d u pper t h orac i c s p i ne i s s u pported w i t h t he other h a n d . The s p i ne is s t a b i l i zed by localized sideflexion of C7, T l and 1'2 to the right and rotation to the left . The motion barrier of t he first costotransverse joint is localized and mobil ized by a p p l y i n g an i n fe r i o r g l i de ( F i g. 6.13) to t h e t u bercle o f t h e r i b a l lowing t he conj u n c t posterior

CI-IAPTER 6 RES TORING FORM CLOS URE OF T H E THORAX

Figure 6.13. Uni lateral posterior rotation restriction of the

right first rib.

To mob i lize t h e left 5th costotransverse joint the follow i n g tec h n iq u e is used. The patient i s right s i de ly ing, the head s u pported on a p i l low and the arm s c ro s s e d to the o p p o s ite s h o u l d ers . The thera p i st sta nds, facing the patie nt's head w ith their feetllegs in a stride position. Wit h t he proximal p h al a n x of t h e right t h u mb, t h e l e Ft 5th r i b i s palpated j u st l ateral to the transverse process of T5 . The other h a n d/arm l ies across the patient's crossed arms to control the th orax (Fig. 6 . 14 ) . Segmental l ocalization i s ach ieved by eexing the joi n t to the motion barrier with the hand/arm con trolling the t horax. This local ization is maintained a s t h e patient is rol l ed s u p i ne only u nt i l contact is made between the table and the dorsal hand. From this position, Further local ization is ach ieved by compress ing the thorax by add ucti ng the dorsal arm , the hand of which is stabi l izing the rib. From t h i s p o s i t i o n , furt h e r rota t i o n of t h e loc a l i zed thorax over t h e �xa t i ng t h u m b d i stracts the cos totran sverse joint. The tec h n iq u e can he graded fro m 1 to 5, the stiff joint w i l l req u ire a s usta ined grade 4 tec h n i q ue.

EXCESSIVE ARTICULAR COM PRESSION -

J

COM PRESSED JOINT Figure 6.14. U n i l ateral rotation restriction of the left fifth

costotransverse joint - distraction technique.

----===

The compressed join t will present with the following objective �ndi ngs. 1. Postural analysis.

ro l l to occ ur. The tec h n i q ue can be graded from I to 5, the stiff joint w i l l require a sustai ned grade 4 tec h n i q ue. Vertebrosternal/vertebrochondral regions - restriction rib rotation

Th i s dysFu n ct i o n i s s e e n w h e n t h e costotran s verse joint i s restricte d . It is com mon to see both a n t erior a n d posterior rot a t i o n restricted w h e n t h i s joi n t i s �brotic a n d d istraction of t h e j o i nt i s t h e m ost effective tec h n i q u e For mob i l izatio n .

The i mpact of a com pressed joint on an i n d i vidual's posture depends on whether the com pre s s i o n is c o n fi ned to a s i ngle segm e n t or span s m u l t i p l e segm ents. A segm e n t a l j o i n t c o m pres s i o n m a y not reve a l i t se l f t hrough postural analys i s . Alternately, it may stand out a s a segm e n t a l rot a t i o n i n the m i d st of a n otherwise normal c urve. M ultisegmental com p re s s i o n ten d s to a l ter the pri mary thorac i c c u rve a n d c a n b e exaggerated ( kyph o s i s ) , reduced ( lordos i s ) or twisted (rotoscoliosis).

R E STO R I N G FO R M C LOS U R E OF T H E T H O RAX C HA PT E R 6

2. F unctional movement tests and active mobility

tests of osteokinematic function.

The pattern of mot ion on repeated testi ng can be variable depending on the i rri tabi l i ty of the segm e n t . A joint which is i n term i ttently com pressed may present with a vari able pattern, c h anging from m o m e n t t o moment a n d test t o tesl . A jo i n t w h i c h is u n der sustai ned com pression (never lets go) w i l l demonstrate a con s i stent pat tern of motion on repeated test i ng. 3. Articu lar function - form closu re.

O n c e a ga i n , t h e p a t t e r n of re s t r i c t i o n o n segme n t a l p a s s i v e m o b i l i t y t e s t i ng c a n b e ' variable with joi nts wh ich are bei ng compressed by the n e u romyofascial system. Wh i le u n d e r com p ress i o n , i n c reased s t i ffn ess i s p a l p a b l e within t he neutral zone a n d while the stiff j o i n t h a s a solid end fee l w h i c h does n o t vary w i t h the speed o f t h e test, the compressed j o i n t i s somewhat softer and t h e a m p l i t ude o f motion can vary w i t h the speed of the test . When the glide is appl ied rapid ly, t he amplitude of motion may be l ess t h a n if t he glide i s appl ied s low ly. This rdlects t he neuromyofasc ial cause of t h e a rt ic u l a r c o m p ress i o n . T h e passive t e s t s for arthrok i net i c fu nct ion ( pass ive s t a b i l i ty) a re oft e n , but not always, norm a l .

D

Unilateral Restriction ofFlexion/Right Sideflexion/Right Rotation W h e n the myofasci a i s overactive and com press ing a left thoracic zygapoph yseal joi n t the following release tec h n i que can be usefu l . The patient i s sitting w i t h the arms crossed to opposite shoulders. W i t h t he dorsal h a n d t he i n tertransverse space i s palpated. The ven t ral h a n d i s p l aced on the con tralateral shoulder. The motion barrier is localized by flexing a n d right side flexing the t horax. From t h i s posi t ion, the patient is i n s t ructed to hold s t i l l w h i le t h e t hera p i s t a p p l i e s gen t l e res i s t a n c e t o left rotation of the tru n k ( F ig. 6. 1 5) . The isomet ric contraction is h e l d for up to 5 second s fol lowing which the patient i s i nstructed t o completely relax. The n e w flexion/s i d e flexion barr i er i s local i zed and t he mob i li zation repeated t h ree t i mes.

4 . Neuromyofascial function - force c l o s u re

and motor contro l .

The prone arm l i ft reveals poor thoracic posi t ion con t ro l . 5 . Neu ral conduction and mo b i l i t y.

Cond uct ion is normal and neuralldural mobil i ty may or may not be rest ricted . 6. Adj u ncti ve tests. X-rays are rarely hel pful; t hey may reveal a roto scol iot ic or kypholordotic c u rve w h i c h is also evident on pos t u ra l a na lysis.

Figure 6. 15. Uni lateral restriction offlexionjright

sideflexionjright rotation at T5-6 - release tech nique.

C HA PT E R 6 R E STO R I N G F O R M C L O S U R E OF T H E T H O RAX

Unilateral Restriction ofInspiration When t he myofascia is overactive and compressing t h e costotransverse j o i n t t h e Fol lowing rel ease technique can be useful to restore posterior rotation of t he right 6th rib. The pat ient is s i l t ing with the arms c ro s s e d t o o p p o s i t e s h o u l d e r s . Wi t h t h e dorsal h a n d t h e 6 t h r i b is palpated . The ve ntral h a n d i s p l a c e d o n t h e p a t i e n t 's c o n t ra l a t e ra l shoulder. The motion bar r i e r i s local ized by leFt s id e fl ex i ng a n d r i g h t rot a t i n g t h e t h o rax ( F i g. 6. 1 6) . From this position, t he patient is i nstructed to ge n t l y rotate the t horax aga i nst t h e t hera p ist's resistance. The isometric con t raction is held For u p to 5 seco n d s fo l l owi ng w h i c h t h e pat ie n t is i nstructed t o c o m pletely re lax. The new motion barrier i s l ocal ized and t h e mobil izat ion repeated t h ree t i mes.

Unilateral Restriction ofExpiration Figure 6.16 Uni lateral restriction of posterior rotation ofthe

right fifth rib - release technique.

When t h e myofasc i a is overact i ve and compress ing the costotransverse joint the fol lowi ng release tec h n ique can be useFul to restore anterior rotat ion of the righ t 6th rib. The pat ient is s i t t ing with t he arms crossed to opposite shou lders. Wit h t he dorsal h a n d t h e 6th r i b is palpated. The ve n t ra l hand i s p l aced on the patient's contralateral shoulder. The motion barrier is local ized by right sidenexing and l eft ro t a t i n g t he t h o rax ( F i g . 6 . 1 7 ) . From t h i s posi t i o n , t h e patient i s inst ruf:ted t o gen t ly rot ate the t horax aga i n s t the t herapist's res istance. The isometric con t raction is held for u p to 5 seconds fol low i ng w h i c h the patient is instru c ted to com pletely rel ax. The new motion barrier is local ized and the mobil iza t ion repeated t h ree t i mes.

EXCESSIVE COM PRESSION WIT H AN UNDE RLYING INSTABILITY

Figure 6.17 Uni lateral restriction of anterior rotation of the

right fifth rib - release technique.

A fixated joint is one which is u nstable and is held compressed in an abnormal pos i t ion by overac t ivat ion 0 1' m u sc les. The mode 0 1 ' onset is always t ra u m a t i c . The loc a t i o n of t h e p a i n may be on t h e i p s i lateral or contra lateral side of t he f ixated

R E STO R I NG F O R M C LO S U R E OF T H E T H O RAX C H APTE R 6

joi n t a n d may racJ iate arou n d or t h rough to t he anterior aspect or the chest . Breat hing is commonly affected when the rib is fixated. The fixated joint w i l l p resent with the fol low i ng object ive f i n d i ngs. J . Postural ana l ysis .

A "ki n k' or sudden deviat ion i n t h e s p i n a l or

costal c u rve at the level or t he f ixation is eas i ly noted. 2 . Functional movement tests and active mobility

tests for osteokinem atic function. A consistent pattern of asymmet ri c motion i s

noted on re peated tes t i ng. M ost m ove ments of the thorax are efFected in neither a zygapophy seal nor a cost otransverse joi n t pattern. 3 . Articul ar function - form c l osure.

No mot ion is palpable. I t is d i ffi c ul t to even fi n d the p lane or t h e joint For testing. Prior to m a n i p u lat i ng t he joi n t , t h e pass i ve tests for a r t h rok i net ic ru n c t i o n ( pass ive stab i l i ty) a re normal. After the joint has been decompressed ( m a n i p u lat ive tec h n ique) the passive tests for arthroki net i c ru nction reveal t h e u nderlying i n sta b i l i ty ( ne u t ra l zo ne of moti o n i s asym metric and excessive com pared to l evels above and below). 4 . Neuro m yofasc i a l function - force closure

and motor control .

T h e Prone A r m Lift test reveals poor t horac i c pos i t ion cont ro l . M a n u a l compression of t he t horax i n c reases pa i n and i n c reases t h e efFort req u i red to l i Ft the arm . 5 . Neura l conduction and m o b ility.

Conduct ion is normal and neuralldura l mobil ity is often rest ricted.

6.

Adjunctive tests .

X-rays reveal a rotoscoliotic cu rve which is a lso evident on post u ra l analys i s .

T h e next section w i l l desc r i be/i J i u st rate spec i f i c m a n i p u la tion tech n iq u e s for t reat i ng fixa tions of the costotra n sverse/costovertebral joint and t h e lateral s h i ft l e s i o n of t h e thorac ic ri ng.

Fixation ofthe costotransverseJcostovertebraljoint Vertebromanubrial region superior fixation right 1 st rib

The patient is supine lying with the head su pported on a p i l low. The s u perior aspect of t he right f i rst r i b is palpated with the lateral aspect of the MC P of t h e i ndex Fi nge r of t h e right h a n d . The m i d c e rv i c a l a n d u p pe r t h oracic s p i n e i s s u p ported w i t h the o t h e r h a n d . The s p i n e i s s t a b i l ized by local ized s ideflexion of C7, T J and T2 to the right and rotation to the left . The motion barrier of t he fi rst costotransverse j o i n t i s loc a l i zed by app lyi ng a n i n ferior gl i de to the t u bercle of the rib. From t h i s pos it ion a h igh veloc ity, low a m pl it ude t h rust is a p p l ied to the fi rst rib in a n i n ferior d i rection ( F ig. 6. 1 3 ) . Vertebrosternal/vertebrochondral region fixation right 5th rib

The pat ient is right sidelyi ng, the head s u pported on a p i l l ow a n d t he arms c rossed to t h e oppos i t e shou lders. The t herapist stands, faci ng t h e patient's head with t he i r feetllegs i n a stride pos i t ion. Wi th the prox i m a l p h a l a nx of t h e right t h u m b, t h e leFt 5t h rib i s p a l p ated j u s t l a teral to t h e t ra nsve rse p rocess oF T5. The other hanel/arm l ies across t he p a t i e n t 's c ro s s e d a r m s t o c o n t ro l t h e t h o r a x . Segmental l ocal i zat ion i s achieved b y f l e x i n g t he joint to t he motion barrier with the hand/arm con t ro l l i n g t h e t h orax . D i s t r ac t i o n of t h e c o s t o t ran sverse j o i n t i s ach ieved by rol l i ng t h e pat ient over t h e dorsal hand only u n t i l contact i s made between t h e table a n d t he dorsal hand. Further axi a l rota t i o n of t h e t horax aga i nst the Fixed r i b w i l l d i s t ract t h e costotransverse joi n t . A very low a m p l i t u d e , h igh veloc i ty t hrust a p p l ied t h rough the t horax in axial rotation wiJJ red uce the fixation ( F ig. 6 . 1 4 ) .

C HAPTE R 6 R ESTO H I N G F O H M C LO S U H E OF T H E T H OHA)(

Thoracolumbar region fixation right 1 2th costovertebral joint

Fixation of the eleve n t h or twelft h ribs at the cos t overte b ra l j o i n t is not c o m m o n given the nexi b i l i ty or this region. A sudden con t ract ion of t h e I'u l l y s t re t c hed q u a d ra t u s l u m bo r u m m u s c l e ( hyperex t e n s i o n from t h e fu l ly fl exed pos i t i o n ) c a n res u l t i n an i n ferior f ixat ion o f t h e twelfth rib. Excessive rot a t i o n of t he trunk while fu l l y flexed c a n a l s o Fixa t e t h e se j o i n t s . W h e n a c u t e , t h e pat i e n t prese n t s w i t h a latera l s h i ft o f t h e t ru n k local ized t o t h e thoracol u m bar j u n c t ion . A l l act ive m ove m e n t s a re b locked at t h e t h oraco l u m ba r j u nc t io n . Any attempt t o correct t h e latera l s h i Ft m e e t s w i t h re s i s t a n c e a n d a n i n crease i n t h e p a t i e n t 's pa i n . Wit h t h e pat ient i n l eFt s i delyi ng, h i ps a n d knees s l ight ly Aexed , the T I 2 - L l i n ters p i nous s pace i s pal pated. The t horac o l u m ba r s p i n e i s rotated by ge n t l y p u l l i n g/gu i d i n g t h e p a t i e n t 's l ower a r m forward u n t i l fu l l rot a t ion of T 1 2- L l is ach ieved . The L 1 -2 i nters p i nous space is p a lpated a n d t h e pat ient's u ppermost h i p a n d knee are Aexed u n t i l Fu l l nexion o f U -2 occ u rs. The Foot of t h e u pper leg rests aga i nst the p o p l i teal fossa of the lower leg. The right s i d e of the s p i nous p rocess of T l 2

is palpa ted w i t h t he therapi st's c ranial hand. The right twelft h rib is pal pated a n d fixed w i t h t h e t h u m b and index f-i nger of t he therapist's left hand. The right costovertebral joint between the twelfth rib and T l 2 i s d i s t racted w i t h a h igh veloc ity, low a m p l i t ude t h rust technique by axially rotat i ng the s p i nous process of T 1 2 away from the Fixed ri b ( F ig. 6 . 1 8) .

Fixation of the 'Ring' This f ixation involves the entire 'ri ng' which incl udes two adjacent t h o racic vert eb rae, t h e i n t erverte bra l d isc, the two ribs and their associated anterior and posterior joints and the sternum. This fixat ion occ u rs primarily in t he vertebrosternal region and occa s i o n a l l y in the ve rtebroc h o n d ra l regio n . I t c a n occ u r when excessive rotat ion i s appl ied to t he u nrestrained t h orax o r when rotation of t he t horax is forced aga i nst a fixed rib cage (seat belt injlllY). At the limit of right rotation in the m idthorax t h e s u perior vert e b ra has t rans lated t o t he left , the left r i b has t ranslated posterolatera l ly and t he r ight rib has trans lated an tero med i a l ly such t hat a fu nct ional U joint is produced (sec biomechan ics - C hapter 3). F u rt he r right rota t ion results in a right lateral t i l t of the s u perior ve rtebra . Fixation

Vertebral Body---,

Superior Costovertebral Joint

Rib

Inferior Costovertebral Joint Horizontal Intra-discal Cleft

Figure 6.18. Thoracolum bar j u nction - u n i lateral fixation of

Figure 6.19. Anatomy of the lateral shift lesion. It is proposed

the right twelfth rib at the costovertebral joint.

that a horizontal cleft occurs through the posterior 1/3 of the i ntervertebral disc confluent with the superior costovertebral joi nts bilaterally allowing the superior vertebra to sublux latera l ly.

R E STO R I NG FORM G LOS U R E O F T H E T H O RAX C HA PT E R 6

or t h e s u p e r i o r vert e b ra occ u rs w h e n t h e l e ft lateral translat ion exceeds the physiological motion barrier and t he vertebra i s u nable to ret u rn to its n e u t ra l pos i t i o n . For t he f'ixat i o n to occ u r i t i s p ro posed t h a t a h o r i zo n t a l c l eft t h ro u gh t h e posterior 1 /3 o r the i ntervertebral d i sc must occu r ( F ig. 6 . J 9 ) .

3 . Articul ar func t ion - form c losure.

There is a complete block to right lateral t rans lat ion. Prior to manipulating the ring, the passive tests for arthrokinetic ru nction ( passive stabil ity) are normal. After the segment has been decom pressed ( m a n i p u lat ive tech n i q ue ) t h e pass ive tests for arthroki net ic fu nct ion f'or left lateral t ra n s l a t i on revea I the u nd e r l y i n g i nsta b i I i t y ( n e u t ra l zo n e of m o t i o n i s asym m e t r i c a n d excessive compared to levels above a n d below) .

