INTRO THORACIC SPINE

© The Manual Therapy Institute PLLC 1998-2020

Anatomy

The thoracic region of the spine is overall stiffer and less mobile than the rest of the spine due to the presence of the ribcage. The ribcage adds significantly to the mechanical stability of the thoracic spine. The thoracic kyphosis is the result of lesser anterior height of the thoracic vertebral body and a slight wedge shape of the thoracic discs. The average thoracic kyphosis ranges from 20 - 40 degrees with the apex of the curve being at the T 7 -T 8 level. The thoracic vertebral bodies are approximately as wide as they are long, and very high. They are heart shaped, and are concave anteriorly. The typical thoracic vertebrae are located from T 2- T 9. T 1 and T12 are a- typical.

The superior aspect of the vertebral body of T 1 is concave in the transverse plane. This concavity is formed by the uncinate processes at the posterolateral corners. They articulate with the inferior aspect of the body of C 7 to form the uncovertebral joints. The inferior aspect of the body is flat. There is an ovoid facet on either side of the vertebral body for articulation with the head of the first rib. On the posterolateral corners of the body there are 2 additional facets for articulation with the head of the 2nd rib. On the ventral aspect of the transverse process there is a concave facet that articulates with the convex facet on the first rib to form the costotransverse joint.

The spinal canal is relatively narrow, especially between T 4 and T9. At T 6 there appears to be a significant decrease in movement of the spinal cord in relation to the surrounding structures, leading to the creation of a tension point. Tension points are vulnerable sites within the nervous system. Clinically this is important, as tension points appear to be capable of causing a variety of complaints. For example, in treating patients with a whiplash disorder, there appears to be frequent occurrence of interscapular pain, and as a later development, lumbar pain. These spinal pains are often close to the tension point areas.

The transverse processes are very large. They are approximately level with their corresponding vertebral body. On T1 - T10 they possess a concave joint surface for articulation with the ribs. In T 1 - 6 they face anterior, while in T 7 - T 10 it faces more superior. The transverse processes of T 11 and 12 do not have costal facets.

The spinous processes project downwards and backwards and vary in inclination, becoming steeper towards the middle and leveling off again towards the low thoracic area. The tips of the spinous processes often have bony anomalies and can deviate as much as 0.5 cm from the mid line. For palpation purposes it is good to keep the “thoracic rule of threes” in mind:

T 1 - T 3 the spinous processes are approximately level with their own body.T 4 -T 6 the spinous processes are approximately level with the inferior disc.

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T 7 - T 9 the spinous processes increase to one segment below the corresponding transverse process.

T 10 - T 12 gradually decreasing inclination to where at T 12, the spinous process and transverse process are close to being on the same horizontal plane.

The superior articular facets of the thoracic vertebra face posterior, lateral and superior. The inferior articular facets face anterior, medial and inferior. The angle of the facets is 20 - 30 degrees away from the frontal plane. This inclination increases in the lower thoracic area. The facet joints are oriented in such way that if the facets were inscribed on the periphery of a circle, the center of the circle would be in the middle of the vertebral body. This orientation allows for a good amount of rotation and sidebending despite the fact that much of the range has been lost due to the ribcage.

T 12 is a transitional vertebra. The superior articular facets are still oriented in the frontal plane, while the inferior articular facets are of the lumbar type, meaning that they are oriented in a more sagittal plane. When articulated with L 1 they restrict rotation. The orientation of T 11- T 12 does not restrict rotation.

The capsular ligaments of the facet joints are thin and loose. They are strengthened anterior by the ligamentum flavum and posterior by the posterior ligament.The facet joints contribute significantly to the clinical stability of the thoracic spine. In the upper and middle portion of the thoracic spine, the facets provide stability primarily against anterior translation. When the orientation gradually changes to a more sagittal orientation in the lower thoracic spine, it provides stability against rotation as well.

The typical segment has a rib that articulates with 2 adjacent vertebrae and the disc at the costovertebral joint. The 1st, 11th and 12th ribs are a- typical in that they only articulate with their own vertebra. T 1 has a costal facet for the 1st rib, and an upper half of a facet on the posterolateral corner for the 2nd rib. At T 2 - 9 there are demi facets on the posterolateral corners of the vertebral body for articulation with the head of the rib. T 10 is variable, as the 10th rib often articulates with T 9 and T 10.

Where they articulate with the vertebral body, the heads of the ribs develop an upward projection, similar to the uncinate processes in the cervical spine. The C -V joint is a compound synovial joint. The joint cavity is divided into a superior and inferior compartment by the intra articular ligament. The intra articular ligament connects the head of the rib with the disc.

