Beruflich Dokumente
Kultur Dokumente
THE THORAX
MANUALTHERAPYFORTHETHORAX
A biomechanical approach
Dope
De lta British Columbia, Canada,
, 1 994
PREFACE
1. ANATOMY 10
VERTEBROMANUBRJAL REGION 11
VERTEBROSTERNAL REGION 13
VERTEBROCHONDRAL REGION 20
THORACOLUMBAR JUNCTION 21
2. BIOMECHANICS 23
LITERATURE REVIEW 23
DEFINITION OF TERMINOLOGY 24
HABITUAL MOVEMENTS 25
Forward bending 25
Backward bending 31
Lateral bending 36
Rotation 42
Respiration
Unilateral elevation of the arm 47
3. CONDITIONS 51
HEALING PROCESS 56
Substrate phase 56
Fibroblastic phase 56
Maturation phase 56
Clinical application to treatment 57
4. ASSESSMENT 59
surUECTIVE EXAMINATION 60
OBJECTIVE EXAMINATION 62
Postura l Analys i s 63
Habitual movement 63
Forward and backward bending 63
Lateral bending 64
Axia l rotation 65
Resp iration 66
Combined movement testing 67
Unilateral elevation of the a rm 68
Articular function 68
Active mobility,
osteokinematic 70
Forward 70
Backward 75
Lateral bending 76
Rotation 77
Respiration 78
Passive
a rthrokinem a tic 80
Zygapophysea l 81
Costotransverse 82
Mediola teral translation 87
93
Inferior
- posterior costal 96
Anterior/Posterior translation
- anterior costa l 97
Superior/Inferior transla tion
anterior costa l
Mediolatera l translation 97
Muscle function
Nerve function
Adj unctive tests 103
CLINICAL SYNJ)ROMES
Vertebromanubrial region
Bila tera l restriction offlexion
Un ilateral restriction offlexion 109
Bila tera l restriction of extension 111
Un ila tera l restriction of extension
Un ilatera l restriction of anterior
rotation - first rib 115
Unilatera l restriction of posterior
rotation rib
Vertebros ternal and vertebrochondral
regions 118
Bilatera l restriction offlexion 118
Un ila teral restriction of flexion
Un ila teral restriction of extension 125
Unilateral restriction of rota tion
(posterior or anterior) - rihs 3 to 10 127
Thoracolumbar j u nction
Unilatera l restriction offlexion 130
Unilateral restriction of extension 132
1
ANATOMY
Figure 1.
The superior a spect of the
first thora c i c v ertebra. The
zygapophyse a l joints lie in
the coronal pla ne.
Manua l Therapy For The Thorax - 11
VERTEBROMANUBRIAL REGION
The first tho racic vertebra is atypical. It has a large , nonbifid s pin
ous process, club like at its end. The superior aspect of the spinous
process tends to lie i n the same transverse plane as the TI-2
zygapophys eal jo ints . The facets on the superior articular process
es lie in the coronal body plane (Fig. 1) w hile those o n the i nferi
o r articul ar process (Fi g . 2) present a gentle curve i n both the trans
verse a n d sagittal planes. The zygapophyseal joints are s y n ovial.
The transverse processes are long and thick. The y are located
between the s u perior and i n ferior articu l ar processes (Fig. 3) at the
dorsal aspect of the pedicle and are ideal ly s i tuated for palpation o f
i ntervertebral motio n . O n the ventral aspect o f the transverse
process there i s a deep, concave facet which articu l ates w i t h a con
v ex facet on the first rib to form the costotransverse j o i n t. In the
normal upright posture, the orientation of this joint is an teroinferior
Figure 2.
The i nferio r aspect of the first
thorac i c vertebra. The
zygapophyseal jo ints are gen
tly convex in both the trans
verse and sag i t tal plan es. The
ventral aspect of the trans
verse process contains a con
cave face t fo r a r t i culat i o n
with t h e firs t rib.
Figure 3.
Anterolateral v i ew of the first
t horacic vertebra. The unci
nate process at each postero
lateral corner creates a con
cav i t y on the superior aspect
of the vertebral body. There
is a full facet at the supe rolat
eral aspect of the vertebral
body for the head of the firs t
rib. A demi-facet on the
infero lateral aspect art i culates
with the head o f the second
rib in the second decade of
life . Note the concave facet
on the transverse process for
art iculati o n w i th the first rib.
12 - Manual Therapy For The Thorax.
The first rib (Fig. 5) is the shortest of the twelve and the broadest
at its anterior end. The first sternochondral joint is unique in that it
is fibrous rather than synovial. The first costocartilage is the short
est and this, together with the fibrous sternochondral joint, con
tributes to the stability of the first ring. The convex head of the first
rib articulates with the body of T1 at the costovertebral joint. The
neck of the rib is located between the head and the tubercle. The
articular portion of the tubercle is convex and directed posterosu
periorly when the head and neck are in the normal upright posture.
The second rib is about twice as long as the first and its features are
similar to the vertebrosternal region described below. Anteriorly,
the cartilage of the second ring articulates with both the manubri
um and the sternum at the manubriosternal symphysis.
Figure 5.
Superior aspect of the fi rst
rib.
Figure 6.
The manubrium.
VERTEBROSTERNAL REGION
The facets on both the superior and inferior articular processes pre
sent a gentle curve in both the transverse and sagittal planes 4 (Fig.
9). This orientation permits multidirectional movement. If two
mixing bowls are placed one inside the other, a model of the
zygapophyseal joints can be made (Fig. 10). The top bowl can
rotate forward, backward, s ideways and around the bottom bow l .
Transl ation o f the top bowl meets immediate resistance. The coro-
14 - Manual Therapy For The Thorax
Figure 7.
The m anubriostern a l symph
ysis is u s u ally main t a i n e d
thro ugh l i fe, however ossifi
cation can occur.
Figure 8.
Poster ior view of the articu
l ated thor a x .
Figure 9.
The superior aspect of the
fourth thoracic vertebra. The
zygapophyseal j oint is ge ntly
convex in both the transverse
and sagittal planes. The ven
tral aspect of the transve rse
process contains a concave
facet for articulation w i t h the
fourth rib.
Figure 10.
Two mixing bowls model the
potential biomechanics of the
zygapophyseal j oints in the
thorax.
Figure 11.
Ante rola tera l v ie w of the
fourth t h o racic vertebra.
Note the concave facet on the
transverse process for articu
lation with the fourth rib as
we ll as the two demi-facets
on the lateral aspect of the
vertebral body for articula
tion with the heads of the
fo urth and fifth ribs.
ture (Fig. 12) influences the conjunct rotation which ocCurs when
the rib glides in a superoinferior direction. When the tubercle of
the rib glides superiorly, the curvature forces the rib to rotate ante
riorly. Conversely, posterior rotation of the rib occurs when the
16 - Manual Therapy For The Thorax
Figure 1 2 .
Posterola t eral view o f the
articu lated th orax, verte
brosternal region. Note the
curvature of the fifth costo
transverse joint (arrow).
Figure 13.
Anterola teral view of the
articulated thorax. Note the
costovertebral joint, v erte
brosternal region (arrow).
Figure 14.
The fourth rib.
Figure 15.
The sternum.
In the skeletally mature, the joint between the head of the rib and
the adj acent vertebral bodies i s div ided into two synovial cav ities,
separated by the intra-articular ligament (Fig. 13). The capsule i s
supported by t h e radiate l i gament which sends fibres from the head
of the rib both anteriorl y and posteriorly to b l end with the vertebral
bod y of the l evel above, the intervertebral disc and the vertebral
body of the level below. The costovertebral joint i s a compound,
synovial joint.
Very little is known about the anatomy and age related changes of
the intervertebral disc in the thorax. They are thinner than the cer
vical and lum bar intervertebral d iscs even i n youth. They are sup
ported anteriorly and posteriorly by w ide longitud inal ligaments.
18 - Manual Therapy For The Thorax
Figure 1 6.
An terior view of t h e articu lat
ed t ho rax.
Figure 17.
An terola teral view of the
eighth thora cic vertebra .
Note the p l a n ar facet on the
transverse process fo r artic u
l a tion with the e ighth rib as
well as the l a rge sup e rior
dem i-fa c e t fo r articu l a t i o n
w i t h t h e h e a d of t h e eighth rib
and the small demi-facet for
a r t i culation with the head o f
the n in th rib .
The sternum (Figs. 7, 15) has eight full concave facets which artic
ulate with the costocartilages of ribs three to six. Superiorly, the
second rib articulates with the sternum at a demi-facet; inferiorly,
the seventh rib articulates with both the xiphoid and the sternum.
These joints are synovial unlike the lateral costochondral joints
which are fibrous, the periosteum and perichondrium continuous.
The costocartilage increases in length from the first to the seventh
ribs and then decreases to the tenth (Fig. 16). Thus the lower part
of the vertebrosternal region (ribs 6, 7) has greater flexibility ante
riorly than the upper part (ribs 3 , 4).
Manual Therapy For The Thorax - 19
Figure 18.
Postero l a ter a l view of the
art i cul a ted thorax, vertebro
chondral region . Note the
planar n a ture of the nin th
costotransverse joint (arrow).
Figure 19.
Pos terior view o f the articu
l a ted t h orax, thoracolu m b a r
regi o n . Occa s i o n a lly the
spinous processes a re bifid .
20 - Manual Therapy For The Thorax
Figure 20.
Lateral view of the twelfth
thoracic vertebra. Note the
change in directio n of the
facets on the superior and
inferior articular p rocesses.
There is one facet on the lat
eral aspect of the vertebral
body for articu lation with the
head of the twelfth rib. There
is no facet on the small trans
verse p rocess, there is no cos
totransverse join t .
Figure 21.