Lef't l ateral s h i f't f ixat ion of' t h e 6 t h ring a n a l y s is . T5 -T6 i s right ro tated , t h e r i g h t s i x t h r i b i s an teromed ial posteriorly a n d t h e left sixt h rib i s posterolatera l posteriorly.

m

I . Postura l

4 . Neur o m yofasc i a l function - force c losure

and motor control.

The Prone Arm Lift test reveals poor t horac ic pos i t i o n contro l . M a n ua l compression of the t horax i n c reases pa i n and i n c reases t h e effort req u i red to l i ft the arm. After the segment has been dec o m p ressed , the l e rt P rone Arm L i rt w i l l reveal a l e rt l at e r a l t r a n s l a t i o n at T 5 - 6 . W h e n m a n u a l com p ressi o n i s a p p l ied to t h e 6th ri ng, the effort req u i red to l i Ft t h e arm w i l l be l e s s a n d the latera l t ra n slation control l e d .

2. Functiona l mo vement tes t s.

A l l ru n c t i onal movements produce a ' k i n k' at T5-6, the most affected movement i s rotation ( F ig. 6.20).

5 . Neura l conduc t io n and mo b i l i t y.

Conduction is normal and neuralldural mobi lity orten restricted.

6.

Adjunctive t ests.

X-rays reveal a rotoscoliotic curve which is also evident on pos t u ra l a n a lysis.

Figure 6.20. This patient sustained a lateral shift ofTS and

the left and right sixth ribs i n a motor vehicle accident one month prior. Note the complete block of right rotation at the fixated segment.

To re lease a l e ft lateral fixat i o n of t he 6 t h r i ng, the fol lowing t ec h n i q ue i s u se d . The patient is in left s idelyi ng, the head s u p ported on a p i l low and the arms c rossed to the oppos ite shou lders . With t h e left hand, the right seventh r i b i s pal pated posteriorly "vi t h the proximal phalanx of t he thumb. T6 is fixed by com pressing the right 7th rib towards the m id l in e . Care m u st be t a ken to avoid fixation of the s ixth ribs which m ust be free to glide relat ive to t h e t ra n sverse p ro c e s s e s of T6 . T h e o t h e r h an d/ar m l ies a c ross t h e p a t i e n t 's c rossed arms to c o n t ro l t h e t horax. Segme n t a l l oc a l iza t i o n i s achieved b y Aexing t h e joint u nt i l a neut ral posit ion

Em

C H A PT E R 6 R E STO R I N G FO R M C LO S U R E O F T H E T H O RAX

of t he zygapophyseal joints is ach ieved. This local ization is maintained as the patient is rolled supine o n ly u n t i l con tact i s made between t he table and t he d orsal h a n d . From this pos i t i o n , T5 a n d t he left a n d right sixth r i b s are t ra n s lated laterally to t he right t h ro ugh the t horax to t he mot ion barrier. S t rong longi t u d i n a l trac t i o n i s a p p l ied t h rough t h e t horax by sh i ft i n g weight [rom the t herapi st's back leg/foot to t h e fron t leg/foot . Th i s t raction i s m a i n t a i ned a n d a h igh velocity, low a m p l i t ude t h r u s t is a p p l i e d to t h e r i n g in a r i g h t l a t e r a l d i rect ion ( F ig. 6 . 2 1 ) . T h e goa l of t he tec h n iq u e i s t o d i s t ract a n d l a t e ra l ly t ra n s l a t e T5 a n d t h e leFt a n d right s i x t h ribs rel a t i ve t o T6.

Once form closure has been restored to the joints o f the t ho rax, a t t e n t i o n s h o u l d once aga i n be directed to force closure analysis and motor control. The f i nd i ngs from t hese tests may be qu ite eli rrcrent t h a n on t h e fi rst eva l u a t i o n so it is prudent t o repeat t hese tests at t h i s t i me. The next s t e p i n treat ment is to ensure t hat force closure a n d motor con t rol are restored. I n the mean t i me, t he t horax c a n be t a ped t o p reve n t excessive t ra n s lat i o n d u ri n g activit ies of daily l ivi ng. Alt ernately, The C o m - P ressoru1 ( F ig. 6 . 2 2 ) (www.opt p .com) - a belt o rigi nally des igned ( D G Lee 2002) to assist in stabil iza t ion or t he pelvic girdle can be used to apply a compressive rorce to t he syst em. The body

Figure 6.21. M a n i p u lation tec h n i q u e for a left lateral shift of the sixth ring. Strong d istraction m u st be maintained throughout

the tech n i que.

R E STO R I N G FO R M C LO S U R E O F T H E T H m�AX C H A PT E R 6

belt is appl ied around t he t h o rax a t t h e level o r t he u n stable segm e n t . T h e c o m p ression s t ra ps a re a p p l ied t o t h e body b e l t a c c o rd i ng t o t h e findings of t he Prone Arm Lift. I f the e Ffort required t o l i ft t h e e l evated a r m is red u ced w h e n c o m pression is appl ied posteriorly (approximating the ribs t o t h e vertebra ) , t he n t he straps are a p p l ied posteriorly to d u pl icate t h i s compression force. If t he anterior costochondra l joi n t s are u nstable and a n t erior com press i o n o f the t ho rax d u ri n g t he Prone A r m Lift reduces t h e req u i red e ffort to l i ft the e levated arm, t hen t he straps are appl ied a nt e r i o rl y to d u p l ic a t e t h i s com p ress ion force . The Com-Pressorr�l should only be used t o augment an exerc ise progra m (Chapter 7) for motor control.

THE (OMPRElIOR"

0;;;-

--...._, ""' ......

.::�

Figure 6.22. The Com- Pressor.

•

7 RESTORING FORCE CLOSURE/ MOTOR CONTROL OF THE THORAX Written by Linda-Joy Lee

With respect to the thorax, it is the coordinated action between the local and global muscle systems that ensures stability without rigidity of posture and without episodes of collapse. This is the goal: "Mobility on Stability". The exercises presented in this chapter focus on balancing tension and compression forces and involve an extensive use of imagery. In this manner, individual muscles are recruited and appropriately timed for the coordinated execution and control of functional movement.

The reader is referred to the CD-ROM which accompanies this text to view short video clips of some of these exercises.

m

C HAPTE R 7

R E STO R I N G FO R C E C L O S U R E/MOTOR C ON T ROL OF THE T H O RAX

Chapter allthor's Hote: The cOHcepts alld exercises presented ill this chapter are based on principles alld ideas published in the worh of IIlal1Y inl10vative researchers ami cliniciaNs such as Hichardson, Jull,

I-Iodges &- I-lides (199-l- 2000), Comerford &- Mot/ralll (2001), O'Sllllivall (1997), Sahlllal1H (2001), and Janda (1978). My ideas have also been influenced by ll'lllllerOllS beell pril'ileged to U'orh with and learn fr0111 in ",),

career. 1 a111 grateflll for the lIIal1), talented illst.rllctors of tl-Ie Calladial1 Orthopaedic Division; il1 this s),stell1 111)' IItamlal therap)' shills and clinical reasoning frameU'oriz were cultivated. Uitilllatel)� it is 11'1)' patients who have cOlltinl1ally pllshed the development of these ideas, as their Itlliq!1e present.atiolls require continual refinelllellt

al/.d problelll solving to help thell1 reach their goals. 1 wOltld lihe to thanh Dr. Palll I-Iodges for his help with SOll1e of the figllres ill this chapter, and 1I10re i1I1portantly for his ellcollragell,ent to purS!1e creatil'e thinhing while critically exa11/ining the evidence a/ld ashing relevant questions. Fillally, r would lihe to thanh Diane Leefor her sllpport alld the opportl11lit)' to present these ideas; her i/lexlw11Stihie energ)� en1l111siaslll, and COllllllit1l1ellt to fostering t.he cOlltillual illspiratirill.

INTRODUCT ION

Recent research has i n c reased our u nderstand i ng of m uscle and joi n t fu nct ion and consequently cha nged the way exerc ises for back pain and dys fun c t ion are prescribed ( Bergmark 1 989, B u l lock Saxton et al 1993, Danneels et a12000, [--[ i des et al 1 994, 1 996, Hodges et a1 1 996, 1 997a,b, 2000, lu l l & R i c h a rd s o n 2 0 0 0 , M os e l ey et al 2 0 0 2 , O'S u l l i v a n a t a l 1 99 7 , R i c h ardson e t a l 1 999 ) . New concepts o f how join t s are stab i li ze d a n d how load i s transferred t h rough t h e body h ighl ight t h e i m po r t a n c e of p ro p r i oc e p t i o n , a u t o m a t i c m u scle act i v i t y, and m o t o r control for rega i n i n g opt i m a l move m e n t aft e r i nj u ry. I t i s c lear from t h i s body of evidence t h a t su ccessfu l rehabil i ta tion of back pain and dysfunction requires exercises t h at d i ffer from t hose u sed for con d i t io n i n g and t ra i n i n g the h e a l t h y, non-p a i n fu l , n o n - i nj u re d popu l a t i o n . Patients typicaJly presen t themselves t o t h e cLn ician for t wo reaso n s : p a i n , a n d/or loss o f fun c t i o n .

Several studies (Bullock-Saxton et a1 1 994, Dangaria Naesh 1 998, [--[ i des & Hichardson 1 996, Hodges & R i c hardson 1996, M a t t i l a et a1 1 986, U h l ig et al 1995) have shown that changes in m uscle fiber type, m uscle bulk, and recru it ment patterns occur with pain and pathology. However, simply relieving pain does not necessarily restore optimum function; these changes can remain even when pain subsides CH ides & R ic hardson 1 996, B u l loc k-Saxton et al 1 994) . C ha nges i n t h e p ropriocept i ve and motor c o n t ro l s y s t e m s a l t e r move m e n t patterns a n d strategies o f load transfer. The result is less efficient moveme n t , s u b-op t i m a l Fu n c t i o n , a h i gher risk for rec u rre n c e of pa i n and i nj u ry ( H i d e s e t al 200 1 ) , and a l t e red joint forces (due to al tered axes o f j o i n t rot a t i o n ) t h a t m ay lead to earl ier degenera tive cha nges and pa i n . &

W h e n p l a n n i n g i nj u ry reh a b i l i t a t i o n , exerc ises s h o u l d be p re s c r i bed a s part o f a n i n t egra ted t reat m e n t plan, not as a stand alone t rea t m e n t . If exerc ise i s p resc ri bed w i t hout fi rst restoring form c los u re (Chapter 6) t he n the pat ient's pa i n and dysfu n c t ion often gets worse. Th i s m a y then lead to t h e conclusion t hat cert a i n exe rc ises a re " ba d " or " u n s uccessfu l" i n t reat i ng back pa in, when rea l ly it m ay be a p roblem of i n a ppropri ately t i med exerc ise i n tervent ion. S i m i l arly, t h e type of exerc ise i n terve n t i on is of u t m o s t i m port a n c e . A c o m m o n t h e m e a r i s i n g from t h e evidence c i ted above i s o n e or correct i ng deficits i n motor con trol rat her t han foc using on s t re n g t h a n d powe r of i n d i v i d u a l m u s c l e s . Pat i e n t s w h o go m i nd lessly t h rough a rou t i ne o f exerc i ses w i l l have l i m i ted success i n ret ra i n i ng motor patterns and may get worse with exe rc ise i f poor patterns and control are reinforced, resulting i n i rritation of joint structures and symptom exac erbation. I t should be con �dered t hat the problem may n o t s i m pl y be W H I CH exerc ise was p re scri bed , but HOW the exerc ise was performed. Th ree people perform i ng a p u s h up can do so w i t h t h ree d i ffere n t movement strategies, with t h ree d i Ffe re n t com b i nat ions of m u scle rec ruit-

d

R E STOR I N G F O R C E C LOS U R E/MOTOR CO N T ROL OF T H E T H O RAX C I-IA PTE R 7

m e n t a n d t i m i n g . T h e re fo re , w h e n p l a n n i ng exerc i se i nterve n t ion c l i n ic ians m u s t re m e m be r t h at "exe rc ise A" does not guarantee t h e use of "musc le A". I t is u p to t h e c l i n ic ia n to obse rve, assess, and decide if "exerc ise A" i s reac h i ng the goa l of t ra i n i n g " m u s c l e A " ( w i t h a p p ro p r i a t e rec ru i t me n t , t i m i ng, e n d u rance, e t c . ) for each pat i e n t . The key t o c o r rec t i ng d y s fu n c t i o n a l patterns of muscle activation is teaching awareness of movement; t h i s req u i res m i n dfu l ness on t h e part of bot h the t h e rapist and the pat i e n t . Wi t h respect t o t h e t horax, i t i s the coordi n a ted action between t he local and global m uscle systems t hat ensures sta b i l ity without rigidity of pos t u re and wit hout episodes of colJapse. Th i s is the goa l : "Mobil ity o n Sta b i l i t y" . The exerc ises p resen ted i n t h i s chapter foc us on ba l a nc i ng tension a n d com pression forces and i nvolve an extens ive use of i mage ry. I n t h i s man ner, i n d i v i d ua1 m u scles are recruited and appropriately t imed for the coor d i n a t e d exe c u t i o n a n d c o n t ro l of fu n c t i o n a l move men t .

CON CEPT S OF LOAD TRAN SFER

The reader is referred to C h apter 2: P r i n c i p l e s of t he I ntegrated M ode l of Function for review of the defi n i t ion of thoracic i m pa i rm e n t and the components that contribute to Fu nct ional stabil ity. To Fu n c t i o n opt i m a l ly is to be able to m a i n t a i n va rious pos t u res and move freely i n a n d o u t o f these postures, without pai n , a n d without u n d u ly stress i ng the joints and s u rrou n d i ng soft t i ssues. Living in gravity requ i res t ransferring loads through the entire body and respond i ng to ground reaction forces. To move and fu nction in our environment, we al so need to t ra n s Fe r loads to other objects u nder the Force of gravity, as in l i ft i ng, push i ng, and pu ll i ng. Thus, opt i mal fu nct ion occ urs when t here is ef fic i e n t and effective t ra nsfer of loads.

How does t h e s p i ne t ra nsfe r loads? Panjabi e t a1

_

( 1 992) noted t h a t the h u ma n spi ne depends on more than the simple stacking of blocks for stabil ity; t h e osseoliga m e n tous spine (the passive system) was shown t o b u c kl e at a load of only 2 kg, far less t h a n normal loads on the spine in s t a n d ing. It is a well-coordin ated active system that provides the capaci ty to t ransm i t t h e large forces to which the s p i n e i s exposed ( Pa nj a b i 1 992). The t e r m " t e nsegrit y" ( te nsion + i ntegrity) w a s coined by B uckm i nster F uller to desc ribe t h e tran s ference of forces t h rough a c o m b i n ation of tension and c o m p ress i o n . H e u s e d t e n segri ty con cept s t o design, a n d u l t i mately construct, b u i ldings such as the geodesic dome. These structur e s t ransm i t loads t h ro ugh a combi nation o f tension a n d com p re s s i o n , w i t ho u t b e n d i n g m o m e n t s o r s h e a r forces (Levin, 1 997) . Applying t e n segrity to t h e h uman spine, the bony structu res (vertebrae, ribs) act as com p ression strut s t h a t are su spen ded by tens ion wires which are com p rised of m u scles, ligaments and fascia. The beauty of t h i s system is its adaptability; finely t u ned motor control allows alteration i n the tension of the myofascial tension "wires" or "slings" to fi t the demands of an i n fi n ite n umber of load transfer requ i rements both t h rough t i me and space. As m e n t ioned i n C hapter 2, stabi lity (or effect ive load t ransfer) is not only about how much a joint is mov i n g, or how resistant s t r u c t u res a re that restrict i t , but about motion control, which al lows load to be t ransferred smooth ly. The exerc i ses i n t h i s chapter a i m to establish a balance between compression and tensegrity wit h i n the t horax and to re t ra i n t h i s balance t h rough mot i o n control such that loads are t ransFerred t h rough the t horax with adequate ( not too much, nor too l ittle) approx i mation of joint surfaces for the given load demands. Optimal Load Transfer Through the Thorax

The t h orax i s a c e n t ra l a re a i n t h e s p i n e t h a t t ransfers loads between the lower quadrant ( lower ext re m i t ie s a n d l u m b ope l v i s), a n d t h e u p p e r q u a d r a n t ( u p p e r e x t re m i t i es a n d n e c k ) . T h i s fun c ti o n i s h ighl ighted i n athletic act i v i t i es such

m

C HA PT E R 7 RESTO H I N G FORC E C LOS U R E/M OTOH CONTHOL OF T H E T H OHAX

as base bal l p i tc hi ng, where t he re is t ra nsm ission of power from the l u m bopelvic region and lower extre m i t ies, up t h rough t he t horax and i n t o t h e u pper ext rem ity. The thorax needs to provide sta b l i l ity as a base for the scapu la and arm, and con currently al low rotational mobil ity and t ransm ission of power and torque from the l u m bar spi ne, pelvis and legs. Occupational activities such as pushi ng, p u l l i ng, and l i ft i ng w i l l place s i m i lar load t ransfer requ i rements on the thorax. In order t o rega i n fun c t i o n , t he req u i rements for opt i mal load t ra nsfer t h ro ugh t he t horax m ust be met . The variety of ways t hat t he t horax t ransfers load can be categorized and assessed . Each ind i vidual m ust have : • •

•

•

•

•

Opt i ma l l u m bopelvic fu nct i o n . The a b i l i ty t o atta i n neutral spinal al ignment wit h i n t he t h orax and in re lat ionsh i p to t he cervical a n d l u mbosacral c u rves. The ability to conscio u sly rec r u i t a n d m a i n tain a tonic, isolated contraction o f the l oc a l s t a b i l i ze rs o f t h e t h o rax t o e n s u re segm e n t a l c o n t ro l (con t rol of t he n e u t ra l zo n e ) .

