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<Lx. The reader is referred to other texts for a review of postural analysis, myofascial syndromes
and neural dysfunction.
I would like to extend my gratitude and recognition to Mr. Frank Crymble who was responsible for the
cover design and all of the art work and photographs in this text. To my colleagues at DOPC for their
ongoing support and constructive reviews or 'yet another presentation on the thorax', my special thanks.
And Fillally, to Thomas, Michael and Chelsea, thank you.
British Columbia, 1994 D. L.

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

..

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

..

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.

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.

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.

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

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

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.

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
.

. '

.
.

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).

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.

\"
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.

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

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

VI

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).

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

'
.
, .
, .
, .

.'

.'

.
.
.
.
.

.
.

.
.

.'

.'

.'

-.

..
..

: 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.

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).

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 CDROM which accompanies
this text to view short video clips of these tests.

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

IIA

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).

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.

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,

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.

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 ffness 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 ) .

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).

III

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

III

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.

III

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

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.

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

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 Tl2.

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

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 -

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 .

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.

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 mAX 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-Pressorrl 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.

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-

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

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 cocontraction 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

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

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 :

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

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 ) :

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 :

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

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 midaxillary 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) ."

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:

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 -

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 .

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 -

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

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 .

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

I ntrathoracIc
Thoracopelvlc

I ntegrated KinetiC Chain

TQble 72
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

General Principles for Progression:

Adding the Global Muscles

"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.

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

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

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 .

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 :

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 midthoracic 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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