The eleventh and twelfth tho
racic and the first lumbar ver
tebrae. Note the orientation
of the zygapophyseal joints.
VERTEBROCHONDRAL REGION
The facet on the ventral aspect of the transverse process is flat and faces
anterolateral and superior (Fig. 18). Therefore, when the tubercle of the
rib glides superiorly, it also glides posteromedially with minimal con
junct rotation. When the tubercle of the rib glide s inferiorly, it also
glides anterolaterally following the plane of the costotransverse joint.
Manual Therapy For The Thorax - 21
Figure 22.
The transverse processes of
the twelfth thoraci c vertebrae
are small tubercles (arrow)
and cannot be used for pal
pating i ntervertebral mot ion.
T8 and T9 have four demifacets for articulation with the head of
the eighth and ninth ribs. T10 is variable. Often, there is only a
small articulation between the superior aspect of the head of the
tenth rib and the inferior aspect of the vertebral body of T9.
Occasionally, the tenth rib will articulate only with T10 at the base
of the pedicle via an unmodified ovoid joint.
Anteriorly the eighth, ninth and tenth ribs articulate indirectly with
the sternum via a series of cartilaginous bars which blend with the
seventh costocartilage (Fig. 16). There is a variable number of syn
ovial joints between the costocartilages (interchondral joints). This
arrangement permits greater flexibility.
THORACOLUMBAR JUNCTION
The spinous processes of Tll and T12 are short, stout and con
tained entirely within the lamina of their own vertebra (Figs. 8, 19,
20). The facets on the articular processes of Tll (Fig. 21) resem
ble those of both the vertebrosternal and vertebrochondral regions.
The facets on the inferior articular process of T12 resemble the
lumbar region. They have a coronal and sagittal component and
when articulated with Ll restrict axial rotation. The orientation of
Tll-12 does not restrict axial rotation.
Laterally, the transverse processes are small tubercles (Fig. 22), the
mamillary processes are larger and more superficial. The spinous
process is a more reliable point for palpating intervertebral motion
in this region.
22 - Manual Therapy For The Thorax
Figure 23.
Lateral view of the thoracic
spine. Note the unmodified
ovo id facet (arrow) for the
head of the twelfth rib.
The heads of the eleventh and twelfth ribs articulate o nly with the
vertebral body at the base of the pedicle via an unmodified ovoid
joint (Fig. 23). There is no costotransverse j oint in this region. The
ribs do not have a neck and do not twist significantly. They remain
detached from the rest of t he tho r ax a n terio rly (Fig. 16) and pro
vide attachment for the diaphragm and trunk musculature. The
shape of the costovertebral joint facil i tate s multi-directio nal move
ment of the vertebral b ody even when the large muscles contract
and fix the eleventh and twelfth ribs. The eleventh segment (Tll,
T12, eleventh rib) is the most flexible in the thorax.
Man u a l For The Thorax 23
BIOMECHANICS
LITERATURE REVIEW
DEFINITION OF TERMINOLOGY
Linear motions are named according to the axis along which the
bone translates. Mediolateral translation occurs along a coronal
axis, anteromedial!posterolateral translation along a paracoronal
Manual Therapy For The Thorax - 25
Figure 25.
Forward sagittal rotation
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 rota
tion around the X axis and
slight compression along the
Y axis. Redrawn from
Panjabi, Brand and White 7.
From: Panjabi et al 1976
From Lee5,6 with permission.
HABITUAL MOVEMENTS
The thorax i s capable of six degrees of motion along and about the
three cardinal axes of the body; however, no movement occurs in
isolation 7. In other words, all angular motion is coupled with a lin
ear motion and vice versa. The habitual movements of the thorax
include forward and backward bending, lateral bending and axial
rotation of the head and trunk. Elevation of the arm also requires
movement of the upper thorax . Simultaneously, the chest moves
during i nspiration and expi ration. The biomechanics of the thorax
varies according to the region cons idered. The common features
and the regional differences will be described.
Forward bending
Th e osteokinematic
motion o f the ribs
during forward
sagittal rotat i o n of
the thoracic verte
brae was not noted
in the study by
Panja b i et a17 .
C l i n i ca l l y, three
m ovement patterns
can o ccur and are
dependant upon the
rel ative flex ibil ity
between the verte
bral column and the
rib cage . In the very
Figure 26. yo ung (less than 1 2
Flexion of the thoracolu mbar y e a rs of age), the
spine in a 6 year o l d .
head of the rib does
not a rticulate with
the inferior aspect of
the superior ve rte
bra . The secondary
ossification centre
for the superi or
aspect of the head of
the rib does not
develop until puber
ty, therefore the
young chest is very
Figure 27.
mobile (Fig. 26) . In
Flexion of the thoracolumbar
spine in a 71 year old.
the ske letally
m ature, the superior
costovertebral j oi nts limit the quantity of vertebral rotation i n all
three planes. With increasing age, the costocartilages stiffen and
decrease the flex ibility of the rib cage (Fig. 27). This change in rel
ative flexibility between the vertebral column and the rib cage is
apparent when examining the specific costal osteokinematics dur
i ng forward and backward bending of the trunk.
Mobile thorax
Flexion
Figure 28.
The osteokinematic and
arthrokinematic motion pro
posed to occur in the mobile
thorax during forward bend
ing - vertebrosternal region.
From Lee5,6 with permission.
tion of the rib. The rib rotates about a paracoronal axis along the
l ine of the neck of the rib such that the anterior aspect travels infe
riorly while the posterior aspect travels superiorl y (Fig. 28). At
those l evels where the superior costovertebral j oint does not exist
(1, 11, 12) or i s very small (10), the anterior translation of the supe
rior vertebra cannot facilitate anterior rotation of the rib below.
Facet
Plane -i--+---:,r
Figure 29.
The osteokinematic and
arthrokinematic motion pro
posed to occur in the mobile
thorax during forward bend
ing - vertebroc hondral region.
Figure 30.
The oste okinemat ic and
arthrokinematic motion pro
posed to occu r in the mobile
thorax during forward bend
i n g - thoracolumbar region.
Manual Therapy For The Thorax - 29
Figure 31.
The osteokinematic and
arthrokinematic motion pro
posed to occur in the stiffer
thorax during forward bend
ing - vertebrostern al r egion
.
The first rib is always less mobile than T1 and the movement pat
tern in the vertebromanubrial region is described b elow (stiffer
thorax). In the thoracolumbar region (Fig. 30), the eleventh and
twelfth costovertebral joints are unmodified ovoid in shape and
flexion of the thoracic vertebra can be a pure spin.
Stiffer thorax
The ribs are less mobile than the vertebral column when the stiffer
thorax is flexed. During forward bending of the head and trunk, the
anterior aspect of the rib travels inferiorly while the posterior
aspect travels superiorly. Once the mobility of the rib cage is
30 - Manual Therapy For The Thorax
Figure 32.
The o s t e okinematic and
art hrokin e m a tic motio n pro
posed to occur in the verte
broma nubrial regio n during
forward ben d i n g.
Facet
Plane -+--i='7FII
Figure 33.
The o s t e ok i n e m a tic and
arthrokin e m a tic m o tion pro
posed to occur in the stiffer
thorax d u r i n g forward bend
ing - vertebrochondral region.
Rigid thorax
When the relative flexibil between the vertebral column and the
rib cage is the same, there is no palpable movement between the
thoracic vertebrae and the ribs. Some superior gliding occurs at the
zygapophyseal but very if any posteroanterior transla
tion occurs.
Limiting factors
Backward bending
vJ
I I
Figure 34.
Backw a r d sa gittal rotation
vi
around the X axis ind uced
posterior translation al ong the
Z axis and slight dis tract i o n
along the Y ax i s . Posterior
t ra n s l a t i o n a l o n g the Z axis ----
3------
in duced b a ckward sagittal
rotat i o n around the X axis
and slight compression along
the Y axis . Red rawn fro m
Panjabi, Bra nd a nd Wh ite 7.
From: Panjabi et al 1976
From Lee56 with permiss i o n .
Extension
Figure 35.
The o s t e o k i n ema tic and
arthro k i n e m a tic motion pro
posed to occur in the mob i l e
thorax duri n g b a ckw ard
bending -
v e r t e brostern al
regi o n . From Lee 5.6 with per
m i ss i o n.
Mobile thorax
Figure 36.
The osteokinematic and
arthrokinematic motion pro
posed to occur in the mobile
thorax during backward
bending - vertebrochondral
region.
Figure 37.
The osteokinematic and
arthrokinematic motion pro
posed to occur in the mobile
thorax during backward
bending thoracol umbar
region.
The first rib is always less mobile than Tl and the movement pat
tern is described below. In the thoracolumbar region, the eleventh
and twelfth costovertebral joints are unmodified ovoid in shape
and extension of the thoracic vertebra can be a pure spin (Fig. 37).
Stiffer thorax
The ribs are less mobile than the vertebral column when the stiffer
thorax is extended. Initially, the anterior aspect of the rib travels
superiorly and the posterior aspect travels inferiorly. Once the
mobility of the rib cage is exhausted, the thoracic vertebrae con-
34 - Manual Therapy For The Thorax
Figure 38.
The o s t e ok i n e m a t i c and
arthro kine m a t i c motion pro
posed to occur in the s tiffer
thorax duri n g backward
bending - vertebrostern a l
region .
Rigid thorax
When the relative flexib i l ity between the vertebral column and the
rib cage is the same, there is no palpable movement between the
thoracic vertebrae and the ribs. Some inferior gliding occurs at the
zygapophyseal j oints, but very l ittle anteroposterior translation
occurs.
L imiting factors
Figure 39.
The osteokinematic and
arthrokinematic m o t i o n pro
posed to occur i n the verte
brom a nubrial reg i o n d uring
bi l a te r a l e l ev a t i o n of the
arm s .