The C-V joint is strengthened by the radiate ligament, which consists of 3 parts. The superior part runs from the head of the rib to the vertebral body above. The middle part runs from the head of the rib to the disc. The inferior part runs from the head of the rib to the vertebral body below.

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The costotransverse joint is a synovial joint between the facets of the transverse process of the vertebra and the rib tubercle. The articular capsule of the C-T joint is weak, but greatly strengthened by 3 ligaments. The medial (or interosseous) and lateral costotransverse ligament extend from the tip of the transverse process to the neck and lateral aspect of the rib, respectively. The superior costotransverse ligament extends from the neck of the rib to the transverse process of the vertebra above.

The first 7 ribs join the sternum by means of individual costal cartilage, the next 3 by means of fused costal cartilage. The last 2 ribs are free floating anteriorly and provide attachment for the diaphragm and trunk musculature. The sternocostal joint between the cartilage of the first rib and the sternum is a synchondrosis. The first costal cartilage is short. This, in combination with a fibrous sternocostal joint increases the stability of the upper thoracic spine. The cartilage of the 2nd rib articulates with demi facets on both the manubrium and the sternum in a synovial joint. The joint is divided in 2 parts by the intra articular sternocostal ligament. The remainder of the sternocostal joints are synovial as well.

The sternum has concave facets that articulate with the costocartilage of the 3rd - 6th rib. The 7th rib articulates with both the xyphoid process and the sternum. The radial costosternal ligaments strengthen the joint capsules of the sternocostal joints anteriorly.The anterior borders of the cartilage of ribs 6 - 10 occasionally articulate with each other via small facets in interchondral joints. Interchondral ligaments support the joints.The costochondral joints connect the bony part of the ribs to the cartilaginous part. Their interlocking nature does not allow for significant movement. It does allow for deformation of the costal cartilage during inspiration though.The manubriosternal synchondrosis usually remains separate through life, although ossification can occur. The manubrium articulates with the clavicle and the costocartilage of the 1st and 2nd rib.

Vertebral ligamentsAs a whole, the spinal ligaments in the thoracic spine are more developed than in the cervical spine, but not as thick or dense as in the lumbar spine.The ligamentum flavum attaches superiorly and inferiorly to the lamina and pedicles. It strengthens the anterior part of the facet joints. The elastic fibers outnumber the collagen fibers 2: 1. Those elastic properties create a “ resting” compression of the disc. This may add some stability to the spine. It also ensures that the ligament won’t bunch up and possibly impinge on the spinal cord during extension. The ligament furthermore prevents flexion.The interspinous ligament is not as well developed in the thoracic spine as it is in the lumbar spine. The supraspinous ligament probably does not play a major role in the stability of this part of the spine. Both do help to limit flexion.

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The anterior longitudinal ligament is distinct and well developed. It covers the anterior aspect of the vertebrae and the discs. It is only indirectly connected with the anterior disc by loose tissue. It’s function is to limit extension and anterior / posterior translation.The posterior longitudinal ligament covers the posterior aspect of the vertebrae and the discs. It does not attach to the concavity of the body, but is separated from it by a fat pad. This fat pad provides cushioning, proprioception, and it blocks venous drainage during flexion. The PLL limits flexion and prevents posterior translation.The transverse processes are connected by cord like intertransverse ligaments.

Intervertebral discsVery little is known about the anatomy of the thoracic intervertebral discs. They are overall thinner and narrower than the discs in the cervical and lumbar area. Disc prolapses are rare in the thoracic spine due to the structure of the disc and the bony and ligamentous boundaries surrounding the disc. Patients with mechanical disorders in the thoracic spine make up less than 2% of all patients experiencing common mechanical backpain (16). Furthermore, there is no experimental evidence that proves that pain can arise from the thoracic discs themselves. However, discogenic pathology appears to happen rather frequently in the thoracic spine. The highest incidence according to level is T7-8, the second highest T6-7 and T9-10. Thoracic discs are no longer thought to be an uncommon cause of thoracic pain. The most common symptom in patients with confirmed thoracic disc herniations was anterior chest pain.

RibsThe first rib is small, but massively built. It is oriented inferiorly. Of all ribs it is the most curved. It has one articular facet as it only articulates with T1.The 2nd-9th ribs are the so-called “typical ribs”. The upper border of the shaft is rounded and blunt, while the inferior is thin and sharp. A horizontal ridge divides the head, where the intra articular ligament attaches. The costovertebral joints act somewhat like the uncovertebral joints in the cervical spine. The articular portion of the tubercle is an oval facet that articulates with the costotransverse joint. The anterior end of the shaft has a small depression at the tip where it articulates with the rib cartilage to form the costochondral joint. The 11th and 12th rib are free floating. The rib angle is nearly absent and there is no joint surface for articulation with the TP. The size of the 12th rib differs from person to person.