T h e ab i l i ty t o m a i n t a i n and con t rol n e u t ra l spine a l i gn me n t d u ri n g i nc reased load i ng from the u pper or lower ext re m i t i es. The a b i l i ty t o m ove in and out of n e u t ra l s p i n e a l i g n m e n t ( Flex, ext e n d , rot a t e , s i d e be n d ) w i t ho u t seg m e n t a l or reg i o n a l c o l l a pse. The a b i l i ty t o m a i n t a i n a l l t he above a n d perroI'm fu nctional, work speci fic, and sport spec i fic movements.

Dysfunctional Load Transfer Through the Thorax

I n t he l u m bopelvic region, i t is com mon t o sec segme n t a l i n h i b i t ion of t he local m uscle system associated w i t h a mu I t isegm enta I overac t i vita t ion 01' the global syst em ( R i c hardson et al 1 999, Radebold et a1 2000, Arendt - N ielse n et al 1 996, Ka igle et aI 2000 ) . C l i n i cal ly, t h is dysfu nct ional f i n d i ng also occ u rs in t he t horax. I I' the local sta b i l izers a re not fu nct ional, low-load tasks such as w a l k i ng, or susta i ned stand i ng can ca use j o i n t i rritat ion and/or pa i n d u e t o poor control o f t he neutral zone. Over-act ivat ion of t he global muscles produces i nc reased compression and orten results in pa i n and rigi d i t y of move m e n t , ra t h e r t h an 'mob i l it y on stab i l i ty'. The object ive exa m i nat ion tests desc ribed in C hapter 4 w i l l reveal speci fic levels a n d d i rect ions of hypermob i l i ty/i nsta b i l i t y i n t he thorax; t hese find ings w i l l direct where a n d h o w t o cue t h e correc t i o n of segme n t a l cont rol during exerc ise. Multisegmentally, post ural changes such as excessive kyphosis, lordosis, or rotosco l i osis are common a n d usua l ly resu l t from dys fu nct ional pat terns in t he gloha l m uscle system (see F igu res 4 . 2 , 4 .3, 4 . 4 ) . These common non opt i ma 1 post u res a re add ressed hy res tori ng and teaching an awareness of t he neutral spine position a n d i n t egra t i ng t h e new post u re i n t o fu nct ional p a t terns. Th is c hapter w i l l p rese n t an exerc ise p rogram a i med at restori ng a n e u t ral t h orac i c s p i ne posit ion followed by restoring t he fu nct ion of the segmental local m uscle system, N ext , t he progressions ror i n tegration 01' t he dysfu nct ional segment back i nto t he t horax such t hat segmental c o n t ro l i s e n s u re d d u r i n g m ove m e n t w i l l be described. Final ly, exercises which rocus on control of the t horax in relat ion to t he lu mbar spine, pelvis, legs, a n d u pper ext re m i t i es w i l l be p resented.

RESTOR I N G F O R C E C LOS U R E/MOTOR CONTROL O F T H E THO RAX C H APTE R 7

DEVE LOP ING THE EXERC ISE PROGRAM

Bef' o re speci fic exerc ises can be desc r i bed, i t is i m portant to d isc uss some key considerat ions [or developing t he program . The t herapist shou l d : •

•

•

Educate t he pat i e n t as t o t he i m portance 01" a new approach t o " exerc ise"; d iscuss what happens to t he b ra i n 's program m i ng of' muscle coord i nat ion with pai n and i njury and t he i m port a n c e of p rac t i ce, m i n dfu l move m e n t , a n d i n corporat i o n i n t o d a i l y act ivit ies. I t is h e l p Fu l t o re m i nd pat i e n ts t hat t h is is not rea l l y exe rc ise b u t rat h e r " changi ng t he way you l ive i n you r body". l ie m i nd the pat i e n t t hat " Pract ice makes Pe rma n e n t , not Pe rFect" t o re i nFo rce t he i m portance of quality of movement, rather t han q uant ity of exerc ise . Ensu re t hat t he exercise program is specific to t he pat ient's needs and not generic. Th is req u i res t hat Fau l t y movement pat terns are ide n t i fied . The t h e rap ist shou ld have determ i ned: t he leve ls of poor con t rol t he d i reet ion (s) o[ poor control t he breis or regions of restricted mob i l i ty t he overact ive/dom i nant global m uscles or sl i ngs of m usc les t h e i nac t i ve/u n d er-re c r u i t e d m usc l es ( l ocal st a b i l izers) or sl i ngs of' m usc les (gl obal m usc les) any spec i fi c m usc le l e ngt h/st rengt h i m balances

•

Design and mod i Fy t h e exerc ise p rogram based on t issue healt h , tissue i rritabi l ity and stage of hea l i ng. Speed of p rogression w i l l depend on a n u m ber of factors including the capac ity of the pat ient for learn i ng new tasks.

Strength , endurance and power of the global trunk m uscles are i m po r t a n t compone n t s of m uscle fu nction t hat should be assessed and t reated when i d e n t ified as defic i ts. H owever, it is not t he i ntent of this chapter t o prese n t exerc ises or protocols for t hese components as several sou rces exist on t hese topics ( M cArd le et al 1 99 1, M c G i l l 2002, Farre l l et al 1 99 4 ) . I ns t e a d , t h e foc u s o f t h e exerc ises p rese n t e d is t h e restorat ion of' motor con t ro l w he re by u n der-rec r u i t e d m usc l es a re reactivated t h ro ugh a m ind-body awareness and i magery. This connection and act ivat ion of under rec r u i ted local a n d global m usc les is esse n t ial prior to prescrib i ng exercises for strengt h, as u n less t h e b ra i n is u s i ng t h e m usc l e , exerc ises given designed to strengthen that m usc le will only serve to strengt hen alternate m uscles be i ng subst i t u ted for t h e act i o n ( e . g . h i p extension exerc ises for gl ute u s maxi m u s c a n be pe rformed u s i n g t h e hamst ri ngs). Thus, t h e focus o f t h e exercises here is cont rol of movement, with opt i m u m tec h n i q ue, and with an awareness of t he segme n ts and areas of poor con t rol t hat need to be corrected. Once t h e b ra i n has 'fo u n d ' t h e m uscl e , protocols [or e n d u rance, st re ngth a n d power can be u sed i f n eeded for pat i e n t spec ific goa ls. Altered muscle length has i m pl ications [or st rengt h ( d u e to l e n gt h - t e ns i o n re l a t i o n s h i ps) a n d fo r rest riction of m o b i l i ty. Assessment of t he u nder lyi ng cause of altered muscle l ength is crucial For correc t i ng t h e dysFu n c t i o n i n t he m uscle. I t is often not s i m ply a matter of stre t c h i n g a t i ght m usc l e . The exerc ises prese nted here are to be used i n conj u nct ion w i t h tec h n iques t hat restore fu nct ional length i n m usc l es, a n d opt i m u m per Fo rmance of t hese exercises w i l l be e n hanced by such tec h n i q ues.

CHAPTER 7 R E STOR I N G F O R C E C LOS U R E/MOTOR CONTROL OF T H E T H O RAX

THE EXERCISE PROGRAM Introduction to Stabilization Exercises for the Lumbopelvic Region

A properly fu nctioning l umbopelvic region serves as t h e base u p o n w h i c h t h e t h o rax moves a n d t ransfe rs l oad . When assessing t h e pat i e n t with t horac ic dysfunction, it i s i mport a n t to i n c l ude a scree n i ng exami nation of the l u m bopelvic region, i nc l ud i ng tests s u c h a s the Act ive S t raight Leg Raise (AS LR) ( Mens et al 1 997, 1999, Lee 1 999) to determine if l oa d t ra ns fer is effe c t i ve a n d to observe t h e motor con t ro l s t rategies u sed by t he pat i e n t . Poor l umbopelvic stabil izat ion s trategies will l i m i t the patient's ability to attain and contro l optimal spi nal postures (and thus opt imal thoraci c p o s i t i o n s ) , as we l l a s l i m i t p rogres s i o n of t h e t h o racic stabil iza tion program t o exerc i ses t h a t requ i re t horacopelvic dissociation and cont rol of neu tral s p i n e . D u ri ng t h e A S L R , s o m e obvious s i g n s t h a t t h e loca l stab i l izers of t he l um bope lvic region need to be addressed i nclude abdomi na l b ra c i ng and rigi d i t y, b u l g i n g of the l ower abdo m e n , b re a t h hold i ng, asymmetry of control between r i g h t a n d left legs, obvious d i ffi c ulty i n l i ft i ng one leg, a n d sign i fic a n t rotat ion/dev i a t ion o f t h e pelvis to one side ( Lee 1 999, Richardson e t a l 1999) . The fou r m u sc les o f i n t e rest a re t he diaphragm, t ransversu s abdo m i n i s (TA), deep fi bres of m u l t ifid u s (d M F) , a n d t h e pelvic floor ( P F ) ( F ig u re 7 . 1 , a l so see C hapter 2 , Force C losure ) . Stu d ies h ave s h ow n t h a t t h ese d e e p l o c a l s t a b i l i z i n g muscles a re a n t ic ipatory, non-d i rect ion s pecifi c , a n d ma i n t a i n t o n i c con t ra c t i o n s a t l ow leve l s t h roughou t activities. I n dysfu n c t io n , t h e local m u scles l ose t hese c h a racte rist ics and become delayed in t h e i r t imi ng, d i rection s pec i fi c , a n d phasic ( H odges & Richardson, 1 996, R ichardson et al 1 999, Moseley et al 2002). To ret rai n t h e local syste m , patients a re first t a u g h t to isolate and m a i n t a i n a t o n i c con t ra c t i o n o f the d e e p

m uscles, separate From t h e global musc les. T h i s is artifi c i a l i n t he sense t ha t in normal fu nction, t hese local m uscles work i n conjunction with the global muscles. However, i n dysfu nct ion this coor d i nated action of t h e l ocal and global systems i s l o s t ; i n o rd e r t o a d d ress t h e c h a n ge i n m o t o r cont rol st rategy the local system m u st b e t ra i ned separa t e l y. T h i s protocol of i so l a t i o n , t ra i n i ng tonic h o l d i ng a b i l i ty, and t hen i n t egrat ion with global m u scles a n d i n to fu nct ional activiti es is a n efFect ive means for ret raining the coord inated function of the local system (O'S u l l ivan et al 1 997, H ides e t a I 1 996, 200]). There are several tech n iques t hat can be used to fac i l i tate isol a t i o n of t h e local m u scle sys t e m , i n c l u d i ng e d u c a t i o n (anatolllY of t he Ill u scles, t h e i r fu n c t i o n , a n d the con t rast between deep m u s c l e s and s u perfi c i a l m u sc l e s ) , dec reas i n g

Multifidus

Sacrum

Diaphragm

Pelvic Floor

Figure 7.1 The local stabilizers ofthe lumbopelvic region. Optimal fu nction ofthe thorax requires optimal function of the lumbopelvic region; proper recruitment of these muscles helps to facil itate isolation of the deep local stabilizing muscles for the thorax. Reproduced with permission from Lee 2001.

HESTO H I N G FOHCE C LOS U R E/MOTOR C O N THOL OF T H E T H O RAX CHAPTER 7

act ivity i n the global m u scle syst e m , fac i l i tat ion of neut ra l s p i n e pos i t i o n , tact i le feedback, a n d co-act ivat ion or ot her deep m u scles (eg. PF con t ract ion to rac i l it ate TA ) . Along w i t h t hese tech n i q u e s , the u sc of i m ages t o help t h e p a t i e n t re-est a b l i s h t he bra i n- body connec t ion has been f 'o und to be very effect ive . I n t h i s sec t i o n some i mages will be described for recru iting and isolati ng t he t ransve rsus a bdom i n is and the deep f i bres of m u l t i f idus components of t h e l u m bopelvic l ocal stabi l izing syst em. The pelvic f loor component is discussed, and d iaphragmatic function is addressed below i n t h e brea t h i ng sec t ion of t h e s t a b i l iza t i on progra m fo r t h e t h o rax. For t hose pa t i e n t s w i t h t horac ic dysfu n c t i o n req u i ri n g a stab i l iza t ion progra m , t he i mages for rec ru i t ment of t he l u m bopelvic region can also be u sed to fac i l i t a te the deep m uscles which stab i l ize the t horax. The two systems appear to Fu n c t ion harmonious ly.

foc u s m o re a n t e r i o r (vagi n a l o r u re t h ra l ) t h a n p o s t e r i o r ( re c t a l ) . H owever, i t i s i m po rt a n t t o recogn ize t h a t i F a s u ccessFu l i solated TA con t ract ion occ u rs with verbal c u e i n g of t h e pelvic floor, it can not be gua ra nteed t hat a proper con t rac t i on of t h e pelvic floor has occ u rred, espe cia l l y i n t hose pat i e n t s w i t h speci fic pelvic f l oor dysfunction (eg. stress i ncontinence, pain syndromes, t ra u m a ) . B u m p et al (199]) fou n d t hat only 49% of female patients prese n t i ng in a gynecological and urodynamic laboratory could perform a correct p e l v i c floor c o n t ra c t i o n w h e n given verba l or written i nstruct ions. Thus, i f the t herapist suspect s either hyperton i c i t y or poor recru i t me n t of' t h e pelvic noor m u s c u l at ur e , a refe rra l to a t h e ra p i st spec ial izing in pelvic f loor dysfu nction and manual assessment of the floor is reco m mended.

The material here is a brier overview on the topic or l u m bopelvic segmental stab i l ity; t he reader is rererred to R ichardson, Ju l l , H odges, and H i des' "Th e ra p e u t i c Exe rc i s e fo r S p i n a l Segme n t a l Stabil izat ion i n Low Back Pain" ( 1 999), Diane Lee's "The Pelvic G i rdle", 2nd edit ion ( 1 999) , and Diane Lee's " I magery 1'01' Core St a b i l iza t i o n " video for more in depth background on assessing and t raining segmental stabi l ity for the l u m bopelvic region.

teach t h is exercise will depend on which posit ion encou rages re laxation of t h e global m u scles w h i l e ideally p rov i d i n g some s t re t c h on t h e abdom i n a l wa l l ror propriocept ive feedback. The best pos i ti o n fo r each p a t i e n t w i l l va ry depend i ng on their substi t u t ion st rategies. For exa m ple, s u p i ne crook lying i s most su pport i ve a n d a l lows relaxa t i on o f globa l m u s c l e s such as t h e e rector s p inae; however, t h e re i s l it t l e s t retch on the abdom i n a l wa l l to provide Feedback for the pat ient of where the "drawing i n " action of TA should occ u r. The s ide lying position provides more stretch on the abdom inal wall due to t he pull or gravity on the a bdomen. When a ro l l ed towel i s p laced u nder the wa ist and a p i l low i n serted between the knees, t he sidelying pos i t ion can be a su pport ive pos i t ion to a l low global m uscle relaxa t i on. The 4-po i n t knee l i ng pos i t io n i s a good s t a rt i ng p lace t o h e l p t h e p a t i e n t u n d e r s t a n d t h e fee l i ng o f ' "draw i n g i n " t h e lower abdome n . Depend i ng on the subst itut ion strategies observed, a more s u pported pos i t i o n may be t h e s u bseq u e n t choice for ru rther t ra in i n g o f an isolated con-

Pelvic floor Sapsf'ord et a I (200 1 ) have shown t hat act ivat i o n of' the abdom inal muscies should accompany con t ract ion of' the pelvic floor mu sc les and vice versa. I mages and explanat ions that i nvolve contraction of the an terior pelvic f l oor (pu bococcyge u s ) are usel'u l rac i l i t a t ion tech n i q u es f' o r obt a i n i ng a n isolated t ransve rsus a bdom i n i s (TA) contraction and are descri bed below. Sapsrord et a I 's research su pports u s i ng a su bmaxi mal con t rac t i o n of t h e pelvic noor i n a pos i t ion o f n e u t ra l pelvic t i l t to best fa c i l i t a t e c o n t rac t i on of TA . Tra i n i n g t h e tonic fu nct ion o f the pel\ric noor m uscles i nvolves a s l ow, ge nt le, s u b m axi m a l con t ra c t i o n , w i t h a

Transversus ahdominis Patie nt pos i t i o n : The i ni t i a l posi t ion chosen to

C I I A PT E H 7 H E STO H I N C F O H C E C LO S U R E/MOTOR CONTROL OF T H E T H O RAX

t ract ion of TA . I deal ly, a neu t ra l posit ion for t h e l u m ba r s p i n e should be attained (avoid a flexed , nat l u m ba r s p i n e a n d posterior pe lvic t i l t ) s i nce t he n e u t ra l spine pos i t ion i s known to fac i l itate the isolation of TA (Sapsford et a l 2 00 1 ) , e s p e c i a l l y i n p a t i e n t s ex h i b i t i n g a d o m i na nce of t h e o b l i q ue m u scles. Therapist pos i t i o n : Pa lpate t h e abdomen 2.5 cm

m e d i a l t o a n d s ligh t l y i n fe r i o r t o t h e A S I S ( a n terior s u perior i liac s p i ne ) b i latera l ly (see F igure 7 . 2 ) . The pat ient should be taught how to p a l pa t e h e re for a p roper c o n t rac t i o n . I n sidelyi ng, t h e t herapist can also ge ntly c u p t he l o w e r a b d o m e n w i t h t h e p a l m t o p ro v i d e feed back o f wh ere t h e contraction should be i n i t i a t e d . O b s e rve t h e a bd o m i n a l wa l l a n d tru n k for signs o f proper isolation without global m u scle activa t i o n .