Figure 40.
The o s te o k i n e m a t i c and
arthroki n e m a t i c m o t i o n pro
posed to occur i n the s t i ffer
t h o ra x d u r i ng b a c k w a rd
be n d i n g - v ertebro c h o n d ral
reg i o n .
and the pos teri o r half of the i nterv ertebral disc and noted the c on
that the unit remained stable until the p o sterio r l o ngitu d i n al liga
ment was transected.
36 - Manual Th erapy For Th e Thorax
Figure 41 .
Right sideftexion around the
Z ax is ind uced left rotation
around the Y axis and right
translation along the X axis.
Right lateral translation along
the X axis induced right side
flexion around the Z ax is and
left rotat ion aro und the Y
axis. Redrawn from Panjabi,
B rand and W h i t e 7 From From : Panjabi et a l 1 976
As the head and trunk bends laterally to the right, a left convex
curve is produced . The thoracic vertebrae sideflex to the right, the
ribs on the right approximate and the ribs on the left separate at
their l ateral m argins (Fig. 42). In both the mobile thorax and the
Manual Therapy For The Thorax - 37
t Figure 42 .
As t he thorax s i d e fl exes to the
right, the ribs on the righ t
approximate and the ribs on
the l eft separate a t their later
al ma rgin s The costal motion
.
Figure 43 .
In the vertebrostern al region,
the superior glide of the right
rib at the costotran sverse j o i n t
i nduces anterior rotation of
the same rib d ue to the c u rv a
ture of the j o int surfaces. The
inferior glide of the left rib at
t he co s t o t r a n sverse j oint
induces posterior rotat ion of
the same r i b . From Lee5.6
with permiss ion.
stiffer thorax, the ribs appear to stop moving before the thoracic
vertebrae. The thoracic vertebrae then continue to sideflex to the
right. This motion can be palpated at the costotransverse j oint.
Figure 44.
In the vertebrosternal region,
anterior rota t ion of the right
rib and posterior rotation of
the left rib facil itates a con
tra l ateral rotation of the supe
---
Panj abi, Brand and White 7 found that right lateral translation along
the X axis (.5 1 mm) occurred during right sideflexion (Fig. 41) .
-
The effect of this right lateral translation is negated by the left lat
eral translation which occurs as the superior vertebra rotates to the
left. The net effect is minimal, if any, mediolateral translation of
the ribs along the l ine of the neck of the rib at the costotransverse
j o i nts. The clinical impress ion is that no anteromedial or postero
lateral sl ide of the ribs (relative to the transverse process to which
they attach) occurs during l ateral bend ing of the trunk.
In the vertebromanubrial region, the head of the first rib does not
articulate with C7 and the superoi nferior glide of the ribs and the
conj unct rotation which occurs cannot influence the di rection of
Manua l Therapy For The Thorax - 39
Figure 45.
The o s t e okin e m a tic and
arthrokin ematic motion pro
posed to occur in the verte
broma nubria l region during
l atera l bend ing of the head to
the righ t .
Figure 46.
R ight l a tera l bending of the
trunk w i t h the apex a t the left
grea ter troch a n ter.
40 - Manual Therapy For The Thorax
Figure 47.
Figure 48.
Right lateral bend ing of the
trunk w i t h the apex within the
thorax.
42 - Manual Therapy For The Thorax
Figure 49.
The o s t e o k i ne m a t i c and
arthrokinematic motion pro
posed to occur duri n g right
l ateral b e n d i n g of the thora
columbar regio n .
Rotation
Figure 50.
Panj ab i , Brand and W h ite7
fo u n d that right rotation
aro u n d the Y axis i n d uced left
s i deflexion around the Z axis
and left translation along the
X a x i s . From Le e5,6 with per
m is s i o n . Fro m : Panj abi et al 1 976
Rotation
Panj abi, Brand and White 7 found that rotation around the Y axis
was coupled with contralateral rotation around the Z axis and con
tralateral translation along the X axis (Fig. 50) . This is not consis
tent with clinical observation (Fig. 5 1) . In both the vertebro
manubrial and vertebrosternal regions, rotation around the Y axis
Manual Th erapy For Th e Thorax - 43
Figure 51 .
Cl i n i cally, t h e m i d thorax
appears to sideflex and rotate
to the same side during rota
tion of the trunk.
The costocarti lage of the left sixth rib was removed for cosmetic
reasons in the 1 7 year old youth illustrated i n Figures 52 and 5 3 .
H e presented four years later with pers istent pain in the m idthorax,
and on examination of axial rotation he could not produce ipsilat
eral rotation/sideftexion of the midthoracic region .
Clinical hypothesis
Figure 52.
The costocarti lage of the left
s i x t h rib was removed ( arrow
poin t s to the inc i s ion) i n t h is
seventeen year old.
Man u a l Therapy For The Thorax - - 45
Figure 53 .
Figure 54.
The osteokinematic and
arthrokinematic m o t i o n p r o
p o s e d to occur i n the verte
brosternal region during right
ro tation of the trunk. From
Lee5 . 6 with perm i s s i o n .
Figure 55.
The osteokinematic and
arthrokinematic motion pro
posed to occur in the verte
broch o n d r a l reg i o n d u r i ng
right ro t a t i o n of the tru n k .
Figure 56.
the limit of left l a teral
t ra n s l a t ion, s u perior
tebra sideflexes to the right
1111!!
111/ii!I!!!I!!!!!I!I!!i!!!,!I!!!I!lil !li!liii!!!iillll,;
a long the plane of the pseudo
' U ' j o i n t (analogous to the
unco v erteb r a l joint of
m i dee rv i c a l fo rmed
the i n tervertebral d isc and the
superior costoverteb ral j oi n t s .
. .
Lee56 permission .
Rlspiration
Figure 5 7.
The osteokinem a tic and
arthrokinematic motion pro
posed to occur i n the thora
columbar regio n d u r i n g right
rotation of the trunk.
During i nspiration, the diaphragm descends and pulls the central
tendon inferiorly through the fixed twelfth ribs and Ll to L3. When
the extensibility of the abdominal wall is reached, the central ten
don becomes stationary and further contraction of the diaphragm
results in posterior rotation of the lower six ribs . This posterior
rotation causes torsion of the cos tocartilage anteriorly. If the cos
tochondral and chondrosternal joints are stable, the torsional forces
are transmitted anteriorly to the sternum .
Figure 58.
D u r i n g elevation of the left
arm the v e r te b r o m a n ub r i a l
region should p r o d u ce a
localized concavi t y on the
side of the e lev a t i n g a r m .
50 - Manual Therapy For The Thorax
3
CONDITIONS
Visceral
Metabolic
Jnfection
Figure 59.
Ossification of the l o ngitudi
nal l iga m e n t s of t h e spine
occurs w i t h d i ffuse i d iopathic
skeletal hy perosto sis .
Neoplastic
Both benign and malignant tumours can occur in the skeletal components
of the thorax. Secondary metastases are common from the lung and breast
and a past history of carcinoma should alert the clinician to this possibility.
Spondylogenic
Figure 60.
The typ i ca l p o s t u re of a
patient with advanced osteo
porosi s .
Figure 61 .
This patient has a ma rked
thoracolumbar scol iosis sec
ondary to p o l i o m y e l i tis .
However, even the most compl iant patient a n d d i l igent therapist can
not prevent the progression of some scoliotic curves with exercise.
Current re search on the et iology o f idiopathic sco l iosis h a s revealed a
possible centra l process i ng or neural componen t 1 8, 1 9 . The reader is
referred to Kend a l l 1 7 for the ev aluation and treatment of muscle i mba l
ances of t h e trunk a n d l ower extre m ities a n d to t h e refe renced m ateri
ai fo r further information on the neural basis of idiopathic sco liosis.
Man u a l Therapy The Thorax
This classification does not provide a specific an atom ical nor phys
iological cause for the aberrant mob i lity noted, however, since
manual therapy techn iques are specific to restoring m ovement pat-
terns, cause is not for
The a i m evaluation procedures is
art i c u l ar, m y o fas c i a l , w h i ch e ffecting
Treatment can then be modified to e ither mob i l ize or stabilize the
appropriate system . If the biomechanics are restored and if the
underlying etiology i s biomechanical in nature, symptomatic and
obj ective im provement fol lows .
HEALING PROCESS
Substrate phase
Matm"ation phase
AS SES SMENT
PAIN/DYSAESTHESIA
S LE E P
Su rfacelPos i t io n : Status i n a . m . :
Night wakeni n g :
GENERAL INFORMATION
Occupation/sport/hobbies:
Mode o f onset
Pain/ dysaesthesia
Sleep
Occupation/leisure activities/sports
General i n fo rmati on
Postural
Articular
ctive/passive mobility tests osteokinematic
Forward
Backward bending
L a tera l bending
Rota tion
R espira tion
Muscle function
Nerve function
Adj unctive
Man u a l Therapy The Thorax
Postural Analysis
Forward ba ckward
Figure 62.
H a b i t u a l movem e n t testing -
forward bending of the h e a d .
Figure 63 .
H a b i t u a l movement tes ting -
forward b e n d i n g of the trunk.
Figure 64.
H a b i tual movemen t tes t i n g -
backward bending of the ver
tebro m anubrial region occurs
d u ring bila teral elevation of
the a r m s .
Figure 65.
Habitual movement testing -
b a c k w a rd bending of the
tru n k .
Figure 66.
Habitu a l move ment testing -
l ateral ben d i n g of the h e a d .
Figure 67.
H a b i t u a l movement testing -
Figure 68.
H a b i t u a l movement test i n g -
l a t e ra l bend ing of the tru n k .
No te the rigid i ty o f the 7 1
y ear old adu l t .
Figure 69.