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Biomechanics and arthrokinematics

Range of motion

Level Flexion/Extension Rotation SidebendingC6-7 18 9 4C7-T1 8 6 4T1-2 4 9 5T2-3 4 8 6T3-4 4 8 5T4-5 4 8 6T5-6 4 8 6T6-7 5 7 6T7-8 6 7 6T8-9 6 6 6T9-10 6 4 6T10-11 9 2 7T11-12 12 2 9T12-L1 12 2 8

During flexion, the inferior facets of the superior thoracic vertebra glide up and tilt forward. The motion is limited by the ligamentous structures in the back and the disc in the front.During extension, the inferior facets of the superior vertebra glide down and tilt backwards. The movement is limited by approximation of the spinous processes, by the disc and by tightening of the anterior longitudinal ligament.During right sidebending, the inferior facet of the superior vertebra on the right will glide down and tilt backwards; the inferior facet on the left will glide up and tilt forwards.During rotation, the inferior facet of the superior vertebra glides down and tilts backwards on the side to which rotation occurs, and glides up and forwards on the side opposite to the rotation.

Coupling Two or more motions are coupled when one motion is always accompanied by another motion. This phenomenon is due to the geometry of the individual vertebrae, the connecting vertebrae and discs, as well as the curvature of the spine. Sidebending and rotation are coupled to the same side in the upper T - spine. In the mid- and lower thoracic spine the coupling can go either way (i.e. sidebending coupled with rotation to the same or opposite side). Clinical experience shows that the lower thoracic spine has the tendency to follow the lumbar spine coupling characteristics (i.e. sidebending coupled with rotation to the opposite side).

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RibsThe costovertebral (CV) joint and the costotransverse (CT) joint form a mechanically linked “joint”. Common movement can only occur about an axis passing through the center of each joint. This axis acts as a swivel for the rib. In the upper thoracic spine, this axis lies nearly parallel to the frontal plane. Elevation of the rib increases the anterior / posterior diameter of the chest, in a so-called “pump handle” motion. In the lower thoracic spine, the axis lies nearly parallel to the sagittal plane. Elevation of the rib increases the transverse diameter of the chest, in a so-called “bucket handle” motion. During respiration, rib movements relative to the sternum and costal cartilage takes place. During inspiration the sternum is raised and the costal cartilage becomes more horizontal. The 1st and 2nd rib move only slightly during quiet respiration.The primary muscles of inspiration are the diaphragm and the external intercostal muscles. The accessory muscles of inspiration are the scalenes, the sternocleidomastoid, the upper trapezius and the pectoralis major and minor. During expiration, most of the recoil of the ribcage is passive. The primary muscles of expiration are the abdominals and the internal intercostal muscles. The accessory muscles are the latissimus dorsi and the quadratus lumborum.

Sympathetic innervation Along the vertebral column lies the sympathetic nerve trunk, just anterior of the costotransverse joints. Mobilization of the nerve trunk is possible to a certain degree through the ribs or the costotransverse joints. This knowledge helps to make sense of the sometimes-odd symptoms reproduced by tension tests. Influencing activity in the sympathetic nervous system is also helpful in managing problems like RSD.Sympathetic innervation of the upper extremities comes from T3-7; lower extremities T7-12; head T1-2; trunk T1-12

Differential diagnosis

Most of the issues pertaining to differential diagnosis for the thoracic spine will be dealt with in the Differential Diagnosis home study course. However, a few topics still bear mentioning here.

FractureCompression fractures of the vertebral bodies usually occur in the lower thoracic area.Rib fractures. Must have history of trauma. If not, suspect serious pathology.Sternum. Resulting from direct trauma.

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Williams and Wilkins Company 1979.2. Butler, D. Mobilization of the nervous system. Churchill Livingstone, 1991.

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3. Evjenth, O and Hamberg, J. Muscle stretching in manual therapy, a clinical manual. Alfta Rehab 1980

4. Clinics in physical therapy. Physical therapy of the cervical and thoracic spine, 3rdd edition. Editor: Ruth Grant. Churchill Livingstone 2002

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Structural defects

ScoliosisCharacterized by both lateral curvature and axial rotation of the vertebrae. All cases where the cause of the scoliosis remains obscure are referred to as idiopathic. About 90 % of all idiopathic curves are probably genetic. This type of scoliosis occurs 7 times more frequently in females. It is classified into infantile, juvenile and adolescent types according to well-defined peak periods of onset. Opposite of what was once thought, scoliosis does not come to a sudden stop once full maturity has been reached. Reasons for adult progression:

1. A strong genetic dose. 2. If the curve pattern throws the body off balance.3. If the person has very poor muscle tone.