Thera p i s t fac i l i ta t i o n : Verbal c u e s

" B rea t h e i n , breat he out, t he n don't b reathe as you slowly, gen t ly d raw you r lower abdomen away From my Fi ngers (or h a n d )" " I m agi ne that t here is a slow tension com i ng up from t h e i n ner t h ighs i nto t he front of your pelvic floor, t he n extend t hat tension up i n t o my Finge rs i n y o u r l ower abdomen" " I magine t hat you are slowly and gently drawing t hese two bones (ASI S's) together" '' Very l ig h t l y a n d slowly t h i n k of l i ft i ng up i n y o u r p e l v i c floor" ( fo r wo m e n c a n i m agi ne l i ft i ng the vagi na, for mcn doing a small l i f"t of t he testes ) . Therapist fac i l i tat i o n : M a n u a l c ues

Provide a s i n k i ng press u re i n to t hc a bdomcn as you give t he vcrba l cues slowly and ge nt ly. Tact i le press u re can a l so be given j ust above t he pubic bone or w i t h t he hand c u pp i ng t h e abdomen; s i n k i nlO t he t issue slowly t o encourage a slow, tonic contraction instead of a fast, phasic response. I F t here is excessive upper abdom inal activi ty, the patient can cont i n ue to pa l pate at t he AS I S p o i n t s w h i l e t he t herapist provides gentle tac t i le pressure b i latcrally into the upper medial t h ighs to take the foc us away from t h c stomach and i magi ne t h e con t ract ion start i ng lower. I de a l res p o n s e : A slow development of ge n t le

Figure 7.2 The oval c i rcles just med i a l t o the A S I S o n each side ind icate the points for palpating contraction of transversus abdom i n is. An isolated contraction will be felt as a slow, gentle flatten ing and tensioning under the fi ngers. Any bulge or rapid contraction is evidence of contraction of the internal oblique. The circle around the pelvis represents the corseting action produced by the co·contraction of transversus abdominis and the deep fibres of multifidus. Reproduced with permission from Lee 2001.

tension i ng u nder t h e Fi ngcrs should bc fc l l . I t s h o u l d be re m e m be red t h at o n l y a 1 5 -20% contraction or t h i s m u scle is req u i red. lf t he pat ient uses too m uc h efrort or performs a fast cont rac t i o n , a b u lge i n to t h e fi ngers w i l l be felt, pushing the f i ngers away from the abdomen; t h is is the i nterna l oblique ( 1 0 ) muscle. There should be no pe lvic or s p i n a l movement, and l i t t le movement i n t he upper abdomen . Hectus abd o m i n i s and t h e o b l i q u es s h o u l d re m a i n re laxed . I f t he rib cage i s deprcssed and drawn

R ESTO RI N G F O R C E C LOS U R E/MOTO R C ONTROL O F T H E THO RAX C H APTE R 7

i n , t h i s is a sign of eXlernal oblique act iva t ion . Perform a sm a l l " w i ggle" of t h e r i b c age by p u s h i ng i t gen t ly latera l ly ; i f t he re i s a lot of res iSlance lo you r pressure t h i s means t h e rib cage is being brClced by overactive global muscles and an isolated TA con t ract ion has not been ach ieved . The rib cage should s t i l l move eas i ly in response to the lateral pressure i n t he presence of an isolated TA cont rac t i o n . Progressions/Ot her c o n s iderati o n s : •

•

•

•

•

When a n isolated c o n t ract i o n h a s been ach ieved , ask t he pat i e n t to m a i n t a i n the contrac l ion w h i le breat h i ng norma l l y. The eve n t u a I goa I is a 1 0 second h o l d , for 1 0 repet i t ions. The absence of spinal movement (eg. pelvic t i l t ) does not necessari ly mean that TA has been i s o l a t e d . A co-co n t ra c t i o n o f t h e i n ternal a n d ext ernal o b l i q ues a long w i t h l he erector sp i nae w i l l res u l t i n n o aberrant s p i n a l mot i o n , but w i l l re s t r i c t r i b c age movement and the a b i l i ty to perform l ateral co s l a l expa n s i o n d u r i n g brea t h i ng . T t i s i m portant t o u se your h a n d s a n d eyes t o assess for s igns o f global muscle subst i t u tion d u ring t he contrac t i o n . U s i ng you r voice i n a slow, ge n t l e manner will Fac i l itate a bet ter pattern. Consider asking the pat ient to reduce t he effort of t h e contract ion and to red u ce the speed to fac i l itate TA isolati o n . O n c e the p a t i e n t i s able to s u s t a i n a ton i c con l ra c l i o n of TA fo r 1 0 sec o n d s , t h e exe rc i se c a n be p rogressed . Spec i fi c s t ra l egies Fo r t h esc p rogre s s i o n s a re described elsewhere ( Lee 200 1 , Richardson et al 1 999) . The princi ples to consider when progres s i ng t hese exerc i ses a re lo e n s u re t hat t here is a pre-contra c t i o n of t h e local system and then add i ng: coord i nat ion w i t h breat h ing co-contraction w i t h d MF and PF

m

a d d i n g t h e g l o b a l m u scles w h i l e m a i n ta i n i ng a n e u t ral s p i ne pos i t i on moving out of neutral spine pos i t ion with global m uscle activity i ntegration i nto fu nctional act ivit ies

Deep fibres of multifidus Pa t i e n t p o s i t i o n : Prone or s i d e ly i n g are good

pos i t ions as t hey al low re laxat ion of the erector s p i nae and access for palpat ion of t h e m u l t i fidus m uscle. However, positions such a s supine can a l so be benefic ial for some p a t i e n t s . Therapist pos i t ion : Pal pate m u l t i fidus j ust lateral

to the spinous p rocesses of the l u mbar s p i n e b i latera l ly a t the l evel of a t rophy. To m o n i tor the deep fi bres , the m u scle must be pal pated close to the spine; in the lower l u mbar segments the l ateral m uscle b u l k consists of t h e more s u p e rfi c i a l fibres. Te a c h t h e p a ti e n t how to fi n d t h e dysfu nc t i o n a l segm e n t a n d how to sink i n to t h e m u scle w i t h t h e fi ngers. Therap i s t faci li ta t io n : Verba l cues

"Feel the muscle u nder my fi nger, t h i n k of a tension coming from i ns i de you r body to make t h i s m u sc le bu lge i n to my fi ngers" Barbie doll : "I magine that you are a Barbie dol l a n d t hat someone h a s p u l led you r leg off and left i t lying a t yo u r p e l v i s , b u t d i scon nected . Imagi n e an energy from i nside your spine that will d raw t he leg into you r body and recon nect i t " . O r, " I magin e t h e re i s a s t r i ng con nected from t h e s p i n e to t h e h i p ( i n t h e groi n ) , i f you p u l l on this string from the muscle i n your back you can con nect t h e leg back i nt o you r body" Guy wi reffent w i re: " I magine t hat t here is tent w i re or string t ha t is connecting from the front of your p e l v i c floor, up and i n t h ro u gh you r body d i agona l l y to my fi n ge rs i n your s p i ne. Breathe in, b reathe o u t , n ow slowly connect a w ire from this fi nger h e re (give press u re at

C H A PT E R 7 R E STO R I N G F O R C E C LOS U RE/MOTOR C O N T R O L OF T H E T H O RAX

u pp e r i n n e r t high ) to t h i s fi nge r h e re (give pressu re into m u lt ifidus)". "You a re c reat i n g a tension in t h e wire to suspend t he spine " .

even t u a l goa l i s a J O seco n d hold, [o r 1 0 repetitions. •

Therapist facil itation : M a n u a l cues: The t i m i ng

of t h e t a c t i l e p re s s u re from t h e t h e ra pis t 's hands c reates the image and p rovides feedback as to how g u i c kl y the m uscle should be con t racted. The fi nge rs should s i n k into t he Ill u l t ifidus and provide a cran ial pressure to encourage a " lifted" or " s u spended" feeling. For t h e t e n t wire images, t h e start of t h e w i re can be j u s t m e d i a l t o t h e A S I S 's , s u perior t o t h e p u bic bone, or frolll the pelvic floor; t h e seg uence of tactile feedback is Frolll the a n terior palpat ion poi nt first, t hen up i nto t he Ill u l t i fidus pa lpat ion poi n L I dea l response: A slow deve lopment of firm ness

in the m u scle will be fe l t as an inden tation of the pads of the palpat i ng fi ngers . A fast con t raction is i nclicat ive of s u perficial ill u i tif i d u s a nd/or e rec tor s p i nae ac tiva tio n ; t h e fi ngers will be guickly pushed off the body. I t is important to t each the patie n t how easy it is to push t h e fl llgers i n t o the Ill uscle when i t is relaxed ("feels like a m u shy banana") as cOlllp a red to when it is cont racted ("feel how i t is firmer and harder to sin k yo u r fi ngers i nto t h e m uscle") . There shou ld be no pelvic or spinal motion observed, and no act ivity in the global abdominal ill uscies or in the hip Illusc u l a t u re . A co-co n t ract ion of TA is acceptable and des i red . Progre s s i on s/Ot her cons idera t i o n s : •

•

T h e illl age t h at is u s e d for t ra i n i n g t h e m u sc l e depends o n w h i c h image gives t h e best isolated contract ion o f deep m u ltifidus. The pat ient is then inst ructed how to fee l t he con t raction a n d how to m o n i tor for any subst i t u t ions. When a n iso l a t e d c o n t ra c t ion has been ac hieved , ask the pat i e n t to Illaintain the cont ract ion while b rea t h i ng normal ly. The

•

U sing you r voice in a slow, gen t l e Ill a n ner w i l l faci l itate a bet ter pat t e rn . Progressions are explained i n detail i n ot her sources ( Lee 200 ] , R ichardson et al J 999 ) ; the pri nciples a re to pre-con t ract the local systelll and t h e n add: coordination w i t h breat hing co-cont raction w i t h TA and P F adding t h e globa l Ill u s c les w h i l e Illain t a i n i ng n e u t ra l s p i ne posit ion Illoving out of neutral spine pos i t ion with globa l ill u scle activity i ntegration into fu nct ional activit ies

Stabilization of the Thorax

O p t i m a l fu nct ion reg u i res segillen tal control at each thorac ic leve l ; t hat is, control of t h e neutra l z o n e of Ill ot ion for e a c h t h orac i c segme n t . For t h e I U lll bar s p i n e , it is we l l establ ished t hat t he m uscles best s u i ted to t h is fu nct ion arc the deep local muscles ( t ransversus abdoil l i n is, deep fibres of m u l t i fi d u s , diaphragm, pelvic noor ) . There are comparatively few s t u d ies on t h e fu nction or t he deep m u scles of t he t horacic s p i ne. Based on t he anatolllY of the t horac i c region , it is hypothes ized t h a t the deep segmenta I m uscles (rotatores, III u l t i fidus) wil l have a sim ilar fu nct ion i n the t horacic regio n . Donisch a n d Basillaj i a n ( 1 9 7 2 ) g u a l ita t ively analysed EMC data frolll the deep Ill usc les b i l atera l l y at t h e level of the T6 and L3 s p i nous p ro c e s s e s in d i ffe re n t po s t u re s a n d ra nge or Illoveille n t tests. They concl uded t h at the deep Ill uscles in both regions acted as stabil izers rat her t han prime movers. M orris et a l ( 1 962) recorded E M C act ivity rrolll t h e deep Ill uscles latera l to t h e spinous process of T 1 0. Qual itat ive analysis revealed variable patterning d u ri ng d i Fferent act iv ities; however, t h e inte r-elect rode d istance was l a rge (2 c m ) , m a k i n g t h e Ill e a s u re m e n t s l e s s s pec i fic . C l early Ill ore resea rch i n t h i s a rea is

R E STO R I N G F O RC E C LOS U RE/MOTOR C O NT R O L OF THE T H O RAX C HAPTER 7

m

needed. C l i n ica l ly it has been t h e author's expe rie nce thal l here is often atrophy and loss of acti va t i o n of t hese deep segm e n t a l m u s c l es at t h e dysfunctional levels in the thorax, a n d that restori ng the tonic fu nct ion of t hese m u sc l es i s esse n t i a l for rega i n i ng segmental s t a b i l ity. T h u s , t he fi rst goa l of t h i s s t a b i l ization p rogram is to teach an isolated contraction of the deep, segmental muscles at the level(s) of hypermob i l i ty. I n order to reac h t h i s goa l , t he i m pact o f t h e global m u scle system must fi rsl be consi dered s i nce excess ive activity of the global system i n h i b its the a b i l ity to rec r u i t the local system.

patients with t horacic dysfu nction i s lateral costal expansion. When l ateral/posterolateral expansion is a b s e n t , e x c e s s i ve exc u r s i o n oc c u rs i n t h e abdomen (making i t d i fficult t o a ttain a fun c t ional transversus abdominis contraction) or in t he upper c hest (associated w i t h excess ive accessory res p iratory m u scle activi ty) . Also commonly prese n l i s h yp e rtoni c i t y a n d b racing w i t h t h e ext e rn a l a n d/or i nternal oblique a nd/or the erector spi nae m uscles; t he presence of this muscle act ivity then c o n tinues to restric t l ower r i b cage moveme n t . C hanging t h e pattern of insp iration c a n b e u sed to release hypertonicity of t hese global m uscles.

Many aUl hors have noted patterns of global m uscle hyperac l ivity and domi nance ( S a h rmann 200 1 , Hall & B rody 1 999, Comerford & Mottram 200 1 , Janda 1 978). A consistent fi n d i ng i n patients with low back pa i n is t hat t here are one or more global m u s c l e s t h a l a re ove ra c t ive, h y p e rt o n i c , a n d dom i n a n l ( liadebold e t a l 2000, Arendt-N i e lsen et a l 1 99 5 , Kaigle e t a l 2000 ) . I n t h e t h ora c i c spine, t he d o m i nant global m u sc les i nclude t h e t hora c i c erector s p i n a e , t he s c a pu l a r m u s c l e s (rhomboids, levator scapu lae, t rapezius), t he latis s i m u s dors i , the ext ernal a n d internal ob l iq ues, a n d t h e rec t u s a b d o m i n i s . T h e re a re s eve r a l methods that can be used t o reduce global muscle tone, i n c l u d i ng u s i ng su rFace E M G as biofeed back fo r dow n t ra i n i n g, d ry n e e d l i n g o r I M S ( I ntramuscular St i m u lation, G u n n 1 999), t rigger po i n t release, e t c . The u s e of d i a p h ragma tic breath i ng and neutral spine posit ion can be very eFfect ive in red u c i ng global m uscle activ i ty and prepa r i ng the motor system to learn new stabi l izat ion slrategies. Th us, tech n iq ues to esta b l i s h m o re o p t i m a l b re a t h i n g p a t t e rn s a n d s p i n a l a l i gn m e n t a re descri bed here p r i o r t o s t a rting segme ntal isolat ion of the deep t horac i c s ta b i liz ing m uscles.

U n d e r normal res p i ra tory d e m a n d , ex p i ra t i o n should b e a passive action resulting from t h e elastic recoil of the chest and abdome n . Any evidence of active expiration by u se of t he abdominal m u sc les should be noted as this pattern can also rei n force restriction of mobil ity in the t horac ic joints.

Breathing Optimal d i a p h ragmatic breat h i ng i nvolves both abdom inal and lower ri bcage expansion ( Detroyer 1 9 8 9 ) . The most com m o n c o m p o n e n t l o s t in

Pat i e n t pos i t i o n : S u p i ne , c rook lyi ng. Therapi s t tec h n ique: Before p l a c i ng you r hands

on the p a t i e n t , fi rst observe and assess t h e habit u a l breathing pattern over several i ns p i rat i on/exp i ra t i o n cyc les. Look for move ment in the u pper chest (apical breathing) , the lateral l ower rib cage (lateral costal expansion ) , and the abdomen ( u p p e r an d lower a b d o m e n ) . Note t h e a rea where most movement occ urs. Next , p lace you r hands on t h e latera l aspect of the lower rib c age to m o n i t o r move m e n t . C heck for amount of movement and symmetry between the left and righ t sides. Ideal pattern : Most of t he movement on i n spi

ration should occur in t he lower latera l rib cage w i t h c o n c u r re n t m o ve m e n t o r t h e u p p e r abdo men . Retra i n i n g l a te ral costal expa nsion i s an i m po r t a n t c o m p o n e n t of the exerc ise p ro gram ; i t h e l p s m a i n t ain m o bi l i ty ga i n ed from t h e m a n u a l t r e a t m e n t a t h y p o m o b i l e leve l s (see C h a p te r 6 ) w h i l e fac i l i t a t i ng l h e use of the deep local m uscle system i n stead of the global system .

'D

CHAPTER 7 R ESTO R I N G F O R C E C LO S U R E/MOTOR C ON T ROL OF T H E T H O RAX

" Let you r chest a nd stern u m go heavy to t he Floor as you exhale" Therap ist fac i l i ta t i o n : Manual cues: Wit h you r

Figure 7.3 Correction Technique: Facilitation of Lateral Costal Expansion. The therapist uses gentle inward compression at the end of expiration to give feedback as to

hands, apply a slow, ge n t l e , i nward press u re b i latera l l y at the end of expirat ion and release this pressure slightly after the start of t he i nspi ration p hase (rib spri nging). Al low you r hands to fol low t h e rib cage ope n i ng, then apply t he ge ntle press u re again at the end of exp i ration. If the restriction of latera l costa l expansion is asym metrica l , apply you r pressure asym met rica l l y and h ave the patient mentally focus on the side of less exc u rsion. To release excessive global tone on exp i rat ion, ge n t ly wiggle/rotate t h e rib cage a s m a l l a m o u n t t o re lease t h e m u scle holding a s t he patient expires.

where the patient needs to d i rect their breath, and releases this pressure as the patient begins inspi ration. In this example, the patient is using one hand to monitor for excessive apical chest movement. The hand can also be placed on the lower abdomen to monitor excessive movement there.