H a b i t u a l movem e n t tes t i n g -
rotat i o n of the tru n k should
produce a smoo t h S cu rve.
c u r v e r e q u i re s fu r t h e r s p e c i fi c m o b i l i t y t e s t i n g
to determine the cause.
Figure 70.
H a b i t u a l movement t e s t i n g -
rotation of t h e tru n k . Note the
flexib i l i t y of the 6 year old
child.
Figure 71 .
H a b i t u a l movement testing -
rotation of the tru n k . Note the
rigid i t y of the 71 y e a r old
adult.
Figure 72.
Hab i t u a l movement testing -
respi ra t i o n .
Figure 73.
H a b i t u a l movement tes t i ng -
respi r a t i o n .
Combined movement
1 . forward bend the h ead/trun k and then right l ateral bend the
head/trun k .
4. backward bend the head/trun k and then left l ateral bend the
head/trunk.
7 . left lateral bend the head/tru nk and then b ackward bend the
he ad/trunk.
Articular functi on
Figure 74.
Active m ob i l i t y t e s ts of
o s t e o ki n e m a t i c fu n c t i o n -
points of p a l p a t ion for T l -2.
Figure 75.
Ac t i v e mob i l i t y tests of
o steoki n em a t i c fu nct i o n - pal
p a t i o n for flexion of T l - 2 .
70 - Manual Therapy For The Thorax
Figure 76.
Act i v e mobility t e s ts of
o s t e o k i nem a t i c fun c t i o n -
po ints of p a l p a t i o n for TS -6.
Forward bending (Figs. 74, 75, 76, 77, 78, 79) . The fol lowing test
is used to determ ine the osteoki nem atic function of two adj acent
thoracic vertebrae during forward bending of the head/trunk. The
transverse processes of two adj acent vertebrae are palpated with
the index finger and thumb of both hands . The patient is i nstructed
to forward bend the head/trunk and the quantity of motion as well
as the sym metry of motion i s noted during flexion of the thoracic
segment. Both index fingers should travel superiorly an equal dis
tance . When interpreting the mobility findings , the position of the
joint at the beginning of the test should be correlated w ith the sub
sequent mobility noted, since alterations in j oint mob ility m ay
merely be a reflection of an a ltered starting pos ition. To determ ine
the position of the superior vertebra, the dorsoventral relationship
of the transverse processes to the coronal body plane is noted and
compared with the level above and below. If the left transverse
process of the superior vertebra is more dorsal than the left trans
verse process of the inferior vertebra then the segment is left rotat-
Manual Therapy For Th e Thorax - 7 1
Figure 77.
Active mob i l i ty tests of
osteokinematic function - pal
pation for flexion o f TS - 6 .
ed. If the left transverse process of the superior vertebra is less dor
sal than the left transverse process of the inferior vertebra but more
dorsal than the right transverse process of the superior vertebra,
then the superior vertebra is relatively right rotated compared to
the level below but left rotated when compared to the coronal body
plane . Thi s is a typical compensatory pattern seen when a superior
segment is derotating or unwinding a primary rotation at a lower
level.
Figure 78.
Act i v e mobi lity tests of
o s t eo k i n e m a t i c fu n c t i o n -
points of pal pation for T9 - 1 0 .
Figure 79.
Active m o b i l i ty tests of
osteoki n e m a t i c fu nction - pal
pation for flexion of T9- 1 0 .
Manual Therapy For The Thorax - 73
Figure 80.
Active m o b i l i ty tests of
osteoki n e m a t i c fu n c t i o n
points of palpation for T l -
first rib .
Figure 81 .
Active m o b i l i t y tests of
osteokinematic fu nction - pal
pation for flexion of the first
costotransverse j o i n t .
ward bending of the head/trunk (Figs . 80, 8 1 , 82, 83). The trans
verse process is palpated with the thumb of one hand. The rib is
palpated j ust lateral to the tubercle and m ed ial to the angle with the
thumb of the other hand. The index finger of this hand rests along
the shaft o f the rib . The patient i s instructed to forward bend the
head/trunk and the relative motion between the transverse process
and the rib is noted.
In the mobile thorax, the rib should anteriorly rotate and the tuber-
74 - Manua l Therapy For The Thorax
Figure 82 .
Active m ob i l i ty tests of
oste o k i n e m a t i c fu n c t i o n -
points of palpatio n fo r T9 -
ninth rib.
Figure 83 .
Active mobility tests of
osteo k i n e m a t i c fu nction - p a l
pation for fl e x ion of t h e n i n t h
costotransverse j oi n t .
cle of the rib travel fu rther su p eriorly than the transverse process.
In the stiffer thorax, the rib should anteriorly rotate and the tuber
cle of the rib stop before ful l thoracic flexion is achieved such that
the transverse process travels further superiorly than the rib When
the relative mobility between the thoracic vertebra and the rib is
the same, no motion is p al pated between the vertebra and the r ib
during forward bending. To determine the patient's normal move
ment pattern it is cr i tical to evaluate levels above, below and con
tralateral to t h e tested segment.
Manu a l Therapy For The Thorax - 75
Figure 84.
Active m ob i l i t y tests of
osteokinem a t i c function - pal
pation for exte n s i o n o f T9- 1 O .
Figure 85.
Active m ob i l i t y tests of
osteo k i n e m a t i c fu nction - p a l
p a t i o n fo r extension o f T l -2 .
Figure 86.
Active mob i l i t y tests of
osteo k i nematic function - p a l
p a t i o n for extension of t h e
n i n t h costotransverse j o i n t .
Figure 8 7.
Active mob i l ity tests of
osteo k i nematic fu nction - pal
pation for e x t e n s i o n of the
first costotra nsverse j o i n t .
In the mobile th orax , the rib should posteri orly rotate and the
tubercle of the rib travel fu rther i nferiorly than the transverse
proces s . I n the stiffer thorax, the rib should posteriorly rotate and
the tubercle of the rib stop before fu ll thoracic exte n s i o n is
achieved such that the transverse process travels further inferi orly
than the rib . When the relative mobil ity between the thoracic ver
tebra and the rib i s the same, no motion is palpated between the
vertebra and the rib during backward bending. To dete r m i n e the
patient 's normal movement pattern i t i s critical to evaluate lev e l s
a b o v e , b e l o w a n d contralateral to t h e tested segm ent. I n the upper
thorax, the stiff pattern is normal both i n the m o b i l e and stiff tho
rax.
Figure 88.
A c t ive m ob i l i t y tests of
osteo k i n e m a t i c function - p a l
p a t i o n fo r r i g h t l a teral be nd
i n g of Tl-2.
Figure 89.
Active m ob i l i t y tests of
osteo k i n e m a t i c function - p a l
pation for r i g h t l a teral b e n d
ing of t h e fi f t h costotrans
verse j o i n t .
Figure 90.
Active mob i l i ty tests of
osteokinema tic fu nction - pal
pation for right rotation of
T5 -6.
Figure 91 .
Active mobility tests of
osteokinematic fu nction - pal
pation for right rotation of the
fift h costotransverse j oint.
concavity moves dorsally and inferiorly (Fig. 9 0) Below T7, the
.
Figure 92.
Active m ob i l i t y tests of
osteoki nematic fu nct i o n - p a l
pat i o n for respira tion o f the
n in th costotransverse j o i n t .
Figure 93 .
Passive m ob i l i t y tests of
arthroki n e m a t i c function -
points of palpation for superi
or glide of the right T4-5
zygapophyseal j o i n t .
Figure 94.
Passive m ob i l i t y tests o f
arthro k i n e m a t i c fu nction -
superior glide of the right T4-
5 zygapophyseaJ j oint .
Figure 95.
Passive mobility tests of
arthrokinematic fu n c t i o n -
p o i n t s of palpation fo r infe r i
or glide of the right T4-5
zygapophysea\ j o i n t .
Figure 96.
Pass i v e m ob i l i t y t es ts of
a r t h ro k i n e m a t i c funct i o n -
i nferior g l i d e of t h e r i g h t T4-
5 zygapophyseal j o i n t .
Figure 97.
Passive m ob i l i ty tests of
a r t h r ok i ne m a t i c fu n c t i o n -
poin t s of palpation for i n feri
or glide of the right fifth cos
totra nsverse j o i n t .
Figure 98.
Passive m o b i l i ty tests of
arthro k i n e m a t i c fu n c t i o n -
i nferior gl ide of the right fifth
costotransverse j o i n t .
patient prone and the thoracic spine in neutral , the inferior aspect
of the transverse process of T5 is palpated with the left thumb . The
right thumb palpates the superior aspect of the right transverse
process of T4. The left thumb fixes T5 and an inferior glide is
appl ied to T4 with the right thumb . The quantity and end feel of
motion i s noted and compared to the levels above and bel ow. This
technique can be used for all thoracic segments.
fifth rib at the costotransverse joint (Figs. 97, 98). This test is used
Manual Therapy For The Thorax - 83
Figure 99.
Passive mobility tests of
arthrok inematic fu n c t i o n -
The d i rection of the cos to
t r a n s verse joint glide is
a n t er o l a t e r o i nfe r i o r at the
l evel o f t he n i n t h rib ( a rrow ) .
Figure 1 00 .
Passive mobility t e s ts of
a r t h r o k i ne m a t i c fu n c t i o n -
i n fe r i o r glide of the right
n i n t h costo t r a n sverse j o i n t .
to determ ine the ab i l ity of the right fifth rib to glide inferiorly rel
ative to the transverse process of T5 . With the patient prone and the
thoracic spine in neutral, the inferior aspect of the right transverse
process of T5 is palpated with the left thumb. The right thumb pal
pates the superior aspect of the right fifth rib j ust lateral to the
tubercle . The left thumb fi xes T5 and an i nferior glide (allowing
the conj unct posterior roll to occur) is appl ied to the fifth rib with
the right thum b . The quantity and end feel of motion is noted and
compared to the levels above and below.
