The Thorax - An Integrated Approach

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Text of The Thorax - An Integrated Approach

  • MCPA I'CAMT

  • THE THORAX

    An Integrated Approach

    DIANE LEE BSR (Honours), FCAMT

    Wh ite Rock, British Columbia, Canada

    Copyright 2003 Diane C. Lee Physiotherapist Corporation

    ISBN 0-9732363-0-2

  • For my mom-I will always remember for both of us

    For my dad and my brother -unconditional love

  • PREFACE, 1ST EDITION

    In the literature pertaining to back pain, the musculoskeletal components of the thorax have received little attention. The reference list at the end of this text reRects the paucity of research available for review. And yet, clinicians are presented daily with the challenge of treating both acute and chronic thoracic pain. It was this challenge which initiated the clinical work presented in this text.

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

    The clinical investigation began in J 990 when Jan Lowcock presented a paper on stability testing of the thorax to the Canadian Orthopaedic Manipulative Physiotherapists. I am indebted to her, and many others, for the subsequent academic and clinical discussions which lead to the evolution of the biomechanical model presented here. Much of this material remains empirical and requires validation through research.

    The First chapter reviews the anatomy of the thorax as it pertains to the biomechanical model. The emphasis has been placed on osseous and articular anatomy although the muscular and neural contribution to function is acknowledged. Chapter two describes the biomechanical model and chapters three to five the clinical application of this model to examination and treatment of the thorax. The purpose of this text is to provide the clinician with the ability to assess and treat articular dysfunction of the thor

  • on human performance. This model was developed in conjunction with Dr. Andry Vleeming (Lee & Vleeming 1998, 2002) and has been applied to the thorax in this edition, the principles of lhis model are described in Chapter 2. Chapter 3, biomechanics of the thorax, has been updated lo include research since the first edition was published.

    Chapter 4 has been updated with video clips on a CDROM to demonstrate the aClive and passive mobility and stability techniques previously described in the first edition. In addition, new techniques are presented which analyse the force closure mechanism (dynamic stability) of a thoracic segmenl. The classification of dysfunction within the thorax has been changed to follow the integraled model of function. Chapter 6 has been updated with video clips on a CDROM lo demonstrate the passive and aClive mobilization and manipulation techniques for the thorax.

    Chapter 7 is brand new for this edition and contains vital information for an exercise program aimed al stabilization of the thorax. Some of the exercises are illustrated via still photos while olhers can be seen on the CDROM. The information is still empirical since research is lacking in this area and comes primarily from clinical experience. This chapter reviews some of the concepts of load transfer through the body, the analomy and function of the lumbopelvic core (Lee D G, 1999) and the application of lhis protocol {'or stabilization of the thorax. Chapter 7 is written by Linda-Joy Lee (BScPT,FCAMT) and demonstrates her phenomenal ability to integrate concepts from many models. She is a superb clinician, excited by clinical and educational challenges and I thank her for laking on lhis one.

    A project such as this does not come together through individual effort and 1 would like to acknowledge the production team whose ideas and guidance have resulted in an educational producl that goes beyond my original intent. Edi Osghian from DV Media Inc. co-ordinated the project and was instrumental in putting it all together, thank you Edi and yes you were righl- a make-up artisl was a greal ideal The still photos were taken by a superb photographer, Goran l3asaric whose attenlion to detail and lighting drove us crazy for two days but in the end - I was impressed with what a little bil of light in the righl place could dol Steve Sara filmed the video clips with a camera that was almost as big as he was. No rewinds or reviews were possible - "trust me, [ got it right" - and he did. And none of the photos or video clips would have been possible without the assistance or our model, Melanie Coffey, Thanks Mel For saying "Sure, J can do that." Little did she know all that we would expect from her. 1 have collaborated on several projects with artist Frank Crymble; and once again he came lo my rescue redrawing the complicated, combined biomechanics of the thorax meeting my demands for visual simplicity, yet accuracy. His patience for my persistence has always impressed me, thank you Frank. And last, but certai n Iy not least, than k you to Lau ra Galloway for design i ng the layoul for a II of th is materia I in such a visually pleasing and easy to read format.

    There are many people who have contributed to my educational and personal growth that has ultimately allowed me to give this material to you, the clinician. J would like to acknowledge my heartfelt appreciation to Dr. Andry Vleeming, who challenged me to let go of my biases and see the human experience from a different perspective and to Karen Angelucci, who taught me to explore a different way of living in my own body through exercise in the method of Pilates. As always, I am especially grateful for my family, Tom, Michael and Chelsea who allow me the time, and provide the encouragement, so necessary to continue along lhis path of enquiry.

    British Columbia, 2003 D.L.

  • CONTENTS

    CHAPTER 1 ANATOMY OF THE THORAX

    OSTEOLOGy ....

    Vertebromanubrial Region.

    Vertebrosternal Region . . .

    Vertebrochondral Region

    Thoracolumbar Region ...

    ARTHROLOGy ................... .

    Zygapophyseal Joints . .. . . . . .. . . .. .

    Costal Joints .. .................... .

    Intervertebral Disc .. .. . . .

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

    Local System - Classification

    Global System - Classification ................ .

    Local System - Anatomy ................... .

    Global System - Anatomy ................ .

    CHAPTER 2

    ... 13

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

    . ... 1 4

    . ... 16

    .......... 18

    . ......... 20

    . ......... 20

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

    . .... 21

    . .... 22

    . .... 22

    ..... 22

    . .... 22

    . .... 22

    . .... 25

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

    INTRODUCTION.

    FIRST COMPONENT - FORM CLOSURE .

    SECOND COMPONENT - FORCE CLOSURE ................ .

    Lumbopelvic Stabilization - The Research Reviewed

    The inner unit - Local system - The core ..

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

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

    FOURTH COMPONENT - EMOTIONS & AWARENESS

    CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    CHAPTER 3 BIOMECHANICS OF THE THORAX ..

    TERMINOLOGY.

    LITERATURE REVIEW

    . .. 30

    . ..... 31

    . ..... 32

    ....... 33

    . ..... 33

    . ...... 36

    . .... 38

    ....... 38

    . ...... 39

    . .. .... 41

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

    .... 42

  • .. CONTENTS

    FUNCTIONAL MOVEMENTS

    Vertebrosternal Region ......................... .

    Flexion ..................... . .

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

    Lateral bending

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

    Vertebrochondral Region

    Flexion/extension

    Lateral bending

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

    Vertebromanubrial and Thoracolumbar Region

    F lexion/extension .................................................. . .

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

    Rotation ...

    RESPIRATION

    SUMMARY

    CHAPTER 4 DIAGNOSING THE THORACIC DYSFUNCTION

    SUBJECTIVE EXAMINATION

    Pain/Dysaesthesia

    Sleep ..

    Occupation/Leisure activities/Sports

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

    OBJECTIVE EXAMINATION

    Postural Analysis .

    Functional Movement Tests - Regional Tests

    Forward and backward bending .. ................ .

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

    Axial rotation

    Respiration ............................................................... .

    Functional Movement Tests - Segmental Tests

    Forward bending. . . . . . . . . . . . . . . .

    Backward bending

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

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

    Respiration

    ......... 43

    . ........ 43

    . ... ... 43

    . ....... 46

    ........ 48

    ....... 5 1

    ...... 53

    ...... 5 4

    .... 5 4

    ..... 55

    ... 55

    . .... 55

    . .. 56

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

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

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

    .....