C orrec t i o n tech nique: Keep you r hands on the

l a t e ra l a s pect of t h e l ower rib c age a n d give t h e patie n t an i mage to redirect t h e i r i n s pira tion (see F igure 7 . 3 ) . Thera p i s t fac i l i ta t i o n : Verbal cues

" As you breathe i n , i m agi ne b r i n g i n g the a i r into my hands" " I magine yo u r ribs a re l i ke a n u m b re l l a , and when you breathe in the bottom of the umbrella i s opening u p " " With each breath open your ribs into m y hands" For m u scle activity o n exp i ration :

" As you brea the o u t , let the air fal l out of you and re lax yo u r stomach" " I magine I a m slowly p u ll i ng the air out of you " "Thi n k of sighing t h e air o u t as you breathe out"

Parameters & functional integration: The patient

s h o u l d pe rfo r m foc u s ed b reat h i ng p a t t e rn retraining 2-3 t i mes a day, u s i n g bot h normal and deeper breaths, for severa l m i n u tes. The patient uses t h e i r own h ands on the sides of the rib cage to provide self-feedback. Alternately, a t heraband can be used around t he l ower rib cage for proprioceptive feedback; use the lowest resistance of band to a l low Hex i b i l ity and r i b cage expansion. To encou rage the t ransfer of the new breat hing pattern into a more automatic stra tegy, h ave the patient "check- i n" on their pattern a t different po ints t h roughout t he day, in different postu res and duri ng d i Fferent activ i t ies (s i t t i ng, standing, wal king, e t c . ) .

Neutral spine S i t t i n g ( see F i gure 7 . 4 , Video C l i p

7.5)

Patie n t pos i t i o n : Sitt i ng o n a c h a i r o r a ba l l . I f

t h e patient has a rest riction o f hip f lexion either u nilatera l l y or b i lateral ly, i n c rease the he ight of the si tting su rface so that t he pelvis is able to move anteriorly ove r the fe m u rs (to a l low the creation of a neutral lordos is i n the l u m bar spine ) .

R E STO R I N G F O R C E C LOS U R E/MOTOR C O N T R O L OF T H E T H O R AX C HAPTER 7

Therapist pos i t i o n : Stand i ng or kneel i ng beside

the pat i e n t . I-l a n d pos i t i o n w i l l d e p e n d o n w h i c h levels o f t h e s p i n e need a c h a n ge of c u rva t u re (see verba l/m a n u a l c u es) . Correct the t horac ic curve Fi rst , then t he l u m bar c u rve, t hen the head/cerv ical posit ion . Thera pist fac i l i t at i o n : Ve rbal cues

For areas or decreased t horac ic kyphosi s ( usually accompan ied by excessive erector spi nae act ivity) : " Let t h e c hest s i n k " or " go heavy u n d e r m y hand" "As your chest sinks, imagine your back open i ng between you r shoulder blades"

III

" I magine that t h e d istance from your ste rn u m to yo u r belly b u t t o n i s d ec rea s i ng as you let t h e chest go heavy" For a reas of i n c reased t horac i c kyp hos i s : " T magi ne a string attached to your back (palpate at leve l of i nc reased c u rve) ; t he string is gen t ly bei ng p u l led u p to heave n "

" I m ag i n e t ha t you r s t e rn u m i s be i ng ge n t l y l i fted" For a decreased l u m b a r l ordosi s ( fl exed l u m ba r spi ne) : " I magi n e a s t r i n g att ached t o your t a i l bone, and someone e l se i s gen t l y p u l l i n g t h e s t r i ng u p to heave n" hG row t a II From t h e tai I bone"

" Let you r pelvis fa l l forward as you grow ta II from my fi ngers" " Le t you r but toc ks go wide, let your h i ps rold" " Al low t he ball to rol l u n derneath you as the pe lvis fa l l s forwa rd" Therap i s t fac i l i t a t i o n : M a n u a l cues/ Key p o i n t s of c o n t ro l :

Options for t he rapist h a n d p l acement ( po i n t s of contro l ) : •

•

Figure 7.4 Neutral Spine: Sitting. Therapist points of

•

control are the stern u m and the l u m bar spine. Patient points of control are the sternum and the superior pubic bone. The therapist's hand helps the patient create a "sinking" or

•

"heaviness" on the sternum to facil itate an increase in thoracic kyphosis in the upper thoracic spine. The therapist's fingers at the lower lu mbar spinous processes produce a gentle cranial and anterior pressure to facil itate a lifting of the sacru m , tilting of the pelvis forward, and gentle l u m bar lordosis for levels of a flattened curve.

•

U pper ste rn u m ( for l oss o f u p pe r t horac i c kyphosis) Lower stern u m ( For l oss of lower t hora c i c kyp hos i s ) Pos t e r i o r t h o rax/r i b c age ( Fo r excess ive t h orac i c kyphos i s ) L u m b a r s p i ne s p i n o u s p rocesses (at level where more lordos i s i s req u ired ) M a n u b riosternal sym p h y s i s a n d s u perior pubic bone ( to c u e ve r t i c a l a l i gn me n t o r t hese po i n t s)

C I I A PT E R 7 R E STO R I N G FORC E C LOS U R E/MOTOR C O NTRO L OF T H E T H ORAX

kyphosis while c rea t i ng a lordosis local ized to t he l u m bar spi ne.

I l i a c c re s t s a n d h i p fo l d s ( t o fac i l i t a t e a n terior pelvic t i l t over h i ps ) A s t he verbal c ues are given, t he t herapist uses the po i n t s of c o n t rol to c reate t h e ideal c u r vat ures. To faci l itate i ncreased thoracic kyphosis, the h a n d on t h e ste rn u m c reates an i n ferior and posterior pressure. To decrease an excessive kyphos i s , the h a n ds l i ft t h e rib cage from t he s i d e s or give a superior a n d s l igh t ly a n terior p res s u re at t he l evels of excessive c urve. To correct a flat l u m ba r s p i ne, t h e fi nge rs p u s h gen t ly anterior and superior, c reat i ng a " l i ft i ng" sensat ion . For a n excessive l u m ba r lordos i s at one or two segm e n t s , foc u s on Fac i l i t a t i ng a lordosis at levels above or below t hat are f l exed, and then "lengthening" or "stretc h i ng" the curve at the hyperextended segme n t ( s ) .

Progressi o n s/Ot her con siderat i o n s : •

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•

•

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As t h e l u m b a r l ordos i s occurs t h e sternal hand should not move s u pe rior or anterior (the thoracic kyphosis should be mai ntained). The goal is to create a ge ntle, even kyphosis in t he t horacic spi ne, a gent le, even lordosi s i n t he l u m bar spi ne, a n d a gentle lordosi s i n t h e cervical spine (avoid having one o r two segments excessivcly flexed or extended ) . The m a n u b rioste rn a l symphysis should be vert ically in l in e w i t h the pubic bone; body weight should be centered equally over t h e i sc h i a l t u berosi t ies ("sitz bones" ) .

Benea t h you r s t e rn u m ( i f m i dt horax i s kyphot i c ) Between you r lowest r i bs Posteriorly ( i r lordot ic) Anteriorly ( i f kyphot ic) •

•

•

T h e e rector s p i nae m u scles s h o u l d n o t b e exc e s s i v e l y a c t ive ( p a l pa t e t o c h e c k for hyperton i c i ty ) . S e e Video C l i p 7 . 5 : T h e patient performs the rirst two postural adjustments i ncorrect ly; t h e s t e rn u m l i ft s a n d t he t ho ra c i c s p i ne extends. The fi nal t wo repetit ions i l l u st rate t h e correct m a i n te n a nce of t h e t h oracic

The b re a t h c a n be u sed t o ra c i l i t a t e t h e proper c u rves as we l l - " breathe deeply and a l low t he a i r to f i l l the spacc : " Between you r s h o u l d e r b l a d e s ( i r m idt horax i s lordot i c )

I deal response: 1 11e creation o f t he lumbar lordosis should be a " re lease" i n to a n opt i m u m c u rve, not a Fo rced e ffort w i t h co n t ra c t i o n o f t h e e rector s p i n ae. •

U se the fee l i n g of a pelvic roc k forwards a n d b a c kwards to h e l p d i s soc i a t e pelvic from t horacic motion, and to feel t he place or body weight over the ischial t u beros it ies - if the pelvis is posteriorly t i lted, the pat ient w i l l fee l t h e i r weight beh i n d t h e i s c h i a l t u be rosit ies; i F t h e pelvis i s anteriorly t i lted, t h ey w i l l fee l t h e i r weight in fro nt of t h e ishcial t u be ros i t ies.

•

O nce you have fac i l i t ated a neu t ra l s p i ne pos i t i o n , a s k t h e p a t i e n t to Illa i n t a i n t h e new pos i t ion and b reat he normal ly. Observe what happens to s p i n a l pos i t ion w i t h b reat h i n g - a p i c a l breat h i ng oft e n causes excessive t horaco l u m bar extension, re-educate brea t h i n g pattern ( lateral costal expansion) to fac i I i tate Illaintenance of the neu t ra l s p i n e pos i t i o n . You c a n u s e t heraband around l he rib cage to give p ro p riocept ive Feedback ror t h e opt i m a l b rea t h i n g p a t t e rn (espec i a l l y e rfec t i ve t o e n c o u rage posl e ro l a l e ra l expa n s i o n a n d m i n i m i ze l h oracol u illbar extension ) . See Video C l i p 7.6. O nce t he neu l ra l spine can be attained and Ill a i n l a i n ed w h i l e b rea t h i ng, add a consc ious rec ru i t ment of t he IU lllbopelvic an d/or l h orac ic local stabi l izers.

R E STO R )

G FO RC E C LOS U R E/MOTOR C O N T R O L O F TH E T H O RAX C I I A PT E R 7

Corre c t i n g rota t i o nalls idebendi ng asymmetry ( see Video C l ip

7.6)

O n c e t he s p i n a l c u rves a re corrected i n t he sagi ttal plane, correc t ions can be made to any rotat ion/sidebe n d i ng Fa u l t s . It i s i m port a n t to rea l i ze t h a l t he pos i t i o n of t h e sc a p u l a a n d altered activity or lengt h/strength relat ionsh i ps of the scapu lot horac ic m uscles can have a s ig n i ncant i m pact o n the posit ion a n d fu nct ion of t h e t horacic s p i ne.

excessive a c t i v i t y i n t h e globa l m u s c l e s ( t o re lease braCi ng) a n d a l l ow you to move a n d s u p port t he t horax i n to a n opt i ma l pos i t i o n . •

•

T h e ra p i s t Fa c i l i t a t i o n : M a n u a l a n d Ve r b a l C ue s : H a nd s on t h e latera l aspect of t h e r i b cage. Fac i l itate a " l i Ft" a n d "lengtheni ng" o f the rib cage on the side of the sidebending concavity. G ive left or right lateral pressure to correct a s h i fl . U sc w i ggl i n g of t h e t h o rax t o release

•

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O n e h a n d u n d e r scapula, o n e h a n d on i l iac c rest; ask the patient to " I magi ne t hat the d istance between my hands i s lengthen i ng" , "open t h e s pace between my h a n d s . " E n c i rc le t he rib cage w i t h o n e arm a n d usc the other hand to s up port t h e s ide c losest to you . P rov i d e ge n t l e t ra c t i o n (" Let m e s u p po r t yo u r r i b cage " ) a n d l a t e ra l l y t ra n s late/rotate t h e rib cage i n to a n e u t ra l pos i t i o n ( Sec Video C l i p 7 . 6 ) . Ask t he patient t o maintain t h e new pos it ion a n d b rea t h e normally ( see c o n s i de ra t i o n s a bove) .

Figure 7.7 Neutral Spine: Standing Forward Lean on Wall. This i s a useful position to train the abi lity o fthe thorax t o transfer loads through a weight bearing u p per extremity. Prior to adding arm movement, the patient must be able to atta in and m a i ntain control of a neutral spine position. I n this example, the therapist uses one arm to support and gently traction the lower thorax. Subsequently, an inferior-posterior force is applied, thus faci l itating an ideal thoracic kyphOSiS. The caudal hand provides a gentle cranial and anterior pressure to facil itate a lumbar lordosis i n the flexed l u m bar segments. Verbal cues are given concurrently with the manual fac i l itation.

""

C I I A PT E R 7

R E STO R I N G FO R C E C LO S U R E/MOTOR C O NTROL OF T H E T H O RAX

These manual a n d verbal cues can be adapted t o fac i l i t a t e n e u t ra l s p i ne in other pos i t io n s s u c h a s s u p ported s t a n d i n g, sta n d i ng, a n d sta n d i ng forward l e a n on wall (see hgu re 7 . 7 ) . Fou r Po i n t Knee l i ng (see Fi g u re

7. 8 )

Pat i e n t pos i t i o n : 4 Poi nt Knee l i ng on the f l oor

or on a p l i nt h ; shoulders over hands, h ips over knees. If t here is a u n ilateral or bi latera l restric t ion of h i p f l exion , the h i ps should be a l lowed t o roc k forwa rd of t h e knees ( o t he rw i se t h e patient w i l l be unable t o attai n a lumbar lordosis). Therapist pos i t i o n : Kneel i n g or standing beside

t he pat i e n t . H a n d p l acement w i l l depend on t h e a reas of t horac i c a n d l u m ba r c u rvat u res t h a t need correct i o n .

Thera p i s t fac i l i t a t i o n : Verba l c u e s

For dcc reased t horac ic kyphos i s : " Let me have you r rib cage; l e t you r back open as l l i ft you r chest" "Take a breath and bri ng the a i r into your back" For dec reased lu m ba r lordos i s : " Let you r but toc ks go w i d e and the low back fa l l i nto a gen t le a rc h " " Keep y o u r u pper b a c k open as you lengt hen u nder my f i ngers" "S tay su pported and open in yo u r rib cage as you let the pelvis fa l l forward towards the floor, letting the h i ps fold"

Figure 7.8 Neutral Spine: 4 Point Kneeling. This position i s more challenging and a progression from the Standing Forward Lean on Wall position. Prior to adding arm or leg movement, the patient m u st be able to attain and maintain control of a neutral spine position. In this example the therapist uses the cranial arm under the rib cage to produce a thoracic kyphosis at the desired levels with a posterior force (lifting the rib cage) . The caudal hand produces a cranial and anterior pressure in the lumbar segments to create a lordosis, while the verbal cues oflengthening through the low back, letting the buttocks go wide and releasing the hips are given.

H E STO H I N G FO H C E C L O S U R E/MOTOH C O N T H O L OF T H E T H O RAX C H A P T E R 7

For i nc reased t horac ic kyphos i s : " Lengthen yo u r s p i n e u nder my h a n d s as you lel you r ribs fai l lo t h e f loor" For i n c reased l u mbar lordos i s : " Round out yo u r back to t he c e i l i ng ( reverse t he e u rve i n t o Aexio n ) , now l e t the low back arch aga i n but t h i n k long and ge n t l e ( m a n u a l cueing i s i m port a n t here; see be low) . Therapist fac i l i t a t i o n : M a n u a l c u e s/ Key p o i n t s of contro l :

Options for t herapist hand placement ( po i n t s of contro l ) : •

•

•

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•

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M a n u b r iost e rn a l sy m p h y s i s ( fo r l os s o f up per t horac ic kyphos i s ) S u pport u n d e r l o w e r r i b cage ( ['o r l o s s of lower t horac ic kyp hos i s ) Posterior t horax along s p i ne ( for excessive t horacic kyp hos is) Lu m bar s p i n e s p i nous processes (at leve l wh ere more lordos is is req u i red or where c u rve needs lengt h e n i ng) I l i ac c rests ( to fac i l i tate more even l u mbar lordosis/lengthe n i ng t h rough spi ne, an terior pelvic t i l t over h i ps) I� J i p c reases ( t o fac i l i t a t e h i p Fo l d i n g a n d widening o f b u t t ocks)

As the verbal cues are given, the t herapist uses the po i n t s of cont rol to c reate t h e ideal c u r vatures. To fac ili tate i ncreased thoracic kyphosis, fi ngers u n der t h e st e rn u m c a n p ress ge n t l y posteriorly ( u p to t he ce i l i ng ) , or t h e w h ole arm can s u pport the rib cage and l i ft it poste riorly to open up the posterior thorax. To decrease an excessive kyphosis, one hand on the posterior t horax produces an anterior and slightly c ranial pressure w h i l e a hand on the sacrum prov ides an i n ferior d i st raction to c reate a sensa t i on of " l engt h e n i ng" t o go w i t h t h e ve rbal c u e . To correct a fl at l u m bar spi ne, t he fi ngers p ush

gently anterior and superior, creating a "length e n i ng" sensation as the pelvis falls forward but the thoracic spine stays supported i nto a neutral kyp hosis. For an excessive l u m ba r lordos i s at one or two segments, h ave the pat i e n t reverse the entire l u m bar curve into flexion, t hen foc us on fac i litating a lordosis at levels above or below t h at are flexed as t h e pat i e n t re t u r n s i n t o a l ordos i s . U se a l ight "w iggle" t h rough the i l iac crests with a caudal pull to c reate the sensation of "lengt h e n i n g" or "stretc h i ng" the c u rve at the hyperextended segment(s). H ead and neck pos i tion is corrected after releasing the support for t h e tru n k. J d e a l r e s p o n s e : A s you re l e a s e yo u r m a n u a l

su pport, the patient should b e able t o maintain t he new posi t ion of ge n t l e t hora c i c kyphos i s a n d l u m bar lordosis, w i t hout excessive b racing w i t h the a bdom i n als or b rea t h h o l d i ng. Ask the patient to maintain the posi tion and breathe normaJJy. I f there is a n a nterior coll apse of the upper thorax, loss of control through the scapulae, l o ss of t h e l u m ba r l o rdo s i s , or b rac i n g a n d breath holding (the e nt ire trunk becomes s t i ff) , t h e p a t i e n t i s not ready for exerc i ses i n t h i s pos i t i o n . The Standing Forward Lean on Wa l l pos i t ion should be u sed fi rst . Progressions/Ot h e r Considera t i o n s : •

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H ave patient b reathe i n , breat he out, t h e n ge n t ly c o n n ec t t o t h e deep l u m bo-pelvic s t a b i li zers. G ra d u a l l y release you r s u p port as you ask the patient to hold t hat pos i tio n . A s the patient to c o m e out of the pos i t ion i nto kneel i ng. G o back i n to 4 po i n t kneel and see if t h e patient can fi nd t h e opt i m a l pos i t i o n o n t h e i r own . R e p e a t t h e manual/verbal cueing a s needed, b u t red uce t he m a n u a l s u pport to t ra i n the patient to fi nd the correc t pos i t i o n on t h e i r own . Rotat i o n a lls i debe n d i ng asy m met ries c a n b e corrected i n t h i s pos i t ion u s i ng c u e s as desc r i be d above i n s i t t i ng.