84 - Manual Therapy For The Thorax
Figure 1 01 .
Passive mobil ity tests of
a r t h ro k i n e m a t i c function -
p o i nts of p a J p a t i o n (b lack box
and wh i t e arrow ) for i n ferior
glIde of the right first costo
transverse j o i n t .
Figure 1 02.
Passive m o b i l i ty tests of
a r t h ro k i n e m a t i c fu n c t i o n -
inferior glide of the right first
costo t r a n sverse j o i n t .
Manual Therapy For The Thorax - 85
Figure 103 .
Passive mob i l ity tests of
art hrok i n e m a t i c function -
points of palpation for superi
or gl ide of the right fifth cos
totransverse joint.
Figure 104.
Passive mob i l i t y te sts of
a r t h r o k i ne m a t i c fu n c tion -
superior g l ide of the right
fi fth cos totransverse joint.
Cos totrans verse join ts - Eg. To test the inferior glide of the right
first rib a t the costotransverse join t (Figs. 1 01, 1 02). This test i s
86 - Manual Therapy For The Thorax
Figure 1 05 .
Passive mo b i l i ty tests of
a r t h ro ki n e m a t i c fu n c t i o n -
The d i rection of the costo
transverse j o i n t g l i d e is pos
teromed iosuperior at the level
of the n int h rib and is
ach ieved b y gli d i n g the trans
verse process of T9 a ntero
l atero i n ferior (a rrow) .
used to determine the ability of the right first rib to g l ide inferior
ly relative to the transverse process of T l . The patient lies supine
with the head and neck comfortably supported on a pillow. Wi th
the lateral aspect of the MCP of the index finger of the left hand,
the superior aspect of the left transverse process of T l is palpated
and fixed. With the lateral aspect of the MCP of the index finger of
the right hand, the superior aspect of the right first rib is palpated
j ust lateral to the costotransverse j o i nt. The left hand fixes Tl and
an inferoanterior glide (allowing the conj unct posterior rotation to
occur) is applied. The quantity and end feel of motion is noted and
compared to the opposite side.
Cos totrans verse joints - Eg. To test the superior glide of the right
fifth rib a t the costotransverse join t (Figs. 1 03, 1 04) . This test is
used to determ ine the ab il ity of the right fifth rib to glide superior
ly relative to the transverse process of T5 . With the patient prone
and the thoracic spine i n neutral , the superior aspect of the trans
verse process of T5 is palpated with the right thumb . The left
thumb palpates the inferior aspect of the right fifth rib j ust lateral
to the tubercle. The right thumb fixes T5 and a superior glide
(allowing the conj unct anterior rol l to occur) is applied to the fifth
rib with the left thumb . The quantity and end feel of motion is
noted and compared to the levels above and below.
Figure 1 06.
Passive mob i l i t y tests of
a r t h ro k i n e m a t i c fu nc t i o n -
of the rib. The right hand fixes the rib and the transverse process is
glided anterolateroi nferior thus producing a relative posteromedio
superior gl ide of the rib at the costotransverse joint (Figs. 1 0 5 ,
1 06) .
Figure 1 0 7.
Passive m o b i l i t y tests of
arthrok i n e m a t i c function -
points of palpation (two white
arrows) for superior glide of
the right first costotransverse
j oi n t .
Figure 1 08.
Passive mobility tests of
arthrok i n e m a t i c fu n c t i o n -
superior glide of the right first
costotransverse j o i n t .
right hand/arm translate the T5 vertebra and the ribs PURELY to
the right in the transverse plane. The quantity and i n particular the
endfeel of motion is noted and compared to the levels above and
below.
Figure 1 09.
P a s s i ve mobility tests of
arthrokinematic fu n c t i o n -
Figure 1 1 0 .
Passive mo b i l i t y t e s t s of
arth roki n e m a t i c fu n c t i o n -
Figure 1 1 1 .
Passive s t a b i l i ty tests of
a rt h rokinetic function - trac
tion of the m iddle and lower
thorax.
Figure 112.
Passive stab i l i t y tests of
art hrokinetic fu nction - com
pres s i o n of the m iddle and
lower thorax.
Manu a l Therapy For The Thorax - 91
Figure 1 1 3 .
Passive stability tests of
arthro k inetic fu nction - po i n ts
of p a l p a t i on fo r anterior
translation (spinal).
Figure 1 1 4.
Passive s t ab i l i t y te s t s of
arthrokinetic fu nction - a n te
rior t ransl a t i o n (spinal).
Compression i s applied t o the m iddle and l ower thorax b y app l y
ing a vertical fo rce throu gh t h e top of t h e patient 's shou lders (Fig.
I n) . Com pres s i o n is applied to the upper tho rax b y appl y i n g a
vertical force through the cran i u m .
Posterior tra nsla tion spina l. Th i s test stresses the anatom ical
structures resist posterior translation of segmental spinal
unit. A positive response i s t h e reproduction of patient 's syrnp-
toms together an i n crease the quanti motion and
decrease i n the resistance at the end of the range of motion . The
patient is s i tting with the arms crossed to opposite shoulders . The
thorax is stab i lized with one hand/arm u nder/over (depending on
the level) crossed and the contralateral s capul a
grasped. transverse o f the vertebra
fixed w i t h the dorsal hand. Static stab i l ity i s tested b y applying an
anteroposterior force to the superior vertebra through the thorax
w h i l e fixing the i nferior vertebra (Figs. 1 1 5 , 1 1 6) . The quantity of
motion, the reproduction of symptom s and the endfeel of
motion is and compared levels above and below.
t1ndings from test should correl ated with of the ante-
rior translation test to determine the level of the instab i l i ty.
Transverse rota tion - spina l. Thi s test stresses the anato m i cal
structures w h i ch resist rotation of a segmental spinal unit. A posi-
tive response reproduction the patient's sym ptom s togeth-
with an i n the of motion decrease in
resistance end of the motion. Wi th patient
l y i ng , the transverse process of the superior vertebra i s palpated.
With the other hand, the contral ateral transverse process of the
inferior vertebra is fixed. A transverse plane rotation force is
appl i ed by apply i ng u n i l ateral
leroanterior while the inferior (Figs .
1 1 8) . The quantity of motion, reproduction
Man u a l Therapy For The Thorax - 93
Figure 1 15.
Passive stability tests of
arthrokinetic fu nction - po ints
of palpation fo r posterior
transla t i o n (sp i n a l ) .
Figure 1 1 6.
Passive stab ility tests of
arthrokinetic function - poste
rior transla t i o n (spi n a l ) .
Figure 11 7.
Passive stab ility tests of
arthrokinetic fu nction - p o i n t s
of p a l p a t i o n f o r l e f t ro tation
(sp i n a l ) .
Figure 1 1 8.
Passive stability tests of
arthro kinetic fu nction - left
rota tion (spinal).
Figure 1 19.
Passive s t ab i l i t y tests of
arthrokine tic function - p o i n t s
of palpation fo r anterior
translation (posterior cost a l ) .
Figure 120.
Passive stab i l i t y tests of
arthroki n e t i c fu nction - ante
rior translation (posterior
costa l ) .
96 - Manual Therapy For The Thorax
Figure 121 .
Passive s t a b i l i ty tests of
arthrok i n e t i c fu nction - points
of palpation for i n ferior trans
l a t i o n (pos terior cos t a l ) .
Figure 1 2 2 .
Passive s t ab i l i t y tests of
arthro k i n e t i c fu nct i o n - inferi
or tra n s l a t i o n (pos t e r i o r
costal).
Figure 123.
Passive stability tests of
a r t h ro k i n e t i c fu n c t i o n
anteroposterior transl ation
(anterior sternocost a l ) .
Figure 124.
Passive s t ab i l i t y tests of
a r t h ro k i n e t i c fu n c t i o n
a nteroposterior translation
(anterior costochondral).
vertebrae when the ribs between them are fixed . This test is used
between the segments T3-4 and T I O- I 1 . The primary structu re
being tested is the intervertebral disc. When the ribs are fixed
b i laterally there should be very little, if any, mediolateral trans
lation between two thoracic vertebrae. A positive response is an
i ncrease in the quantity of motion and a decrease in the resis
tance at the end of the range . To test the TS - 6 segment, the
patient is sitting with the arms crossed to opposite shoulders .
With the right hand/arm, the thorax i s palpated such that the
Manual Therapy For The Thorax - 99
Figure 125.
Passive s t ab i l i t y tests of
arthrok inetic fu nction - supe
rior translation (anterior ster
nocost a l ) .
Figure 126.
Passive s t ab i l i t y tests of
arthrokinetic function - i n fe r i
or transl a t i o n (anterior ster
nocostal ) .
fifth finger of the right hand l i es along the fifth rib . With the left
hand, T6 and the s i xth ribs are fixed b i l aterally by compressing
the ribs centra lly tow ards the i r costovertebral j oints (Fig. 1 27) .
The T5 vertebra is trans lated through the thorax PURELY i n the
transverse plane . The quantity of motion, the reproduction of
any symptoms and the endfeel of motion is noted and compared
to the levels above and below.
1 00 - Man u a l Therapy For The Thorax
Figure 1 2 7.
Passive s t ab i l i t y tests of
arthrokinetic function TS - 6
-
Figure 128.
When the d iaphragm is
h y p e rt o n i c , overa c l l v l l y of
the m i d t horacic spinal exten
sors can produce a loc a l ized
lordosis .
Nerve function
Figure 129.
The slump test.
Figure 130.
Modifica t i o n of the slump test
for the detect i o n of segme n t al
neura l dysfu n c t i o n with i n the
thorax.