The most common treatment is bracing and exercises, or a combination of surgery and exercises. Cave: a lateral shift in the thoracic spine is usually a sign of serious pathology.

KyphosisCauses:1. Genetics2. Osteoporosis3. Spondylosis4. Pathological fractures5. Scheuermann’s disease.

Osteochondrosis of the vertebrae. Vertebral version of Perthes’ disease and Osgood Schlatter’s diseasePrevalent between 10 and 20 years of age. It is more of a degenerative process than inflammatory. Problem occurs where disc and vertebrae connect. Defects in the endplate leads to protrusion of the nucleus, causing disturbance of the growth plate anteriorly. This leads to collapse of the vertebra anteriorly, making the vertebra wedge shaped. Pain usually starts a few years after the deformity becomes visible. Patients usually complain of slowly increasing pain,

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never severe, brought on by heavy labor, increasing as the day goes on. The gold standard for diagnosis is an X ray, with 3 adjacent vertebrae show a minimum of 5 degrees of wedging, and the kyphotic angle is>45 degrees. Frequent c/o fatigue in mid back. T-L problems can develop later in life as a result of overcompensation. Treatment should be focused on postural exercises, joint and soft tissue mobilizations, stretching and strengthening ex. Early intervention is important.

Reference

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2012;21(5):819-824. Available from: CINAHL Complete, Ipswich, MA. Accessed March 20, 2014

2. Damborg F, Engell V, Nielsen J, Kyvik K, Andersen M, Thomsen K. Genetic epidemiology of

Scheuermann's disease. Acta Orthopaedica [serial online]. October 2011;82(5):602-605. Available

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3. Arlet V, Schlenzka D. Scheuermann's kyphosis: surgical management. European Spine Journal:

Official Publication Of The European Spine Society, The European Spinal Deformity Society, And The

European Section Of The Cervical Spine Research Society [serial online]. November 2005;14(9):817-

827. Available from: MEDLINE Complete, Ipswich, MA. Accessed March 20, 2014.

4. Papagelopoulos P, Mavrogenis A, Savvidou O, Mitsiokapa E, Themistocleous G, Soucacos P. Current

concepts in Scheuermann's kyphosis. Orthopedics [serial online]. 2008;31(1):52-60. Available from:

CINAHL Complete, Ipswich, MA. Accessed March 20, 2014

5. Goodman C, Fuller K. Pathology: Implications for the Physical Therapist. St. Louis, MO: Saunders

Elsevier Publishing; 2009

6. Koptan W, ElMiligui Y, ElSebaie H. All pedicle screw instrumentation for Scheuermann's kyphosis

correction: is it worth it?. Spine Journal [serial online]. n.d.;9(4):296-302. Available from: Science

Citation Index, Ipswich, MA. Accessed March 22, 2014.

7. Poolman R, Been H, Ubags L. Clinical outcome and radiographic results after operative treatment of

Scheuermann's disease. European Spine Journal: Official Publication Of The European Spine Society,

The European Spinal Deformity Society, And The European Section Of The Cervical Spine Research

Society [serial online]. December 2002;11(6):561-569. Available from: MEDLINE Complete, Ipswich,

MA. Accessed March 20, 2014.

8. Koller H, Juliane Z, Umstaetter M, Meier O, Schmidt R, Hitzl W. Surgical treatment of Scheuermann's

kyphosis using a combined antero-posterior strategy and pedicle screw constructs: efficacy,

radiographic and clinical outcomes in 111 cases. European Spine Journal [serial online]. January

2014;23(1):180-191. Available from: Academic Search Complete, Ipswich, MA. Accessed March 20,

2014.

9. Soo C, Noble P, Esses S. Scheuermann kyphosis: long-term follow-up. The Spine Journal [serial

online]. January 2010;2(1): 49-56. Available from: Science Direct. Accessed March 20, 2014.

10. Mauroy J, Weiss H, Van Loon P, et al. 7th SOSORT consensus paper: conservative treatment of

idiopathic & Scheuermann's kyphosis. Scoliosis (17487161) [serial online]. January 2010;5:9-23.