C I I A PT E R 7

R E STO R I N G F O R C E C LOS U R E/MOTOR C ON T ROL OF T H E T H O RAX

Isolation of the local thoracic segmental stabilizers Pa t i e n t p o s i t i o n : Fac i l i t a t i o n of t h e t h o ra c i c

segmental stabilizers can be done i n any position; genera l ly it i s easiest t o m i n i m i ze excess ive global a c t i v i t y in m o re s u p ported pos i t i o n s (prone); once a confident cont ract ion is attained in t hese pos i t ions then more upright and fu nc t io n a l pos i t ions can be u sed as a progress i o n . S i nce t he p rone pos i t ion i s u sed to assess t h e Illuscle bulk (see F igure 4 . 3 2, Video C l i p 4.32), it can be t he first position used to teach isolat ion ohhe segmental stabi l izers. I r the pat i e n t has d i ffi c u lty i n t h i s pos i t i o n , s i U i n g ( i n n e u t ral spine) may be easier, due to the i ncreased pro priocept ive and afferen t i n p u t t hat an uprigh t , we ight bea r i ng pos i t ion provides.

i n to t he m uscle ( prov i d i n g tactile and propri ocept ive i n p u t ) w h i le the verba l com m a nds a re give n . The other hand w i l l pa l pate at one of fou r places to help c reate t he i mage be i ng used: •

In prone or s i t t i ng, palpate j u st med ial and i n fe r i o r t o the A S I S ( w here you p a l p a t e t ra n sversus abdom i n i s ) on o n e s i d e . I f t he

P ro n e : e n s u re that t h e t horax i s su pported i n t o

as neu t ra l a pos i t ion as poss i ble and t ha t t here is re l axation of t h e t hora c i c erec tor s p i nae. J f t he re is a lordosis i n t h e thorax, a rol led towel can be placed vertically u nder the ste rn u m to p a s s i ve l y s u p port t h e t h o rax i n t o kyphos i s . Arms shou I d be relaxed a t the sides o r over the edge o f the bed. Arms ove rhead s h o u l d be avo ided as t h i s can a l te r s p i n a l pos i t ion i f the l a t i ss i m u s dors i m uscle i s t ight, a n d can also i nc rease erector spi nae tone. S i t t i ng: use t he tec h n i q u e s desc r i bed a bove to

hel p the patient find neutral spi ne. The patient shou l d be s i t t i n g o n a fi rm s u rface w i t h t h e a r m s re l axed a n d h a n d s rest i n g on t he t h igh s . I f t he pat i e n t has great d i Ff i c u l t y attai n i ng o r m a i n ta i n i ng n e u t ra l s p i n e i n s i t t i ng it w i l l n o t b e a good pos i t i on t o fac i l i t a t e t h e t h ora c i c segmental stabilizers a n d an al ternate pos i t ion s u c h as prone should be u sed .

Figure 7. 9 Isolation of Thoracic Segmental Stabilizers: Sitting. The height ofthe stool a l l ows the patient to attain a neutral l u m bopelvic position when there is a restriction of hip flexion range of motion. The therapist pal pates and s i nks the finger and t h u m b bil aterally i nto the segmental stabilizing muscles at one thoracic level. The other hand applies bilateral pressure i n the upper inner thigh with the thumb and first finger. Deepening pressure is applied at these points sequentially as the patient is given an image of connecti ng a guy wire to suspend the spine. " B reathe in, then breathe out. Slowly, gently imagine you are connecting a wire that is

Therapist pos i t i o n : Stan d i ng beside t he pati e n t ,

pa l p a t e b i l a terally a n d c l o s e t o t h e s p i no u s p rocesses a t t h e leve l y o u w a n t t o fac i l i t a t e . O n e hand w i l l fac i l i tate t h e segm e n t a l con t raction by lett i ng t he fi ngers or t h u m bs s i n k

starting from here (give pressure at the inner thighs), coming up and through your body, and connecti ng to my fi ngers here in your spine (give anterior and cranial pressure at the thoracic segment) ". If the image is effective for the patient, you will feel a slow development oftension in the segmental muscle. Assess for symmetry between the right and left sides. (The arrow indi cates the image of the wire.)

R E STO R I N C F O R C E C LOS U R E/MOTO R C O NTROL OF T H E T H O RAX C H A PT E R 7

pat ient is s i t t i ng, a b i lateral pal pation can be ach i eved by sprea d i n g you r hand s u c h t h a t you r t h u m b s i n ks i n t o o n e s ide a n d you r fo u rt h or fi ft h Fi nger s i n ks i n t o t h e other. •

•

•

I n prone or s i t t i ng, p a l pa t e between t he upper i n ner t h igh (bi lateral p ressure) (see Figure 7 . 9 ) . I n sitt i ng, pal pate just su perior t o t he pubic bone. In p ro n e or s i t t i n g, p a l pate i n the m i d a,xi l lary l i ne, at t he rib correlati ng t o t he level

m

of the segmental muscle t hat you are t rying to i solate ( pa l pate at t he s ide of less b u l k) ( see F igu re 7 . 10 ) . Therapist faci l it a t i o n : Verbal c u es

The i mage of support i ng tent-wires, guy-wires, or c o n n e c t i ng s t r i ngs is u sed i n a l l of t h ese images (see Figure 7. 1 l ). The poi nt of palpation of t h e s eg m e n t a l m u s c l e is t h e co n s i s t e n t feat u re, a n d t h i s i s w here t h e guy- w i re s a re i maged to be attac hed to. The varyi ng factor i s where the i n i t iation of the connection st arts ( t he d i fferen t palpation poi n t s above) ; c hoose the poi n t t h a t p rod uces t he best contraction of the segmental m uscle. The image is created verbally w i t h t hese i nstruct ions:

Figure 7.11 I mages that create the feeling of the spine being "suspended" are effective for facilitating a connection to the deep stabilizing muscles ofthe spine. Various descriptions can be used, but the common theme is that the spine is a central pole that needs to be supported by tension wires ITom both sides. The tension in the wires needs to be equal on the right and left sides; if there is a loss of activity in one side ofthe segmental stabilizing muscles it can be described as a loss ofthe connection in the wire, allowing rotation and collapse of the spine on that side. The idea of energy coming vertically up the wires to support the spine helps to create the sense of "suspension". This figure is reproduced courtesy of Dr. Paul Hodges and was adapted by Lee L J for this text.

Figure 7.10 Isolation of Thoracic Segmental Stabilizers: Sitting. The therapist facilitates the image of drawing the ribs into the spine by palpating in the m i d ·axillary line. The fingers of the other hand sink into the segmental m u scles at one thoracic level. As you give the verbal cues, apply sequential pressure, first i n the mid·axillary l i ne, then at the thoracic segment. " B reathe in, breathe out. Now slowly, lightly connect a l i ne from your rib here (pressure in mid· axi llary l i ne) , to my fi ngers i n your spine here (pressure at thoracic segment) ."

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CHAPTER 7 R ESTO H I N C FO H C E C LOS U H E//VIOTOH C ON T HOL OF TH E T H O HAX

" I magine a t e n t w i re t h at is goi ng to suspend you r spine, a n d i t i s start i ng From you r pelvic Roor (palpate at pubic bone) and slowly coming up and t h rough yo u r body to con nect to t h e po i n t whe re m y finge rs a re i n t h i s m u scle i n you r back." " B re a t h e i n , b rea t h e o u t , and c o n n e c t you r s u p port w i re from here ( provide t ac t i le cue at p u b i c bone or o t h e r poi n t ) t o h e re ( p ro v i d e tac t i l e cue a t segme n t a l m uscle)".

t i o n w i t h rhom b o i d s a n d m i d d l e t ra pe z i u s m u sc les. You should see no erector s p i nae o r sca p u l a r m u scle activi ty. Progress i o n s/Ot her c o n s i derat ions: •

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For t h e palpation poi n t in t h e m id-ax i l lary l i ne, a few d i ffere n t i m ages can be used: " J magine you a re d rawi n g t h e ribs i n t o yo u r s p i ne" " I m agi ne the vertebra i s a n u t , and the ribs as a nutcracker. Th i n k of drawing the ribs towards t he vertebra a n d squeezing t h e n u t "

•

" C o n n e c t a l i n e from m y fi n ge r h e re to m y fi nge r here" •

M a n u a l c u es/Key p o i n t s of c o n t ro l : P rovide

slow, deepe n i n g pressure with you r fi n ge rs as you h e l p t h e p at i e n t c reate t he i m age - t h e p r e s s u re i s a p p l i e d s e q u e n t i a l l y f r o m t h e a nterior/inFerior poin t first then at the segmental m u sc l e poi n t posteriorly. At both p o i n t s t he p re s s u re i s s l i g h t l y c ra n i a l t o re i n force t h e fee l i ng of t h e s p i ne being s u s pe nded by t h e w i re ( t e n segri ty vs. compress i o n ) . I de a l res p o n s e : A d e e p , t o n i c swel l i n g of t h e segm e n t a l m u sc l e , w h i c h i s fe l t as a grad u a l i nc rease i n t e n s io n u n der you r f i ngers (c lose to t h e s p i n o u s p rocesses ) . You s h o u l d s e n se t h a t t he con t raction s t a rt s deeply and comes u p i nto your fingers, as i F the pads of your fi ngers a re be i n g i n d e n t e d , rat h e r t h a n t h e fi n gers being p u s hed off t h e back. Any rap i d recruit ment is i nd icative of a recru itment of the super ficial m uscles. With the ri b cueing ( m id-axi llary l i n e ) , be part i c u l arly obse rva n t for s u bs t i t u -

•

•

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H ave t he paL ient m a i n t a i n the con nect ion t o t h e segme n t a l m u s c l e and bre a t h e n o r m a l ly. E n s u re a n opt i m a l hreat h i n g pattern. Wa t c h For a ny rec r u i t m e n t of the global m uscles (obliq ues, t horac ic erector spi nae, rec t u s abd o m i n i s , h i p m u scles, sca p u l a r m u s c l e s , s t e rn oc le i d o m a s t o i d ) a n d/or brac i n g of t h e r i b cage w h i c h i n d i c ates exc e s s i ve e Ffort and rec ru i t m e n t of t h e d o m i n a n t global m uscles. Check for glohal rigidity by ge n t l e "wiggl i ng" the rib cage; i f t h e r i b cage i s m o b i l e t h e n t h e global m u scle system i s not overac L ive. T h e re s h o u l d be no c h a n ge in s p i n a l orie ntation ( m a i n t a i n n e u t ra l spine) when t he segm e n t a l m u scles a re recruited. The scapular muscles shou ld remain relaxed ( no sca p u l a r moveme n t ) . I F you p a l pate a co-c o n t ra c t i o n of t ra n sve rsus abdom i n i s a n d/or the paL i e n t report s a fee l i n g o f l i ft i n g i n t he pelvic Roor (submaximal) t h is is opt imal as it is engaging the local stabi l izers and a part of the normal low- load s p i n a l s u p porL mec h a n i s m . The pos i t i o n of n e u t ra l s p i ne i s key i n fac i l iLat i ng t h i s muscle. Tap i ng c a n b e used to su p port a leve l of hypermob i l iLy or "give" or for propriocept ive feedback at des i red levels. A s i gn i fi c a n t a l t e ra t i o n in t h e sca p u l a r res L i n g pos i t i o n , e s pec i a l l y a " d u m ped" s ca p u l a ( d e p ressed and downwardly rotaLed ) can affect neutra l t horac ic posiL ion and m a ke e ngagi ng t he t horacic segmenLal stabi l ize rs more d i ffic u l t . To assess i f L h i s i s a Fac t o r, m a n u a l l y s u p port t h e sca p u l a i n t o a n e u t ra l pos i t i o n a n d repeat t h e

R ESTO R I NG F O R C E C LO S U RE/MOTOR C O N T R O L OF TH E T H O RAX C HA PT E R 7

segme n t Cl l muscle contract ion fac i l i tat ion . I F i t i m p rove s , u se t a p i n g to s u p port t h e scapula i n to a neutra l pos i t i o n . •

Ed ucate t he pat i e n t on d u rat ion of holds, n u m be r of re pe t i t i o n s , a n d fre q u e n c y of exerc ise. The goa l i s 1 0 seco n d holds, 1 0 repet i t i ons, w i t h norma l b rea t h i ng. T h i s w i l l not be t h e start i ng poi n t for t he mCljority of pat i e n t s . The key i s t o m a i n t a i n a n i so l ated con t rac t i o n w i t h b rea t hi na Cln d b' w i t hout s u bst i t u t ion with global m u sc u l a t u re . Yo u r asses s m e n t of t h e pat ient's abi l i ty w i l l guide your p rescription (you may f i nd that aFter 3 seconds of hol d i ng t he patient starts to breath hold; you wou l d t h e n advise o n ly 3 second holds, a n d t h e n assess how many repetit ions t h e pati e n t can pe rForm and m a i n t a i n a good q u a l i ty of con t ract i o n ) . The exerc ises s h o u l d b e p ra c t i c ed as Fre q u e n t l y as p os s i b l e to Fac i l i t a t e opt i m a l motor lea r n i ng; s h ort sessions performed oft e n t h rougho u t the day a re preFerred to one long sess i o n .

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As t h e p a t i e n t i s able to perform i solated segmen t a l recruitment for longe r d urat ions a n d i n c re a s i n g repe t i t i o n s , p rogress t h e exerc i s e b y mov i n g Fro m t h e i n i t i a l s u ppor t e d pos i t io n s t o more fu n c t i o n a l , u pr i g h t p os i t i o n s ( s i t t i ng, s u p ported standi ng, stan d i ng lean forward on wal l ) . I t i s i m porta n t to a s s e s s t h e a b i l i ty of t h e p a t i e n t to perform the isolated recru i t m e n t o f t h e segm e n t a l m u s c l es i n each new posit ion . S igns of excessive global m uscle recru i t m e n t (eg. b rac i ng) a n d c h a n ge i n b reath i n g p a ttern are i n d i cations t h a t the n ew pos i t i o n i s too d e m a n d i n g and w i l l d i rect the choice o f posi t io n u sed. When i n t rod u c i n g a new po s i t i o n , use t h e strategies descri bed above for fac i l itat i n g a n e u t ral s p i n e p os t u re , t h e n assess for i s o l a t i o n of t h e t h ora c i c segm e n t a l stabil izers i n t h e n e w pos i t io n , a n d e n s u re t h a t normal b reat h i n g can be m a i n t a i ned befo re a d d i n g l i m b move m e n t or o t h e r global m uscle progressions i n that pos i t i o n .

Add G lobal M uscle System Goal: Co-activation of Local & G lobal System (Table 7.2)

Table 7.1 Program for Stabilization ofthe Thorax

I!!I

C H A PT E R 7

R E STO R I N G F O R C E C LOS U R E/MOTOR C ON T ROL OF TH E T H O RAX

Exercise Progression -

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Adding the Global Muscles

O nce t he pat ie n t can isolate and hold a confident contraction of t he t h oraci c segmental s t a b i l izers at the dysFu nctional segment without global m uscle a c t i v i t y a n d w i t h normal brea t h i ng, i n tegra t i o n w i t h t he global m uscles can b e started. The goal is to maintain the co-contract ion of the deep local system (t horac i c segm e n t a l stab i l izers, t ransver s u s abdom i n i s , deep fibres of m u l t i fi d u s , pelvic floor) w h i le m a i n t a i n i n g pos i t i o n s and co n t ro l l i ng movements t hat requ i re low load global m uscle a c t i v ity. C a re m u s t be taken not to start global m u scle exerc i ses too early, and the a b il i ty to vol u n t a r i l y i so l a t e and ton i c a l ly hold a segm e n t a l contract ion s h o u l d be reassessed often t o ensure t ha t cont rol of t he local system has not been los t . T h e s pec i f i c exerci se p rogression used w i l l vary depe n d i ng on each pat ient's presentation, but a ge neral p rotocol for p rogression i s p resented i n Tables 7 . 1 and 7 . 2 . This protocol i s adapted fTom t h e gu i d e l i n e s d e ve l o p e d by 11 i c hardson et a l ( 1 999) For t h e l u mbopelvic regio n . G e neral P r i n c i p l es ( Ta b l e •

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7.3)

" C o n n e c t f i r s t " - t e a c h t h e pat i e n t t o perform a p re-contra c t i o n o f t h e t horaci c segme n t a l stabil i zers a s the starti n g po i n t for each exerci se .

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Pa l pa te and mon itor t he segmental muscle rec r u i t m e n t and c o n t ro l of j o i n t pos it ion during t he exerc ises, especially when add ing a new p rogression. E n s u re that the muscle does not turn off and that there are no s igns of l oss of c o n t ro l i n to t h e d i re c t i o n of hypermob i l i ty. Focus on low load and control of movement. U se t h e " M a n u a l C u e s/Key Po i n t s of C o n t ro l " d e s c r i bed a bove for a t t a i n i n g n e u t ra l s p i n e a n d i solat i n g t he segmental s t a b i l izers to prov ide tact i l e feedback and assist cont rol at the levels where segmental h ypermobi l i t y or m u l t isegme ntal col lapse occ urs d u ri n g the exerc ise movements. Avoid fast ba l l i s t i c movements. Progress from stable to u n stable s u rfaces to i n c rease pro p riocept ive i n p u t a n d c h a llenge . C heck For excessive global m u scle activity by mon i to r i ng b rea t h i ng pattern ( s h o u l d con t i nue to see lateral costal a n d abdom i nal expa n s i o n ) a n d by mon i tori ng for brac i ng/rigidity. I ncorpora t e loc a l m u sc l e co-c o n t rac t ion i nto d a i l y fu nct ional activit ies as early and as often as poss ible; break down fu nctional tasks i n to component movements and use separate components as a n exerc ise.