5
CLINICAL SYNDROMES
Magnetic i m aging
frequency di agnosis of disc Thoraci c
discs are no l onger thought to be an uncomm o n cause of thoracic
pai n . I n a study by Brown et a1 24 the most common symptom i n
patients with confirmed thoracic disc herniations w a s anterior
chest pain Other included lower extrern ity
dysaesthesia (8%) and
gastric pain
The sympathetic chain can also refe r symptoms into the upper or
lower extre m i ty. These patients commonly report temperature
changes, heavy sensations associated with fatigue and nonspecific
n u mbness i nvolved The upper thorax can
refer p a i n cranium the sympathetic pathway.
The thorax will be divided into the anatom ical regions for further
discussion. The obj ective mobil i ty/stabi lity findings, the relevant
treatment and a exercise w il l described.
Manual Therapy For The Thorax - 1 07
Vertebromanubrial region
Figure 131 .
Vertebrom a n ub r i a l region -
b i l a te r a l flex i o n res t r i c t i o n .
Longitu d i n a l tract i o n .
1 08 - Manual Therapy For The Thorax
Figure 132.
Vertebro m a n u bri al region -
b i l atera l fl e x i o n restrictio n .
Long i t u d i n a l tractio n .
a s c e r t a i n e d . G r a d e s 1 to 4 l o n g i t u d i n a l t r a c t i o n i s a p p l i e d
b y fi x i n g t h e c a u d a l v e r t e b r a a n d p u l l i n g t h e c r a n i a l v e r t e
bra superiorly.
Stronger distraction techniques are done with the patient either sit
ting or standing with both hands behind the neck, fingers i nterl aced
(Fig. 1 32) . The therapist winds both of their arms beneath the
p atient's ax i l lae through the tri angu l a r space created by the flexed
elbows. The fi ngers are interl aced and p l aced over the p at i e n t ' s
hands. T h e thorax is gently gripped by adducting t h e arm s . The
patient i s i n structed to look forward and the therapist ensures that
the l i gamentum nuchae is not o n fu l l stretch . From this position, a
Grade 3 to 5 longitudinal traction techn ique is applied by rocking
the patient b ackwards and forwards until a pendul ar type m o t i o n is
produced . Gravity provides the distractive fo rce . A h igh v e l ocity,
low ampl itude thrust techn ique (Grade 5) is app l i ed at the apex of
the descent when the patient 's body weight is droppi n g .
Figure 133.
Vertebro m a n ubrial region -
b i l a teral flexion res t r i c t i o n .
Home exercise.
quently (up to ten t i m e s , ten times per day). Wi th the fingers inter
l aced behind the neck and the i ndex fingers i n the appropriate i n ter
spi nous space, the patient is in structed to fl ex the he ad/neck. The
fin gers m a y assist the motion by app l y i n g a superior pressure to the
inferi or aspect of the spinous process of the superior verteb ra. The
ampli tude of the exercise should be i n the pai nfree range and
should not aggrav ate any sympto m s .
Figure 134.
Vertebromanubrial region -
unilateral flexion restriction
of the right zygapophysea l
joint at T l -2. Mobilization
technique.
The right transverse process of Tl w i ll be more dorsal than the left.
Left rotation and left lateral bending of the head/neck will be
restricted in a consistent pattern in both the H and I combined
movement tests . Unilateral elevation of the left arm w i l l produce
right sideflexion and left rotation of T l -2. The superior arthrokine
m atic glide of the right zygapophyseaJ j o int at T l -2 will be restrict
ed if the dysfunction is intra-articular.
To
Home exercise for a restriction offlexion on the right a t Tl -2.
m ob i l i ty the patient i nstructed to left
frequently to ten
Unilateral elevation of arm may
lems with repetitive rotation through the craniovertebral and mid
cervical regions. The amplitude of the exercise should be in the
painfree range and should not aggravate any symptoms.
B ilatera l restriction of
Figure 1 35.
Vertebro m a n ub r i a l region -
b i l a t e r a l extension res trict i o n .
Mobi l iz a t i o n tech n i q u e .
irritabil ity of the surrounding tissue. The grade of the mobil ization
technique is directed by these factors (Chapter 3).
Figure 136.
Vertebro m a n ubrial region -
u n i l a teral extension restric
tion of t h e right zygapoph y
seal joint at T l -2.
Mobi l i z a t i o n t e c h n i qu e .
An act i v e m o b i l i z at i o n a s s i s t ( m u s c l e e n e r g y t e c h n i q u e )
m a y b e u s e d to effe c t a ch ange i n t h e m u s c l e t o n e s e g m e n
t a l l y W h e n t h e m o t i o n b ar r i e r h a s b e e n l o ca l i z e d , t h e
.
p a t i e n t i s i n s t r u c t e d t o r e s i s t fu r t h e r m o t i o n w h i l e t h e t h e r
a p i s t app l i e s a g e n t l e s i d e fl e x i o n fo rce t o t h e h e a d/n e c k .
T h e i s o m e t r i c c o n tract i o n i s h e l d fo r u p to fi v e s e c o n d s fo l
l o w e d b y a p e r i o d o f c o m p l e t e re l ax a t i o n . T h e j o i n t i s t h e n
p a s s i v e l y t a k e n to th e n ew m o t i o n b a r r i e r, t h e t e c h n i q u e i s
r e p e a t e d t h r e e t i m e s a n d fo l l o w e d b y r e - e v a l u a t i o n o f
o s teo k i n e m a t i c fu n ct i o n .
The Thorax
Figure 1 3 7.
Vertebromanub rial region -
un i l ateral anterior rotation
restriction of the right first
costotransverse j o in t .
Figure 138.
Vertebromanubrial region -
un il a t e r a l an t e r i or rotation
res triction of the r i g h t first
cos totransverse j o int. Active
mobil ization assis t .
Figure 139.
Vertebromanubrial region -
un i l a teral anterior rot a t i on
restriction of t h e right fi rst
costotransverse j o in t . Home
exercise.
m e d i u s m u s c l e s . T h e h e ad/n e c k i s s i d e fl e x e d t o t h e r i g h t
a n d s l i g h t l y fl e x e d w i t h t h e l e ft h a n d w h i l e t h e r i g h t h a n d
m o n i t o r s t h e r e s p o n s e i n t h e s c a l e n e m u s cu l a t u r e ( Fi g .
1 3 8 ) . T h e p a t i e n t i s i n s t r u c t e d t o r e s i s t a g e n t l e s i d e fl e x i o n
fo rce t o t h e h e a d/neck a pp l i e d w i t h t h e l e ft h a n d . T h e i s o
m e t r i c c o n t r a ct i o n i s h e l d fo r u p t o fi v e s e c o n d s fo l l o w e d
b y a period of complete relaxation . The j o i nt i s then pas
s i v e l y t a k e n t o t h e n e w m o t i o n b ar r i e r , t h e t e ch n i q u e i s
Manual Therapy For The Thorax - 117
Figure 140.
Vertebro m a nubri al r eg i o n -
u n i l ateral p o s teri o r ro t a t i o n
rest riction o f t h e right first
cos t o t r a n s v e rs e j oint.
M o b i l iza t i o n technique.
Figure 141 .
Vertebro manubrial region -
Figure 142.
Vertebroste rnal a n d vertebro
chondral reg i o n bila teral
fl e x i o n restriction - longit u d i
n a l traction - p o i n ts o f palpa
tion for the mob i l iz a t i o n tech
n i que.
T h e p r e s e n c e or a b s e n c e of p a i n d e p e n d s u p o n t h e s t a g e o f
the pathology (substrate, fibrob l astic, maturation) and the
i r r i t a b i l i t y o f t h e s u r r o u n d i n g t i s s u e . T h e g r a d e o f t h e mob i -
120 - Manual Therapy For The Thorax
Figure 143.
Vertebrosternal and vertebro
chondral region - b ilateral
flexion restriction - specific
longi tudinal trac t i o n .
Mob i l i z a t i o n techniq u e .
The supine technique is performed as fol lows (Figs . 1 42, 1 43). The
patient is sidelying, the head supported o n a pillow and the arms
crossed to the opposite shoulders . With the tubercle of the scaphoid
bone and the flexed PIP j oint of the long finger, the transverse
processes of the inferior vertebra are palpated. The other hand/arm
lies across the patient's crossed arms to contro l the thorax.
Segmental localization is achieved by flexing the j oint to the
motion barrier with the hand/arm contro l l i ng the thorax. This
local ization is maintained as the patient is rolled supi ne only until
contact is made between the table and the dorsal hand. From this
position, longitudinal traction is applied through the thorax to pro
duce a superior glide of the zygapophyseal joint bilateral ly. This is
an arthrokinematic mobil ization. By restoring the accessory glide,
the osteokinematic motion will be restored. The technique can be
graded from 1 to 5 .
Figure 1 44.
Vertebrosternal and vertebro
chondral region - b i l ateral
flexion restriction - general
longi t u d i n a l tract i o n .
Mob i l ization teCh n ique.
Figure 1 45 .
Figure 146.
Vertebrosternal and vertebro
chond ral region - u n i l ateral
flex i o n/ex t e n s i o n res triction
of the l eft zygapophyseal
j oi n t a t TS -6. Po ints of palpa
tion for the mob i l ization tech
n i qu e .
Figure 1 4 7.
Vertebros tern a l and vertebro
chondral region - u n i l a teral
flexion restriction of the left
zyga p ophyseal joint at TS-6.
Mob i l i z a t i o n tec h n i q u e .
Figure 1 48.
Vertebrosternal a n d vertebro
chondral re gion - un i la teral
flexion restriction of the left
zygapophyseal j o i n t at TS -6.
Active mobil ization assist.
Figure 1 49.
Vertebrosternal and ve rtebro
chondral region - u n i l ateral
flexion restriction of the left
zygapophyseal j o i n t at TS - 6 .
Home exercise.
Figure 150.