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11. Coe J, Smith J, Shaffrey C, et al. Complications of spinal fusion for scheuermann kyphosis: a report

of the scoliosis research society morbidity and mortality committee. Spine [serial online]. 2010 Jan 1

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12. Stanley L. Comparison of Scheuermann Kyphosis Correction by Posterior-Only Thoracic Pedicle

Screw Fixation Versus Combined Anterior/Posterior Fusion. Spine [serial online]. September 15,

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22, 2014.

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2009;4 Available from: CINAHL Complete, Ipswich, MA. Accessed March 20, 2014.

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Suppl): S115-9. Accessed March 20, 2014.

Ankylosing spondylitis A chronic rheumatoid disorder that almost always affects the SI joint. Usually the disease is progressive and spreads to the thoracic spine and the costovertebral joints as well. Periods of relative inactivity are interrupted by long lasting exacerbations with severe pain, restricted ROM and malaise. Prevalence: .1-2% of US population. Average onset: 25 years of age. There is a higher incidence in men. There is a hereditary factor (incidence is 20 times higher than in the average population).

Clinical presentationMid-low back pain and stiffness >3 monthsWorse in morning, lasting > 1 hourChest expansion < 2cm on full inhalationPain improves with activity, not with rest

DiagnosisPositive HLA-B27 blood testX ray and MRI with fused spineLow back pain > 3monthsLimited chest expansion

Reference

1. Bond, D. Ankylosing: diagnosis and management. Nursing Standard; 2013. 28: 16-18. doi: 10.7748/ns2013.12.28.16.52.e7807. 2. Van Tubergen, Astrid, and Ulrich Weber. "Diagnosis And Classification In Spondyloarthritis: Identifying A Chameleon". N.p., 2017. Print. 3. Caple C, Schub T. Spondylitis, Ankylosing. CINAHL Nursing Guide [serial online]. May 6, 2016;Available from: Nursing Reference Center Plus, Ipswich, MA. Accessed February 21, 2017. 4. Rodeghero T. Ankylosing Spondylitis. http://www.physio-pedia.com/Ankylosing_Spondylitis. Accessed March 6, 2017. 5. Tsui F, Tsui H, Akram A, Haroon N, Inman R. The genetic basis of ankylosing spondylitis: new

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insights into disease pathogenesis. The Application Of Clinical Genetics, Vol 2014, Iss Default, Pp 105-115 (2014) [serial online]. 2014;(default):105. 6. Giannoti, et al. Effects of physical therapy for the management of patient with ankylosing spondylitis in the biological era. 2014; 33: 1217-1230. 7. Rosu OM, Ancuta C. McKenzie training in patients with early stages of ankylosing spondylitis: results of a 24-week controlled study. Eur J Phys Rehabil Med. 2015;51:261-8. 8. Regnaux JP, Lefevre-Colau MM, Palazzo C, Poiraudeau S, Ravaund P, Boutron I. Exercise therapy for ankylosing spondylitis (Protocol). Cochrane Database of Systematic Reviews. 2014;10.

ArticularArthritisMost DJD occurs at C7-T1, T4-5 and lower T spine. Bonespurring usually doesn’t lead to clear incidence of nerve root interference as it does in the cervical and lumbar spine. There will be palpable loss of movement and signs of joint irritation. The CV joints share in localized and painful loss of movement.

DiscsThoracic disc lesions occur mostly in patients between 40 and 60 years old. All derangements are posterior or posterolateral, all suitable for extension treatment.Since the intervertebral foramen is bigger and each nerve root is responsible for a much smaller area, disc lesions in the thoracic spine cause fewer problems than in the cervical and lumbar spine. There is lots of overlap in dermatomes and myotomes, so a neurological evaluation doesn’t give clear information. Thoracic disc surgery is rare, only 1 in 1000-disc surgeries is thoracic. Symptoms: anterior chest pain. Sudden onset of thoracic pain with radiating symptoms in the intercostal region. Increased symptoms with coughing or sneezing, repetitive movements and weight bearing.

Costochondral conditionsCaused by direct trauma. There will be pain and swelling at the bone/cartilage junction, 1-inch lateral to the lateral margin of the sternum. Acute costochondrosis is a benign inflammatory process also known as Tietze’s syndrome.

SternomanubrialResulting from a hyperflexion injury or secondary to sternal split injury.