Moving Out of Neutral Spine •

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I ntrathoracIc Thoracopelvlc

I ntegrated KinetiC Chain

TQble 7·2 Adding the Global Muscle System

R E STO R I N G F O R C E C LO S U RE/MOTOR C O N T R O L OF T H E THORAX C HA PT E R 7

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General Principles for Progression: Adding the Global Muscles •

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"Connect first": i n s t ru c t t h e patient t o pre-con t ract t he t h o rac i c segm e n t a l stabil iz i ng m u sc les. Pa l pate and m o n i tor the m a i n t e n a n c e of t o n i c recru i t m e n t of t h e d e e p segm e n t a l m u s c l e s t hrough o u t t he exercise.

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Foc u s on l ow load a n d c o n t ro l of movemen t . U se " Key Po i n t s o f Control" to p rovide tactile feedback and assist control at the level s where segmental hypermobi l i ty or m u l t i segmental c o l lapse occurs. Avoid fast ballistic movements. Progress from stable to u nstable surfaces to i n c rease proprioceptive i np u t a n d challenge . M o n i t o r b rea t h i ng p a t t e r n a n d avoi d bracing/rigi d ity. I ncorporate local muscle co-con t raction i n to daily fu n c t i o n a l activities as early and as often as possible. Foc us on co-contraction and contro l of pos i t ion i n stead of s i ngle m uscle stre ngthen ing. Uppe r/m i d d l e t h orac i c dysfu nc t i o n : ensure i ntegration with arm movements; midd l e/lower t ho rac ic dysfu nc t i o n : e nsure i ntegration w i t h l e g movements; m a ny fu n c t i o n a l a c t i vi t ies regu i re i n tegrat ion of whole kinetic c h ai n . I f h igh load and h igh speed activities are reg u i red, add at e n d s t ages . C o n t i n u e w i t h concurren t l o w load exercises. Design exerc ise progressions based on i n d iv i d u a l pat i e n t prese n t a t i o n and fun c t ional reg u i rements.

Tab/e n

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III

Foc u s o n co-c o n t rac t i o n a n d c o n t ro l o f pos i t i o n i ns tead of s i ngle m u s c l e s t re ngt h e ni ng. For u p p e r and m i d d l e t h o rac i c c o n t ro l i ntegrat i on w i t h a r m movements is key; for m i d d l e a n d l o w e r t h o raci c con t ro l i ntegration w i t h leg movements i s key. M any sport specific a n d work a c t i v i t ies reg u i re i ntegra t i o n of the whole ki netic c h a i n . I f h i gh l oad a n e! h igh speed a c t iv i t i es a re regu i red for work or sport, add t hese at end stages and ensure that low load, slow speed con trol is present for t h e same moveme n t pattern first. H igh speed/high load activit ies s h o u l d b e o n l y one part of t h e p a t i e n t 's exercise p rogram ; low load exercises should be co n t i n u ed c o n c u rre n t l y t o e n s u re conti nued fun c t i o n of t he l oc a l system. T h e re are m a n y var i a t i o n s a n d o p t i o n s possible for each o f t he following categories. For each sec t i o n , several p rogressions a re presented, b u t the reader i s encou raged to use t h e p r i n c i p l es a n d gu i d e l i nes i n t h i s c h ap t e r t o gu i de t he c reat i o n o f o t h e r exercise progressions t h a t may b e necessary for a spec ific patie n t p rese n ta t i o n .

Maintaining neutral spine while adding load The goal for a l l exerc i s e s i n t h is s e c t i o n i s t o main tain a local system co-con t raction i n a neut ral spine position against the challenge of l i m b loading. The spinal c u rves should be monitored and the relationship between the l u m bopelvic region and the thorax shou l d be m a i ntained t h roughout the exercise. The movements should be slow and con trolled in both the concentric and eccentric phases of movement. Tru nk-Arm Dissociation

1 ) S u pi ne Patient position : C rook lying i n neutral spine on a flat s u rface; can p rogress to l y i ng on a 1 12 r o l l or other u n s u pported su rface. A r m s a re

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C I I A PTE R 7 R E STO R I N C FORCE C LOS U R E/MOTOH C O N T H O L OF T H E T I- I 0 HA)(

f l exed to 900 so t h a t t h e hands a re vert i ca l ly over t he shoulder joints. Exercise instruction: C u e the i mage that faci l itates the contraction of the t horac ic segmental stabil izers at t he dysfu nctional leve l , then cue b reat h i ng. Ask the pat ient to keep the spine st i l l and the c hest heavy as t hey move the arm s i n to elevation t h rough flexion. Progressions/Ot h e r cons idera t i o n s : •

P rogress from b i l a t e r a l t o u n i l a t e r a l move m e n t s of t h e a r m s . B i l at e ra l movements w i l l provide more c h a l l e nge t o nexion/exte nsion control i n t he thorax, while u n i lateral movcments w i l l provide challenge to rotational contro l .

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O t h e r options i nc l ude a r m abduct ion (see F igure 7 . 1 2 ) and arm extension ( rrom 90° flex i o n down to t h e bed ; c a n p rogre ss to past neutra l ove r t he edge or the bed ) . Add l i ght weights (one t o five pounds) i n t he hancls t o i n c rease c h a l le nge .

2 ) S it t i ng Pat i e n t pos i t i o n : S i t t i ng on a firm s u rface,

feet on t he f loor, i n neutra l spine. Exercise instru ction: C ue t he i mage t hat fac il i tates t he contraction of t he segmental thoracic stabil izers, then cue breath i ng. Ask the pat ient to m a i n t a i n the s p i n a l pos i t ion and the con nect ion to the i mage w h i le moving the arms i nto f l exion, abduction, extension, or d iagonal f l exion/extension patterns.

Figure 7.12 Maintaining Neutral Spine while adding Load: Trunk-Arm Dissociation. Supine. The therapist mon itors control of lateral shift at the rib cage and observes for rotation of the thorax as the patient moves the right arm into abduction.

R E STO R I N C F O RC E C LOS U R E/M OTO R C O NT R O L O F TH E T H O RAX C H A PTE R 7

Progressions/Ot her Considera t i o n s : •

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Progress to s i t t i ng on a ball a n d/or feet on s issels. Start w i t h no res i stance, t he n p rogress to t heraband res istance. Pull down motions req u i re flexion contro l of t h e t h orax, p u l l u p mot i o n s req u i re extension cont rol, and u n i lateral or d iagonal motions req u i re rotat ional contro l . Examples: Video C l i p 7 . 1 3 : The pat i e n t i s s i t t i ng on a b a l l w i t h a st a rt i n g pos i t i o n o f t h o ra c i c l o rdos i s ( l oss o f n o r m a l ky p h os i s ) . The t h e ra p i s t m a n u a l l y fac i l i tates a n e u t ra l spine pos i t ion, and t he n cues recru i t me n t of t h e t h orac i c seg m e n t a l s t a b i l i ze r s . W h e n t h e contraction is Fe lt t he r i b cage i s gen t l y rocked s i d e to s ide to c h e c k [or rigi d i ty. The thoracic segmental musc les are then moni tored [or t o n i c cont raction d u r i n g t he arm move m e n t . T h e pat i e n t starts w i t h b i l a t e ra l p u l l d o w n s t h e n

EI

d e m o n s t rates a p rogre s s i o n of t h e exerc i se to u n i latera l p u l l dow n s . Video C l i p 7 . 1 4 T h e pat ient is s i t t i ng o n a ball with t he t horacic spine i n a start i ng pos i t i on of r i g h t s i d e be n d i n g a n d left l a t e r a l s h i ft . The t he ra p i s t m a n u a l l y fac i l i t a t e s a n e u t ra l s p i n e pos i t i o n by correc t i n g t h e r i gh t s i d e b e n d a n d exten s i o n . The pati e n t connects to the local stab i l i zers and t h e n p u l l s t he arm i n t o a d i ago n a l flex i o n pa t t e rn . The t herapist con t i n ues to prov ide feedback t o p reve n t col l a pse o f the t h o rax i n t o right s idebe nd i ng d u r i n g the exerc ise. 3 ) S u p ported S t a n d i ng/ Stand i ng The same arm m ove m e n t s descri bed a bove for t he sitting posi t ion can be used in supported s t a n d i ng ( w i t h t h e b a c k aga i n s t a wa l l ) o r s t a n d i n g (see F igure 7 . 1 5 ) . To c h a l l enge t h e base of s up port fu rt her, c h a nge t h e pos i t ion of the feet to a l u n ge stance, t hen to stan d i ng on one leg, w h i l e m a i n t a i n i ng neu t ra l s p i n a l al ignment and perform i ng t he arm movements. 4 ) Prone on Ball ( F igu re 7 . 1 6 ) Pat i e n t pos i t i o n : K n ee l i ng prone over a ball w i t h t h e t horax posi t ioned so t hat the c u rve of t he ball fac i l i tates mai ntenance of t he n e u t ral t horacic kyphos i s . If add i t ional su p port in the thorac ic c urve is needed (for excessively lordot ic c u rves) a towe l rol l can be p l aced vert i c a l l y u nder t he stern u m . Exercise i n struction: C u e t h e image t hat facil

Figure 7.15 Maintaining Neutral Spine while adding Load: Trunk-Arm Dissociation. Standing.

i tates t he contraction of the t horacic segmental stab i l izers at the dysfu nctional levc l , t hen cue breath i ng. Ask t h e pat i e n t to keep t h e t h orax open and the l u mbar s p i n e l e ngthened as t he arm is l i fted off the ba l l .

The patient stands in neutral spine with weight equal on both feet. The segmental stabilizing m u scles are recruited prior to moving the arm. I n this exam ple the therapist i s facilitating t h e right thoracic segmental m uscles w h i l e cueing control of the scapula d u ring u n i lateral arm fiexion against theraband resistance.

Progressions/Other considerations: As a pro gression to bot h Tru n k-Arm D i ssoc iation and Tru n k- Leg D i ssoc i a t i o n (see below ) , add an oppos i t e leg ext e n s i o n t o the a r m l i ft . S t a rt

PI

C HA PT E R 7 R ESTO R I N G F O R C E C LO S U R E/MOTOR C O NTROL OF TH E T H O RA-X

Figure 7.16 Maintaining Neutral Spine while adding

Figure 7.18 Maintaining Neutral Spine while adding Load:

Load: Trunk-Arm Dissociation. Prone over Ball.

Trunk-Arm Dissociation. Upper Extremity Weight Bearing

The therapist provides feedback at the thoracic segmental

in Four Point Kneeling. The therapist's cranial hand provides

stabilizing muscles to facil itate a tonic contraction while

tactile feedback under the upper sternum to cue the thoracic

gently cueing control of the l u m bar lordosis as the patient

kyphosis while the caudal hand cues the maintenance of the

slowly lifts the arm. The arm does not have to move th rough

lumbar lordosis. The levels of poor control are observed for

a large range of motion but the neutral spine position and

aberrant movements as the patient lifts the arm from the floor.

the local muscle contraction needs to be maintained throughout the exercise. The therapist observes for any extension, rotation, or lateral s h ifts i n the thoracic segment as the arm is lifted.

with a sma ll range of motion and ensure control or t he neutra l spine berore progressing to larger ra nges of motion .

I n t h is video cl i p, the pa t ient fi rst performs three left arm l i rts with poor techn ique. The start i ng pos i t ion is a lordot ic and right sidc bent t h orax. As the I c f't a rm is l i ft e d , ext e n s io n 0(' t h e t ho rax i nc reases a nd a rotat ion occurs. The t herapist then corrects the s t a rt i ng posi t i o n t o a ne u t ra l s p i n e pOS i t i O n , c u e s a segm e n t a l m u s c l e c o n t ra c t i o n t o c o n t ro l t h e l e v e l o r dysfu nct ion, then has the pat ient repeat the a rm l i l't w i t h no s p i n a l move m e n t .

5 ) U p p e r Ext re m i t y We i g h t B e a r i n g ( C l osed Ki net i c C h a i n ) Patient pos i t i o n : The Stand i ng Forward Lean on Wa l l pos i t i o n is t h e s t a rt i n g pos i t io n For t ra i n i ng load t ransfer t h rough a weight bearing u p per extre m i ty. Exercise i nstruction: Th e t herapist Fac i l i tates a n e u t ra l s p i n e p os i t i o n a n d t h e n c u e s t h e segm e n t a l m u s c l e c o n t rac t i o n . S t a rt w i t h b i l at e ra l control b y i ns t ruc t i ng t h e p a t i e n t to pe rform a push u p action; ask t h e pat i e n t to keep the thorax still (no collapsing i nto extension) and let the move m e n t occur as a h inge from the feet so t ha t t h e s p i n e s tays connected as one u ni t . Progre s s i ons/Other c o n s idera t i o n s : •

P rogress t o rot a t i o n a l con t ro l w i t h a o n e arm l i ft from the wa l l : s e e Video C l i p 7 . 1 7.

•

•

•

P rogre s s fro m t h e wa l l to Fo u r Po i n t Knee l i ng; sec F igu re 7. 1 8. For t he one arm l i ft , s t a rt w i t h t h e hands p l aced c l ose t oge t h e r ( n a rrow ) , t h e n progress to h a n d s wider apart . If t he exercises can not be controlled in the Sta n d i ng Forward Lea n on Wa l l pos i t ion, do not progress to Fou r Po i n t Knee l i ng.

6) Funct ional I nt egration The patient can be made aware or contro l l i ng n e u t ra l s p i n e pos i t i on d u ring act ivit ies such

R E STO R I N G F O R C E C LO S U R E/MOTOR C O N T R O L OF TI- I E THO RAX C I I A PTE R 7

as reac h i ng for a n d p u s h i ng obj e cts w i t h t h e a r m s . Choose activit ies t hat are m o s t relevan t t o t h e pat ient's work a n d sport req u i rements. S i m u lation of these activit ies can be performed in the c l i n ic to re i n force appropriate pattern i ng and contro l . Tru n k- Leg D issoc iation

1 ) S u p i ne Leg load i ng exerc ises a n d t h e i r p rogress i o n s have been descri bed as exerci ses to t ra i n l u m bope lvic control ( Lee 200 1 , Richard son et a i , 1 999, Sahrmann 200 1 ) ; examples incl ude heel s l i des, bent I nee fal l-outs, and one leg alter nat i ng leg lifts performed from t he start position of c rook lyi ng. These exerc ises c a n be c h a l lengi ng for pat ients w i t h thorac ic dysfu nction , especially when t he dysfu nction is in the middle to lower thorac ic regions. Compensatory shifts and loss of cont rol of t he neutral spine position ca n be observed . Fo r a descri p t i o n of t h ese exerc ises the reader i s referred t o the above sources. The key to applyi ng t hese exerc i ses to t horaci c stabil ization is the focus on t horac ic segmental cont rol and maintain i ng t he correct relat i on s h i p between t h e l u m bope l v i s a n d t horax ( n e u t ra l s p i ne ) d u ri ng l e g movements.

2 ) S i tL ing I n this posit ion Tru n k Leg Dissoc iation exercises can focus on eit her a) movement of t he tru n k on the h i ps or b) movement of the legs u nder the trun k . -

a) S i l t i ng lean forward (see Video C l i p 7 . 1 9) Pat i e n t Pos i t i o n : S i t t i ng on t he edge of a p l i n t h chair, or ba l l . I f there is a restriction of h i p f l exion ra nge of motion t h e s urface shou ld be h igh enou gh to al low the pelvis to f l e x over the femoral heads. The feet are supported on t he f l oor. ,

Exerc ise instruction : C ue a neutra l s p i n e pos i t i o n ; t hen p lace t he patient's h a n d s i n t he anterior h i p c reases. H ave t he p a t i e n t

mJ

"connect" to the local system, then instruct the patient to h i nge at the h ips to bri ng t he t r u n k forward over t he h i p s w h i l e keepi ng the spi ne stil l Only al low movement t hrough a range of motion where there is n o l oss of n e u t ra l spine. Start with s m a l l amounts of move m e n t a n d p rogress to l a rger range s . This exercise c a n b e progressed to standing (Sahrma n n's "Waite r's Bow" (200 1 ) ) . .

b ) H i p flexion o r knee exte n s ion Pat i e n t pos it i o n : S i t ti n g i n neutra l s p i ne, feet s upported on t he floor; exerci se can be progressed to sitting on a ball or other u nstable s u rface. E x e rc i s e i n s t r u c t i o n : " C o n n e c t t o t h e t horac ic segmental stab i l i ze rs , t he n slowly l ift one knee up a n d fo l d a t t h e h i p ( h i p flexion) a s you keep t h e s p i ne sti l l . " O r, ask the p a t i e n t to s t ra i gh t e n t h e knee w h i le kee p i n g t h e spine sti l l .

3 ) S u pported Stan d i ng ( see F igure 7 . 20) Pat i e n t pos it ion : S t a n d i n g i n n e u t ra l s p i ne aga i n s t a bal l o n the wal l . The ball should be placed such that it supports the l umbar lordosis a n d does n o t res t r i c t t he move m e n t of t he t horax i n to a neutral kyphosis. The hips sho u ld be i n n e u t ra l rotat i o n , t h e knees u n d e r t h e h ips, t h e second toe of each foot i n l i n e w i t h t he m i d d l e of t h e pate l l a , w i t h e q u a l b o d y wei gh t d istributed over each foot. Exercise i n st r u c t i o n : Advise t he pat ient t h a t movement is only to occur i n t he legs ; t he spine stays s t i l l and s u spended by the "guy w i re s . The pat ient i s asked to squat "as if s i t t i ng i n a c h a i r", fl exing a t t he h ip s , knees a n d a n kles, while mainta i n i ng the n e u t ra l spine pos i t i o n . "

Progressions/Other considerations: Progressions can i n c l ude: l unge pos it i on (see F igu re 7 . 2 1 ) , l u nge t he n knee l i ft ( posterior leg l i fts u p into hip flexion), squat on wobble board, one leg squat.