Vertebrostern a l and vertebro
chondral region - u n ilateral
extension res trict i o n of the
left z y gapophyseal j o i n t at
TS-6. M ob i l i za t i o n tech
n i que.
Figure 1 5 1 .
Vertebrostern a l a n d vertebro
chondral region - u n il a t e r a l
extension re s t r i c t i o n of the
l eft zygapo p h y s e a l j o i n t at
T5 - 6 . Act i v e mobil ization
assist.
Figure 152.
Vertebrosternal a n d vertebro
chondral region - u n i l a teral
exte n s i o n restrict i o n of the
l eft zyga p o p h y seal j o i n t at
T5 -6. H o m e exercise.
Figure 153.
Left rotation of the m i d thorax
i s fa irly free even i n the pres
ence of a m a rked scoliosis
secondary to po l i omye l i t i s .
Figure 154.
Right rot a t i o n of t h e m id tho
rax is b l ocked due to the
i n abi l ity o f the r i g h t sixth r i b
to posteriorly ro t a t e .
Figure 155.
Vertebrosternal a n d vertebro
chondral regi o n - u n i l a teral
restriction of pos t e r i o r rota
tion of the ri ght fi ft h rib.
Ac t i v e mob i l i zation tech
nique.
Figure 156.
Vertebrosternal and vertebro
chondral region - u n i l ateral
restri c t i o n of a nt e r i o r rota t i o n
of t h e right fi f t h rib. Active
m o b i l ization tec h n i q u e .
Figure 1 5 7.
Vertebrosternal and vertebro
chondral region - unilateral
restriction of anterior rotation
of the right fifth rib. Home
exercise .
results in reciprocal i nhibition of the antago nistic hypertonic mus
cle .
Thoracolumbar j unction
Figure 158.
T h o raco l u m b a r junction -
u n i lateral restriction of flex
ion of the right zygapop hy
seal joint at T 1 1 - 1 2.
Mob i l ization techn ique.
Figure 1 59.
T '1 o r a co l u mb a r j unction -
u n i l atera l res t r i ct i o n of flex
i o n of the right zygap ophy
s e a l j o i n t a t T l 1 - 1 2. Home
exerc i s e .
Figure 1 60.
Th orac o l u m b a r j un c t i o n -
u n i l a teral restriction of e x t e n
s ion of t h e r i g h t zygapo p h y
seal j o i n t a t T l l - 1 2 w i l l co m
pletely bl ock t h e form a t i o n o f
t h e S c u rv e d u r i n g rotation of
t h e tru n k .
Figure 1 61 .
Thoraco l u m b a r j u nction -
u n i l a te r a l rest riction of e x t e n
s i o n of t h e r i g h t zygapophy
seal joint at Tl l- 12.
Mob i l i z a t i o n tech niqu e .
Figure 1 62 .
Thoraco l u m b a r j u n c t i o n -
u n i lateral restriction of exten- .
sion of the right zygapophy
seal j oint a t T l 1 - 1 2 . Home
exercise.
Manual Therapy For The Thorax - 135
p a i n fr e e r a n g e a n d s h o u l d n o t a g g r a v a t e a n y s y m p t o m s .
Figu re 1 64.
Vertebrosternal and vertebro
chondral region - u n ilateral
subluxation of the right fifth
rib a t the costotransverse
joint. Po i n t of palpation for
fixation of t h e rib.
Figure 1 65.
Vertebrosternal and vertebro
chon dral region - u n i l a teral
subluxation of the right fi fth
rib at the costotransverse
j oi n t . S u p i n e m o b i l i z a t i o n
tech nique.
rest, education regarding lim iting t h e use of the shoulder (to avoid
further separation of the j oint with contraction of the serratus ante
rior and/or pectoralis maj or/m inor muscles), local electrotherapeu
tic modalities for pain relief and control of infl ammation and tap
ing to limit motion of the thorax .
138 - Manual Therapy For The Thorax
Figure 1 66.
Vertebrosternal and vertebro
chondral region - u n i l ateral
subl uxation of the r i ght fifth
rib at the c o s t o t r a n sv e rse
joint. Prone m ob i l i z a t i o n
techn i q u e .
Thoracolumbar junction
When acute, the patient presents with a lateral shift of the trunk
localized to the thoracolumbar j unction. All active movements are
blocked at the thoracolumbar j unction. Any attempt to correct the
lateral shift meets with resistance and an increase in the patient 's
pai n . The lumbar myofascia is hypertonic on the side of the later
al sh ift. The subluxed costovertebral joint is extremely tender to
local palpation of the soft tissue overly ing the joint. Specific
mob ility testing reveals a reduction in the arthrokinematic gl ide of
the zygapophyseal j o ints between Tl 1 - 1 2 or T1 2-Ll and a com-
Figure 1 6 7.
T h o r a co l u m b a r j unction -
u n i l a teral subl u x a t i o n of the
right twe l fth rib at the cos
t o v e r te b r a l joint.
Mob i l ization technique.
1 40 - Manual Therapy For Thorax
plete block of any glide b etween the suhluxed rib and its associat
ed vertebra, The treatment technique to red uce a subluxed cosIo
transverse j o int is a grade 5 distracti o n technique.
Thi s subluxation i nvolves the entire ' ring' which i ncludes two
adj acen t thoracic vertebrae , the i n tervertebral d i sc , the two ribs and
their associated anterior and posterior j o ints and the sternum . Th is
subluxation occurs primaril y the vertebrosternal region
occasionaHy i n the vertebrochondral region. It can occur when
excessive rotation i s appl ied to the unrestrained thorax or when
rotation of the thorax i s forced against a fixed rib cage (seat helt
i nj u ry). the l im i t right rotati o n in m i dthorax the
vertebra has transl ated to the left, the left rib has translated pos
tero laterally and the right rib has transl ated anteromedially such
that a functional U j o i n t is produced (Chapter 2) . Further right rota
tion in right lateral tilt 0 t h e superior v e rtehra .
Subluxation of the superior vertebra occurs when the left lateral
translation exceeds the physio logical motion barrier and the verte
hra i s unable to return to i ts neutral position For the subluxation to
occur proposed a horizontal cleft through posteri o r
of t h e i n tervertebral d i s c m ust occur (Fig. 1 68).
Positionally, the follow i ng findi ngs are noted with a left l ateral
shift subl uxation the sixth (T5 -T6 and the ribs),
Manual Therapy For The Thorax - 1 41
S u p e ri o r
Costove rt e b ra l
Figure 1 68.
R i b ----r-,.,,;.;.
Anatomy of the lateral shift
lesion It is p ro p osed that a
.
Figure 1 69.
This patient sustained a left
l ateral s h i ft of T5 and the left
and right sixth ribs in a motor
vehicle accident one month
prior. Note the com p lete
block of right rotation a t the
subluxed segment.
1 42 - Manual Therapy For The Thorax
Figure 1 70.
Mobilization tech n ique for a
left latera l shift of the sixth
ring. Stron g d istraction must
be m a i n t a i ned t h roughout the
tec h n i que.
Mobilization technique for a left lateral shift of the sixth ring (Fig. 1 70)
s u p i n e o n ly u n t i l c o n t a c t i s m a d e b e t w e en t h e t a b le a n d
th e dors a l h a n d.
Fr o m t h i s p o s i t e ft a n d r i g h t s i x t h r i
tra n s l a t e d l at e r a through t h e t h o r ax
m o t i o n b a r r i e r. n a l d i s tr a ct i o n i s
through t h e t h e application of
v e l o c ity, l o w The thrust is in a
d i re c t i o n i n t h e t r a n s v e r s e p l a n e . T h e g o a l o f t h e t e c h
n i q u e i s t o l a t e r a l l y t r a n s l a t e T 5 a n d t h e l e ft a n d r i g h t
sixth ribs r e lative to T6.
Fo l l o w i n g r e d u c t i o n o f t h e s ub l u x a t i o n , t h e a r t h r o k i n e t i c
t e s t s fo r m e d i o l a t e r a l t r a n s l a t i o n w i l l r e v e a l t h e u n d e r l y
i n g i n s t ab i l i t y ization is then req
S TA B I LI ZAT I O
E s s e n t i a l l y, t h e to specifica l l y recru
t ru n k m u s c l e s y d then to mainta
brace a s t h e y m o v e the u p p e r a n d lower e x trem i t i e s i n d e
p e n d e n t l y . I n i t i a l l y, t h e b a s e o f s u p p o r t i s v e r y s t a b l e .
T h e p r o g r a m i s p r o g r e s s e d b y i n cr e a s i n g t h e d e g r e e o f
d iffi c u l t y b y r e d u c i n g t h e b a s e o f s u p p o r t , b y m a k i n g t h e
b a s e m o r e u n s t a b l e a n d/o r b y i n c r e a s i n g t h e l o a d w h i c h
must be control led The program is directed by the
p at i e n t ' s n e e d s only b y the therap
imagination . Th asti c ball s , rol ls , b
boards and pu 1 tabi l i za t i o n therapy
e ffe c t i v e , f u n allenging. Figures
1 9 1 i l l u s tr a t e rci ses used i n stab i l
t h e r a p y . T h e r e a d e r i s r e fe r r e d t o I r i o n 26 a n d S a a 1 27 fo r
fu r t h e r i d e a s o n s t a b i l i z a t i o n t r a i n i n g w h i c h i n v o l v e s t h e
t o t a l m u scu l o s k e l e t a l s y s te m .
1 44 - Manual Therapy For The Thorax
Figure 1 71 .