Movement dysfunctions

Thoracic facet joint dysfunction Unilateral limitation and pain in rotation Asymmetrical segmental mobility findings Asymmetrical palpatory findings (pain, tissue texture abnormalities,

positional faults)

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Costovertebral joint dysfunctions Intense sharp pain unilaterally Movement restriction predominantly in sidebending Problems with deep breathing, sneezing and coughing

Differential diagnosis costovertebral joint dysfunction: Cardiac involvement Pneumonia, Pleuritis Rib fracture, Herpes zoster ANNT long thoracic nerve

First rib dysfunctionNormal biomechanics and pathomechanics of 1st rib motion are not clear. Little movement takes place at first and second rib with breathing. Dysfunction can be caused by direct trauma such as powerful pushing/pulling, falls on outstretched arm, or by somatic dysfunction of cervical facet joint (example: dysfunction C3-4 leads to irritation of the nerve root, which increase the tone in scaleni, causing a superior subluxed 1st rib). Subluxations are more common in young adults, less common after the age of 50. Presence of a cervical rib needs to be ruled out before you do any form of mobilization. If the first rib is higher, up to 1 cm, suspect joint dysfunction. If the difference is more than 2 cm, suspect cervical rib. X rays will tell. There will be restricted mobility of the rib in inhalation/exhalation or both. Asymmetrical resistance will be felt on rib springing. Possible swelling and point tenderness in supraclavicular area, over the costo sternal joint or over the head of the rib.Rotation towards, sidebending away can be restricted. Shoulder ROM WNL, possibly painful in endrange. No neuro signs, but paresthesia in C8, T1 dematome have been reported. Dysfunction of the first costovertebral can irritate the stellate ganglion, which lies in front of C7-T2. This may account for occasional RSD like symptoms occurring in conjunction with first rib problems.

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Cervicothoracic region

The cervicothoracic junction includes C6 - T3. It is one of the key regions in the spine, an area of transition where the function of the spine changes. The plane of the facet joints change from an oblique orientation to a more frontal plane. Movements in the sagittal plane tend to decrease when going from cervical to thoracic spine. Sidebending and rotation are coupled to the same side. The CT region is constantly on call during the waking hours and is probably the hardest working of all vertebral regions. Powerful shoulder girdle muscles attach to this area. This, in combination with the stress placed on it by the weight of the head, makes it a fairly vulnerable area.

Clinical presentationPatient presents with localized cervicothoracic pain with possible radiating pain into suprascapular or upper thoracic region. Persistent cervical joint dysfunctions may not disappear until CT junction is treated. Pattern of pain and limitation: Sidebend/rotation to the same sideFlexion and/or extension.

Differential diagnosis for restrictions in cervical flexion: restriction in upper thoracic spine, CT junction. cervical disc soft tissue restrictions cervical spine

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EvaluationPostural evaluation

Cardinal plane movementsLook for pattern of pain and limitation. Look for quality of movement.

Neurological evaluationSensory testing not reliable due to overlapping of thoracic nerve roots. Key musculature cannot be tested segmentally for the same reason. No reflexes available. Do check for central nervous system involvement (clonus, Babinski, hyperreflexia of DTR’s LE) when indicated.

Segmental mobility testing

Special testingCompression/distractionPercussion: in select patients the SP’s are percussed with ulnar aspect of a loose fist. If pt experiences deep pain, nausea or visceral pain, suspect more serious pathology.

PalpationPositional faults: TP’s palpate interspinous space for tenderness, decrease/increase size of interspinous space.Tissue texture abnormalities.

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ROM testingExtensionPt sitting, preferably long sitting to produce countercurve locking (flexion) in lumbar spine. Pt holds hands to opposite elbows and over his head. Then he is asked to bring elbows back. Look for areas that don’t move or that remain in kyphosis. Movement will occur from T5 and down.

FlexionInstruct pt to do a cranio caudal flexion, to see a segmental pattern downward. Look for areas that are skipped during flexion.

RotationPt sitting, preferably long sitting to create locking in the lumbar spine. Pt brings hands on opposite shoulders, and then rotates.

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SidebendingPt sitting. Hands behind head. Pt sidebends cranio caudal.

Rib cage examination

General assessment of inhalation/exhalation restriction.Superior ribs (pump handle motion)Place hands inferior to clavicle on either side in a discrete manner over several rib segments. Have patient “take a deep breath” “hold” and “breath in a little more”. Feel if there is symmetrical expansion when additional breath is taken in. Then have patient “breath out” “hold” and “breath out some more”. Feel if there is symmetrical depression when additional air is let out.

Inferior ribs (bucket handle motion)Spread hands and fingers over lower ribs on lateral rib cage. Test as with superior ribs.

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Upper rib mobilization, separationPatient supine. Left thenar eminence and thumb between the 2 ribs to be treated, to fixate the caudal rib. Pull patient’s left arm in cranial direction. This moves the upper rib further in a cranial direction. This technique can be used to move the lower rib in caudal direction (exhalation restriction) or the upper rib in cranial direction (inhalation restriction). Do not fully elevate the shoulder if this produces shoulder pain.