C H A PT E R 7

R E STO R I N G F O RC E C LO S U R E/MOTOR C ON T ROL OF T H E TI- I O RA-'<

4 ) U p p e r E x t re m i ty We i g h t B ea r i n g ( C l osed K i ne t i c C h a i n ) Pat i e n t pos i t ioning a n d c u e i ng is t h e same as For Tru n k-Arm D i ssoc ia t i o n ( p ro n e on b a l l , fou r poi n L knee l i ng), but the exercise movement i nvolves I i h i n g one leg at a t i me i nto extension or d iagonal extension movements.

5 ) Standing: Rotat ion ConLrol (sec Video Clip 7 22) Pat i e n t pos i t i o n : Stand i ng in ne u L ral s p i ne, in sLance pos i L ion w i L h t he legs, back leg is u p on the ba l l of" the fool . We ighL i s foc used o n t h e fro n L leg. Knee rema i n s faC i ng a n L e rior. m i d d l e of t h e pa L e l l a is ove r t h e second toe and i n l i ne w i L h the h i p jo i n l .

Figure 7.21 Maintaining Neutral Spine while adding Load: Trunk-Leg Dissociation. Lunge in Supported Figure 7.20 Maintaining Neutral Spine while adding Load: Trunk-Leg Dissociation. Squat in Supported Standing. The thera p i st is b i l aterally palpating medial to the A S I S ' s and c u e i n g a guy-wire i m age up to the thoracic segmental stabil izers in the mid·thoracic spine. The patient performs a squat as the therapist mon itors the neutral spine position and segmental thoracic contraction. There should be no change in the thoracic or l u m bopelvic position as the hips and knees are flexi ng.

Standing. Changing the base of su pport is a progression of the squat exercise. The patient's body weight is distributed equally over both legs, with the posterior leg supported up on the ball of the foot. The deep local stabilizing muscles are recruited prior to the l u nge movement; i n this example the therapist provides tactile feedback at the anterior hip creases to facil itate folding (flexion) of the h i ps equally and maintenance of pelvic position during the movement. The thorax is observed for areas ofloss of control and manual feedback provided as needed. Further challenge can be added by having the patient stand on 'sissels' or other unstable su rfaces.

R E STO R I N G FO R C E C LOS U R E/MOTOR C O N T R O L O F TH E TH ORAX C H A PT E R 7

Exerc i se i n s t ru c t i o n : C u e lu mbopelvic a n d segmental t horacic local m uscle recru i t m e n t , a n d i n struct t he pat ient to keep t h e l e g st i l l and the knee I'orward w h i Ie rotat i ng the pelvis and t ru n k as one u n i t over t he leg (spin pe lvis over re mora l head ) . C ue t h e i n i t iat ion of t he rot a t i o n move m e n t com i ng from j u s t i n s i d e the AS I S . Progressions/Ot he r considera t i o n s : Do not a l low any lateral or posterior pelvic t i l t i ng as t he pe lvis rot ates. M on i tor the knee and give tact i l e cueing to keep the knee fac i ng forward . M o n i t or t h e t h orac i c level of poor c o n t ro l , specifrcally watching for rotation andlor sidebend ing. Progress to perform i ng the exerc ise w h i le weight bea ring o n ly on t h e Front leg.

6) Funct ional I n tegra t i on There are many opt ions ror progression in t h i s category; a Few exa mp les are l isted here. Aga i n , t he key i s the m a i ntena nce or a n e u t ra l s p i n e position; observe for any loss o f thoracic posit ion, l u m bopelvic pos i t ion, and t h e re l a t ion s h i p of t h e t h orax over t h e pel v i s . T h ro u g h o u t t h e movements t h e s p i n e should b e "suspended" and "st i l l " but not braced. Exerc ise exam ples: a) S i t to Stand rrom chair or ba l l . b) Forward Lu nge agai nst U n i lateral t heraband resistance (sec Video C l i p 7.23): The patient performs a forward l u nge with the left leg with light resistance around the right shoulder fro m beh i n d . The First t h ree re pet i t i o n s demonst rate a loss o r thorac ic control, w i t h t h e thorax col lapsing i nto right rotation a n d right s i deben d i ng. The t h e ra p i s t provides manual correc t i o n i n to n e u t ra l s p i ne; t h e last three repet i t ions arc performed correctly mainta i n i ng t horaci c cont rol. The theraband res i stance can be placed on the i p s i l atera l or con t ra latera l shoulder.

II1II

c ) Step Up/Step Down (see Video C l i p 7 . 2 4 ) : The patient performs a step u p with the left leg; note the right side bending and extension oc c u rr i n g i n t h e T7 a rea d u ri ng t he fi rst t h ree repet i t i o n s . The t h e ra p i st c u e s a n awareness o f t h e area o f poor c o n t ro l by fac i l i ta t i ng a n "open ing" on the right s ide; c o n t i n ued tac t i l e fee d b a c k p reve n t s t he right sidebend i ng as the exercise is repeated .

Moving out of neutral spine C o n t ro l of m ove m e n t s o u t of n e u t ra l s p i n e i s essent ial for stabi l ity d uring many fu nct ional act iv i t ies. The t h e ra p i s t m u s t carefu l l y m o n i tor t h e i ntersegmental relationships during these movements to ensure that there is egual movement and load ing o c c u rr i n g at e a c h s e g m e n t a n d from e a c h c o m po n e n t i n t h e k i n e t i c c h a i n of move m e n t . Fo r fu n c t i o n a l l o a d t ra n s fe r, t h e hype r m o b i l e segment(s) must be controlled during I ntrathoracic m ove m e n t s o u t of n e u t ra l , d u r i ng c h a n ges i n Thoracopelvic orientation, and a s a c o m ponent part of an I ntegrated F u n c t i o n a l K i ne t i c C h a i n . I n t ra t h oracic

Foc u s on r e t ra i n i n g t h e m ove m e n t w h ere t h e d i re c t i o na l hyperm o b i l i t y i s m o s t poorly c o n t ro l led. Controlled segmen t a l Aexion, extension, rotation, s idebe n d i ng, and combi ned movements a re necessary for normal fun c t i o n . Start in more s u p p o r t e d p os i t i o n s ( s i t t i n g) a n d p rogre s s t o knee l i ng, t h e n stand i ng, i ncorpora t i n g u n stable s u rfaces whenever appropriate. Some exa m p les of exerc i ses i n t h i s category i n c l ude:

1 ) S i t t i n g: C e rv i c a l and Thorac i c flex i o n a n d Ret u rn t o Neutral S p i ne (see Video C l ip 7.25): The patient starts i n a position of neutra l spine, u s i n g the local s t a b i l izing syste m to m a i n ta i n this start pos i t ion. The t herapist cues segmental c e rv i c a l flex i o n , c o n t i n u i ng down i n t o t h e t horac i c s p i n e . Tac t i l e feed ba c k i s p rovided a long the s p i nous processes. O nce the desi red amount of Aexion has occurred, cue a segmental ret u rn to n e u t ra l s p i ne, avoid i ng braC i ng w i t h

CHAPTER 7 R E STO R I N G F O R C E C LO S U R E/MOTOR C ON T ROL OF TH E T H O RAX

the globa l m u sc ul a t ure of the t horax or neck. P rogress by a s k i ng the pat i e n t to perform the exerc ise w i t h t he eyes closed. 2 ) Video C l i p 7 . 2 6 Stand i ng P u re Rotation and Com bi ned Rotation w i t h Flexion (this exercise should be first acco m p l i s hed i n s i t t i ng) : The therapist cues a neutral spine position and con nection to the segmental stabilizers. Theraband a round the left shou l der p rovides resi stance to right thoracic rotation; the therapist cues a pure rotat ion w h i le prov i d i n g feedback at the i liac c rests to m a i n t a i n a s t i l l pelvis. A progression is to add segmental Aexion with the rotation. To add fu rther chal lenge, the upper extre mity i s added to the c h a i n of movement. Th i s pro gression is shown i n s i t t i ng in Figure 7.27. The t he rapist is provi d i ng t ac t i le feedback to help t h e p a t i e n t s t ay c o n n ec t e d t o the t h orac i c segmental stabilizers while the patient performs a P N F Aexion pattern w i t h the left arm along

w i t h right rotat ion and Aexion. Use of the ba l l i n c reases p roprioceptive dema nd. Figure 7.28 i l l ustrates further increasi ng complexity by pro gressi ng to stand i ng; i n t h i s exa m p l e an arm extension PNF pattern comb i ned with thoracic rotation and extension is shown. Each component of t h e c h a i n m u s t be m o n i t ored for c o n t rol ( t horac ic segment , t horax mov i ng over stable pelvis/lower ext re m ity, scapular movement on thorax, arm movement with scapu la.

Figure 7.27 Moving out of Neutral Spine: Intrathoracic.

Figure 7.28 Moving out of Neutral Spine: Intrathoracic.

Combined segmental rotation and flexion with upper

Combined segmental rotation and extension with upper

extremity integration. The therapist is provi d i n g tactile

extremity integration. The patient has developed an internal

facil itation of the 'guy-wire' i m age for the right side (the side

sense of the i mages req u i red to ach ieve recruitment of the

of decreased thoracic segmental m u scle recru itment). The

thoracic local stabilizers and lumbopelvic local stabilizers to

patient performs a flexion PN F pattern with the left arm

the point where manual facil itation from the therapist is no

com bined with right thoracic rotation and flexion. Prior to

longer req u i red. The starting position for the right hand is in

this exercise progression the patient should master control of

front ofthe left h i p. Prior to performing the movement, the

right rotation i n sitting, then right rotation and flexion.

patient thinks of "connecting", then moves the right arm in a diagonal extension P N F pattern while right rotating and extending the thorax. The pelvis remains sti ll.

R ESTO R I NG F O R C E C L O S U R E/MOTOR C ON T ROL OF T H E T H O RAX C HA PTE R 7

Figure 7.29 Moving out of Neutral Spine: Intrathoracic:

Figure 7.30 Moving out of Neutral Spine: Intrathoracic:

Wall Side Bend. The patient stands against a wall to provide

Wall Side Bend. As the patient performs the side bending

feedback; the goal i s to achieve pure sidebend ing of the tru nk

movement the therapist uses the ribcage to faci l itate a

without thoracic or pelvic rotation away from the wa l l . The

pattern of segmental movement rather than h i nging at one

therapist can provide tactile feedback to cue where the

thoracic level.

movement should occur and to prevent collapse, hinging, or rotation at a specific level. I n th is example the therapist mon itors pelvic position.

3) Wa l l S i d e B e n d ( s e e F i gu res 7 . 2 9 , 7 . 3 0 ) : Th i s exerc i se t ra i n s control o f p u re s idebend i ng wit hout segmental lateral shift i ng, h i ngi ng, or rotat ion. The wal l provides tac t i l e feedback so t he pat ient can monitor if t he pelvis or thorax rotates away [rom the wa l l . The t h e rapist can add manual feedback at the rib cage or pe lvis to e n c o u rage move m e n t o r c o n t ro l a t des i red leve l s . Thoracopelvic

These exerc i ses foc u s on t ra i n i ng the a b i l i t y to dissociate movement of t he t horax from t he pelvis and vice versa. The ability to cont rol thoracopelvic

move m e n t is an esse n t i a l req u i re m e n t of many fu nctional act ivit ies, from those as basic as walking to m o re c o m p lex s port m a n e u ve rs . These two exerc i ses p rovide a starti n g poi n t , b u t t h e p r i n c ip l es can b e a p p l i e d to component movements of re levan t functional act i vi ties (e.g. a gol f swi ng) to produce a m u l t i t ude of patient-spec inc exerc ise p rogressions. 1 ) How i ng Back (see Video C l i p 7.3 1 ) : the patient starts s i t t i ng w i t h t he knees bent on a p l i n t h or t h e floor. P l a c e a s m a J J ba l l between t h e u pper i n ner t h ighs t o faci l i tate a "con nection" to the a n terior pelvic floor and m a i n te na n ce

mI

C H A PTE R 7 R E STORING FORC E CLOSU RE/M OTOR CONTROL OF THE TH ORAX

of neu t ra l h i p a l i gn m e n t d u ri n g the exerc i se. The ball is not to be squeezed, but merely held i n place by the t h ighs s i n ki ng i nto t h e s i des of the baH . C orrec t for n e u t r a l s p i n e p o s i t i o n , then cue a recru i t me n t of the l umbopelvic and segmental t horac i c stabil izers . Ask the patient to ge n t l y fol d a t the lower s t e r n u m and ro l l s l i gh t l y b a c k o n t h e p e l v i s . O n l y a s m a l l move me n t i s req u i re d . The p a t i e n t i s t h e n asked to slow l y rotate t h e t h o rax to t h e righ t and left, i magi n i ng t h a t t he r i b cage i s a l i d on a jar t ha t i s t urni ng w h i le the jar (pelvis) stays s t i l l . The t hera p i st p rovides m a n u a l feedback t o e n s ure t h a t the d i s t a n c e between the ri b cage a n d i l iac crests does n o t change a n d that no latera l shift or collapse of the t horax occurs d u r i n g t h e rota t i o n . 2) Bridge a n d Rotate (see Video C l i p 7 . 3 2 ) : The p a t i e n t s tarts i n c rook lyi ng. Check for latera l costal expan s ion d u ring b rea t h ing. A t t h e e n d of a breath o u t , cue t h e l u m bopelvic stabi liz e rs a n d t h e t h orac i c stabil izers, then i nstruct t he patient to roll t he pelvis back i nto a posterior p e l v i c t i l t by p u s h i n g t h ro u g h t h e fee t a n d l i ft i ng t h e h i ps off t h e f l oor. C u e a conti n ue d lu mbar spine flexion as t h e h ips are l ifted. The m id t horax rem a i n s on t h e fl oor. At t h e top of t h e "bri dge" pos i t i on, t h e pat i e n t is aske d to release the h ips and pelvi s i nto a n eutral pelvic t i l t pos i t ion ("let t he b uttocks drop and the h i p creases fold"), creating a neutral l u mbar lordosis. Once t h i s i s mastered, pelvic rot a ti o n u nder t h e thorax is added ("rotate t he jar u nder the lid"). C u e a fol d i ng of t he h i p as the pelvis is slowly rotated to one s i de; to return to neutral, have t h e p a t i e n t t h i n k of d ra w i n g the pelvis up from j ust i nside the ASI S . Repeat the rotation to the oppo s i te s ide. Movement m ust be con t ro l l e d t h rough both p hases of the rotat i o n . Retu rn t o t h e start i ng pos i t i o n b y flexing t h e t horax ("let the c h e s t go heavy") , t h e n flex i n g the l u mbar s p i n e ( " b r i n g your low back down

to t he bed"), and Rnally releas i ng into a neutral l u m bar lordosi s ("let the pelvis tilt forward and the b u t tocks go w i d e " ) . A b a l l between t h e u p p e r i n ner t h ighs c a n b e u sed to fac i l i tate control d u r i n g t he exerc ise. I n tegrated fu nctional ki netic c h a i n 1 ) Low t o H i gh P u l l eys (see Video C l i p 7 . 3 3 ) :

T h i s exerc ise i n tegra tes congrue nt rota t i on t h rough m u l t i p le joints in a fu nct ional kinetic c h a i n . The movement can be performed from low to h igh ( fl exion to extension) or from h igh to low (extension to flexio n ) . The feet need to be able to p i vot to a l l ow movement t h rough the whole c h a i n ; start w i t h the feet fac i ng t he pulleys and then R n ish the movement with the feet poi n t i ng 1 800 from the start pos i t ion. Aim to m a i n t a i n t h e normal sagittal c u rves of t he spine throughout ( flexion and extension should occur a t t he h i ps and knees) . The arms s tart low at the p u l l eys by fl exi ng at the h i ps and knees, t h e n rotation occ u rs t h rough t he legs, pelvis, a n d t horax as t h e arms are t a ke n i n a d i agona l extension and e l evat ion pat tern, the fron t h i p and knee extends and weight is t rans ferred t o t h e o t h e r l eg. There s h o u l d be no segm e n t a l s h i ft i ng or an tero pos terior loss of c urves i n the spi ne. The goal i s a smooth con trolled trans i t ion and i ntegration of the rotat ion and exte nsion at a l l joints a long the chain. U se only l igh t res i stance as the foc us is on control . The fi n a l progression i s the s i m u la t i o n of work a n d sport -speci fic maneuvers t h at req u i re i n te gra t i o n of movement t h ro ugh several joi n t s . As m e n tioned p reviou sly, component parts of t hese comp lex maneuvers can be used as exerc ises i n earl ier s tages i n t h e stabil ization program, when t hey are appropriate. N ow is t he t i me to pract i ce the complete maneuver, but modiRed for speed a n d load. Start with low speed and low loads u n t i l contro l o f the i n tegrated movement is achieved, t h e n progress t o the speeds and loads t h a t t h e fu n c t i o n a l task req u i re s . Co n t i n u e to conc ur-

R E STO R I N G FO R C E C LO S U R E/MOTOR C ON T ROL OF T H E TH ORAX C HA PT E R 7

re n t l y pract ice low load a n d l ow s peed t a s ks to e n s u re segm e n t a l a n d m u l t i segm e n t a l c o n t ro l w i t h t he loca l stab i l i z i ng syste m . The a b i l i t y t o consc iously isolate the segm e n t a l m u scle con traction at the dysfu nctional thorac ic levels should be regu larly checked and monitored t h roughout the progressions through the rehabilitation program, as episodes of rec u rren t pa i n and changed motor patterns can affect t h i s abi l ity to "con nect" to the local syst e m .

lSI

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