Tru n k bracing - level 1 . Th e
patient is taught to co-con
tract the a n terior a n d poster i
or trunk mu scles isometrical
ly without excess ive posterior
pelv i c t i l t i ng. When done cor
rec t l y t h e lower cos t a l m a r g i n
should be level with the
pelvic gird l e u n l i ke t h e m o d e l
i n t h i s i l lustration who is p o s
teriorly t i l t i ng h i s pelvic g i r
dle too much. A pressure
b i ofee d b ack u n i t o r a blood
press ure cuff p l aced in the
lumbar region c a n be a useful
tool for e d uca t i o n . Proper co
contract i o n o f the trunk mus
cles will elevate the pressure
i n the cuff 10 to 1 5 points on
t he pre s s u re gauge.
Figure 1 72 .
T r u n k braci n g - level 2. The
p a t i e n t is i n s tructed to m a i n
t a i n the co-co ntraction as i n
level l a n d t o flex the h i p a n d
knee t o 90 d egrees. T h e pres
s u re gauge s h o u l d rem a i n at
the same level if the co-con
tract i o n is m a i n t a i ned proper
ly.
N O R M A L M O B I LI T Y W I T H PA I N
P a t i e n t s p r e s e n t i n g w i th p a i n i n t h e t h o r a x w i t h o u t o bj e c
t i v e m e c h a n i c a l f i n d i n g s c a n b e a c h a l l e n g e to t r e a t .
G i v e n t h e n a t u r e o f v i s c e r a l r e fe r r a l o f p a i n t o t h e t h o r a x ,
a team appro ach t o t h e p rob l em i s b e s t . I f all m e d i c a :
c o n d i t i o n s a r e r u l e d o u t and t h e re i s n o s p e c i f i c a r t i c u l ar,
m u s c u l a r , n e u r a l o r d u r a l m o b i l i t y d y s f u n c t i o n t o be
fo u n d t h e n a p o s t u r a l a p p r o a c h fo l l o w i n g the p r i n c i p l e s
Manual Therapy For The Thorax - 145
Figure 1 73.
Trunk bracing - level 3 . From
the starting pos i t i o n of level
2, the patient i s i n s t ructed to
maintain the co-cont raction
of the trunk and to bring the
opposite h i p and knee to 90
degrees w i t ho u t l o s i n g t runk
contro l .
Figure 1 74.
Trunk bracing - l evel 4. From
the starting p o s i t i o n of level
3 , the patient i s instructed to
maintain t he co-co n traction
of the trunk and slowly
extend o n e l e g w i t h o u t l o s i n g
trunk con t ro l .
of s t ab i l i z a t i o n t h e r a p y c a n be t r i e d . R e p e t i t i v e o v e r u s e
o f t h e a r t i c u l a r a n d m y o fa s c i a l t i s s u e w i l l r e s p o n d t o t h e
ap p r o p r i a t e co r r e c t i o n o f r e s t i n g a n d w o r k i n g p o s t u r e s
t o g e t h e r w i t h a n e x e r c i s e p ro g r a m a i m e d at b a l a n c i n g t h e
trunk musculature and restoring optimal movement pat
t e r n s . D i l i g e n c e a n d co m m i t m e n t o n t h e p a r t o f t h e
p a t i e n t a n d t h e r a p i s t i s r e q u i r e d t o a c h i e v e s u c c e s s fu l
r e h ab i l i t a t i o n .
146 - Man u a l Therapy For The Thorax
Figure 1 75.
Trunk bracing - level 5. From
the starting position of level
4 , the patient is instructed to
m a i n t a i n the co-contraction
of the t ru n k and s lowly
extend both legs without los
ing trunk contro l .
Figure 1 76.
Trunk control with an unsta
ble base. The patient is
i nstructed to co-contract the
trunk, tighten the b u t tocks
(recr u i t the gl uteus max
imus), press the inner thighs
together (recruit the adduc
tors if there is an unstable
pubic symphysis) and then to
use the hamstrings to l i ft the
trunk off of the table. The l ift
should occur at the scapular
l ev e l and not through the
uns table segment. This exer
cise is p rogressed by i ncreas
i ng the height of the eleva
t i o n . O nce fu l l l i ft is
achieved, the patient is
i nstructed to rol l the ball from
s ide to side w i t h contro l .
Manual Therapy For The Thorax - 1 47
Figure 1 77.
Tru n k c o n trol w i t h an u n s t a
ble base. I f t h e pa t i e n t is
u na b l e to l i ft the trun k with
out r e p ro d u c i n g symptoms
the b a s e m a y be a l tered b y
placing t h e pa t i e n t o n a 1/2
ro l l . With t h e trunk b raced , a
vari e t y of e x e r c i s es m a y be
perform e d such as u n i l ateral
or b i l a teral e l ev a t i o n o f the
arms, u n i l ateral or b i l ateral
elev a t i o n of t h e feet or roll ing
a ball w i t h o n e or two fee t .
T h e therapist c a n in crease t he
c h a l l enge by app l y i n g re sis
tance to the stick held
between the pa t i e n t s h a n d s .'
Figure 1 78.
Tru n k control in fo ur p o i n t
knee l i n g . Pro p ri ocep t i o n
from t h e s upport i n g su rface i s
decreased thus i n c r e a s i ng the
diffi c u l t y of the e x e rcise . The
pa t i e n t is i n s t r u cted to find
their n e u t ra l t h o raco l u m b a r
pos i t i o n .
1 48 - Manual Therapy For The Thorax
Figure 1 79.
Tru n k control in fo u r p o i n t
k n e e l i ng . The p at ie nt is
i n structed to ma i ntain their
n e u tral t r u n k pos i t i o n and to
s i t back w i t h o u t flex i n g or
' b re a k i n g ' through their
u n s t able regi o n .
Figure 180.
Re-education of the s e g m e n
t a l neutral p o s i t i o n . An u n s t a
b le s egm e n t oft e n re m a i n s
kyphosed w h e n t h e rest o f t h e
vertebral col u m n extends.
Specific e x t e ns i o n exercises
over a ball (ro l l ing fo rward
and backward) t o gethe r w i t h
a 50 Hz m uscle s t i m u l a t i n g
curre n t over t h e i n volved seg
ment can help to res t o r e the
appropr i a t e m o t i o n .
Manual Therapy For The Thorax - 1 49
Figure 1 81 .
Trunk control with i ndepen
dent arm movemen t . A p ro
gression to the above exercise
is to i n struct the patient to
u n i laterally ab d u c t or
elevate
one arm while m a i n taining a
stable tru n k .
Figure 182.
Tru n k control w ith indepen
dent arm movement. A fur
ther progression to the above
exercise is to i n struct the
p at ient to l ift one arm for
ward, the other arm backward
and to s pecifica l l y e x tend the
as they roll forward on
tru n k
the bal l . The arm pos i tion is
then reversed as t h e y rol l
back.
150 - Man u a l Th erapy For Th e Thorax
Figure 183.
Taping for p roprio cep t ive
input. When the segmental
myofascia is unable to control
excessive angular or linear
motion, tape can be a useful
temporary rem i nder as to
which movements the p atient
s h o u l d avo id . Flexi o n and
rotation can be controlled but
not preve nted by app l y i ng
tape obliquely across t h e
unstable region.
Manual Therapy For The Thorax - 151
Figure 1 84.
Tru nk control with i n d epen
Figure 1 85 .
Tru nk control with indepen
dent a r m and leg movement
on a n unstable base. The dif
ficulty of the above exe rcise
can be increased by decreas
ing t he base of support with
two 1/2 rolls.
152 - Manual Therapy For The Thorax
Figure 1 86.
Tru n k control - s i tting. The
p a t i e n t is taught to ach ieve a
n e u t r a l t r u n k pos i t i o n while
s i t t i n g o n a bal l . The exercise
is progressed b y having them
move the ball backwards, fo r
wards and sideways while
m a i n t a i n i n g t r u n k contro l .
Figure 188.
Tru n k control - s t a n d i n g . The
patient is i n s t ructed to co
contract the trunk and to
m ove the body w e i g h t for
wards, backwards, s i d ew a y s
a n d arou n d w h i le s t a n d i n g o n
a wobb l e board .
Figure 1 8 7.
Tru n k control - si tting. The
exercise is progressed b y hav
i n g t h e patient s l owly lower
the contro l l ed t ru n k i n to a
supine s u pp o r t e d pos i t i o n
fro m t h e seated posi t i o n . Care
is taken to e n s u re that the
unstable segment does not
fl e x or t r a n s l a te d u r i n g t h i s
exercise.
Manual Therapy For The Thorax - 153
Figure 1 89.
Tru n k con t rol - s t a n d i n g and
ro t a t i n g . The patient is
i n s tructed t o co-co n t ract the
t r u n k a n d to m o v e t h e body
through ro t a t i o n by turning
around the weight bearing
fem u r . T h i s exercise requi res
control o f the t r u n k and t h e
h i p rotators . Resista nce m a y
be added t hro u g h pu l l ey s o r
res i s ti v e tub i n g .
Figure 1 90.
Tr u n k control - s t a n d i n g a n d
p u s h i n g/pu l l i n g. The p a t i e n t
is i n s tructed to co-con tract
t h e trunk a n d t o push/p u l l a
load by using the l ow e r
extrem i t i e s . Care is taken to
ens ure that the u n s t a b l e seg
ment does not fl e x or translate
d u r i n g t h i s ex erci s e .
Figure 1 9 1 .
Trun k contro l - s t a n d i n g . T h e
p a t i e n t is i nstructed to s t a n d
on a 1 /2 ro l l , to co-contract
the t r u n k and then to u n i later
ally and b i l a t eral l y e l ev a t e
t h e i r arms. T h e exercise can
be progressed by toss i n g a
ball to the p a t i e n t v a r y i n g t h e
speed and t h e d irec t i o n of t h e
t h row .
154 - Manual Therapy For Thorax
REFERENCES
27. Saal J A 1992 The n e w b ack school prescript ion : stab i l i zation
trai n i n g Part II Occupational Med icine 7 : 1 33 -42