Lower rib mobilization, separationPatient on left side. Therapist right forearm is pronated. Web space is placed between 2 ribs to be treated, to fixate the lower rib in caudal direction. Index finger is placed parallel to rib. Pull patients right arm cranially, moving the upper rib further cranially to produce separation between the ribs.

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Ribs 2-4 anterior-posterior restrictionsTherapist faces patient, with patient sitting or supine. Place your fingers along the second rib, which is the first rib palpable under the clavicle. Palpate the costochondral junction. Look for a sense of a “ledge” or a “step off” in the transition between the rib and the chondral portion. The patient will withdraw from the palpating hand if there is abnormal function with significant tenderness in this area. Repeat palpation for the chondrosternal junction. Observe if the chondral portion is anterior or posterior relative to the sternum with abnormal degrees.

Interpretation of findingsIf there is a posterior subluxation the pectoral area on the involved side will seem “empty” and significantly softer and deeper on palpation than the opposite side. Palpating on the backside you will find more prominence near the rib angle as if there is more muscle bulk here. A posterior subluxation can occur at both the costochondral joint and the chondrosternal joint.

If there is an anterior subluxation the ribs will feel more prominent anteriorly. The pectoral area will feel like there is more muscle tone, and the muscle bulk will feel “fuller” on the involved side. On the posterior side there will be less fullness at the rib angles if there is less muscle bulk there. It will feel deeper and softer on palpation. An anterior subluxation can occur both at the costochondral and chondrosternal junction.

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TreatmentFor a right rib posterior subluxation•Pt makes fist with right hand, place on chondral portion of rib, or with a chondral posterior subluxation, on sternum itself.•Left hand is placed on top of the fist. •Lift left elbow to level of the rib being treated. •PT places right hand at the angle of the dysfunctional rib. •Place left hand on patients elbow. •Pt presses left elbow forward while pressing the left hand back into fist. •PT resists both on the elbow and at the rib angle. •Hold 6-8 seconds. Repeat 3-4 times.

For a right anterior subluxation•Pt places right fist on the chondral portion or lateral to the chondral portion of dysfunctional rib.•Place left hand on fist and lift the left elbow to the level of the dysfunctional rib. •Stand behind pt and place left hand on the anterior side of the elbow. •Put pincer grip with right hand on left side of SP at level of dysfunctional rib. •Ask the patient to push the elbow straight forward against an unyielding resistance and at the same time push the left hand back into the right fist. •PT resists both on the elbow and at the spinous processes. •Hold 6-8 seconds. Repeat 3-4 times.

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Segmental mobility testing

CT flexionPatient sitting. Flex head and palpate for gapping of interspinous space.

CT extensionPatient sitting. Hands behind neck, interlace fingers, elbows together. Extend, feel for approximation of spinous processes

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CT rotation Patient sitting. Palpate laterally of spinous process with thumb, rotate head and feel SP kick out.

CT sidebendingPatient sitting. Palpate laterally of SP with thumb, sidebend head and feel SP kick out.

Mid thoracic flexionPatient sitting on corner of table, lumbar spine in neutral. Patients brings hands behind neck, elbows together in front. Therapist supports elbows with one hand/forearm. Palpate the interspinous space and feel for the gapping as you flex the spine.

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ExtensionPosition as in flexion. Palpate for approximation of the spinous processes as you extend the thoracic spine.

RotationPosition as in flexion. Rotate spine. Palpate with indexfinger on side opposite to which rotation occurs. Feel for spinous process move against palpating finger.

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SidebendingFor upper thoracic, position as in flexion. Therapist’s right arm weaves through patients arms. Sidebend spine, palpate for movement in between the spinous processes. For lower thoracic spine, have the patient interlace fingers behind neck, and bring elbows back. The right humerus rests on the therapist’s shoulder. Therapist stands on patient’s side, reaches around trunk. Sidebend low thoracic spine, palpate with thumb for motion between the spinous processes.

P-A testingPatient prone. Index and middle finger placed on TP’s of caudal vertebra. Ulnar side of other hand placed on top of fingers. Press vertebra anterior. Feel for range, endfeel and note changes in symptoms. This method may localize a lesion to within 2 segments.

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A-P glidingPatient in sidelying. Palpating finger of caudal hand between SP’s of the segments tested. The remaining part of the hand provides stabilization caudal to the segment. If patient can’t clasp hands behind neck, fold arms across chest. Therapist’s cranial hand grasps pt’s upper arm. Therapist body acts as an extension of the moving hand with contact to the pt elbows. Alternately push/pull through pt arms to produce translatoric gliding of the vertebrae. Evaluate range and endfeel

Lower rib test and mobilizationPatient prone. Therapist on right side of patient. Ulnar side of left hand on right TP’s, fingers pointing cranially. Ulnar side of right hand on left rib, with pisiform just medial of rib angle. The 5th finger is placed along the rib. Move rib in anterior/lateral/inferior direction

Upper rib test and mobilizationPatient prone. Ulnar side right hand, fingers pointing caudally, is placed on the right TP’s. Ulnar side of left hand is placed on the rib to be treated, pisiform medial of rib angle. Move rib in anterior/lateral direction.

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Joint mobilizations

Upper thoracic mobilization, proneUse pincher grip on spinous process of upper segment involved. Mobilize segment up and forward. General low-grade mobilization for upper thoracic region.

Alternative version

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Upper thoracic gapping, pronePlace both pisiforms over the transverse processes of the inferior vertebra of the involved segment. Mobilize in anterior and slightly inferior direction. This will gap the involved segment

Upper thoracic rotation/sidebendingPatient sitting. Right hand over upper trap with thumb just lateral of SP of segment to be treated. Left forearm and hand control the head. Sidebend head to the right, down to level to be treated. The right hand mobilizes the segment in caudal / inferior direction (towards the opposite hip).

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Bilateral upper thoracic releaseThis technique has 2 aspects: a soft tissue mobilization component, and a P - A mobilization of the upper thoracic spine. Pt is supine. Therapist sits behind pt. Hands are slipped in between pt and table. Make contact on either side of the SP’s. Apply moderate pressure in anterior direction, and then oscillate in cranial/caudal direction. Promotes inhibition. Then mobilize in anterior/posterior direction. The entire thorax should be seen moving in an anterior direction. Hard on the hands.

Mid thoracic flexionPt sitting at corner of table with legs abducted. Therapist supports low back with thigh as shown. Pt makes collar around neck with elbows together in front. Stabilize vertebra below with heel of hand. Flex thoracic spine with other hand by pushing down on pt elbows.

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Mid thoracic extensionPosition as in flexion mobilization. Stabilize vertebra below with heel of hand. Mobilizing hand lifts upon patient’s elbows, extending the spine.

Mid thoracic P-A, bilateralPt prone. Index finger and middle finger point cranially and are placed on the TP’s of the caudal vertebra. The other hand is placed on top of the distal part of these fingers. Mobilize vertebra anterior. This is a testing as well as a treatment technique.

Mid thoracic P - A, unilateralPt prone. Indexfinger of left hand is on right TP of caudal segment. Middle finger of left hand is on left TP of cranial segment. Right hand over left hand. Mobilize in anterior direction. This will distract only the right facet joint, which makes the technique more specific.

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First ribPatient sitting. Therapist behind patient. Upper arm and elbow placed on top of shoulder, forearm and hand against side of head. Side bend head towards side to be treated to relax scaleni. Webspace other hand placed over 1st rib, mobilizing it in inferior/medial direction.

Second ribPatient sitting. Therapist on left side. Side bend and rotate head to the left. Find 1st rib, then move down 1 thumbswidth in a 45 degree angle. This will put you on the 2nd rib. Be careful not to put your hand on the scapular border, as they are close. Place pisiform on 2nd rib and mobilize in inferior direction.

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Self mobilization CT junction

Selfmobilization mid T area using chair

First rib self mobilization, using towel

Tennis balls for self-mobilization mid T spine

References1. Butler, D. Mobilization of the nervous system. Churchill Livingstone, 1991.

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2. Evjenth, O and Hamberg, J. Muscle stretching in manual therapy, a clinical manual. Alfta Rehab 1980

3. Clinics in physical therapy. Physical therapy of the cervical and thoracic spine, 3rdd edition. Editor: Ruth Grant. Churchill Livingstone 2002

4. Greenman, P. Principles of Manual Medicine, 3rd edition. Lippincott, Williams and Wilkins. 2005

5. Grieve’s Modern Manual Therapy, 3rd edition. Boyling J. and Jull G. editors. Elsevier 2004.6. Lee, D Manual Therapy for the thorax, a biomechanical approach. DOPC 1994.7. Meadows, J. Manual Therapy: biomechanical assessment and treatment. Swodeam

consulting, 1995.8. Sahrmann, S. Diagnosis and Treatment of Movement Impairment Syndromes. Mosby, 20029. McKenzie R. The lumbar Spine, Mechanical Diagnosis and Therapy. Spine Publications New

Zealand 2003

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