Académique Documents
Professionnel Documents
Culture Documents
THE THORAX
An Integrated Approach
ISBN 0-9732363-0-2
For my momI
on human performance. This model was developed in conjunction with Dr. Andry Vleeming (Lee &
Vleeming 1998, 2002) and has been applied to the thorax in this edition, the principles of lhis model
are described in Chapter 2. Chapter 3, biomechanics of the thorax, has been updated lo include research
since the first edition was published.
Chapter 4 has been updated with video clips on a CDROM to demonstrate the aClive and passive
mobility and stability techniques previously described in the first edition. In addition, new techniques
are presented which analyse the force closure mechanism (dynamic stability) of a thoracic segmenl.
The classification of dysfunction within the thorax has been changed to follow the integraled model of
function. Chapter6 has been updated with video clips on a CDROM lo demonstrate the passive and
aClive mobilization and manipulation techniques for the thorax.
Chapter 7 is brand new for this edition and contains vital information for an exercise program aimed
al stabilization of the thorax. Some of the exercises are illustrated via still photos while olhers can be
seen on the CDROM. The information is still empirical since research is lacking in this area and comes
primarily from clinical experience. This chapter reviews some of the concepts of load transfer through
the body, the analomy and function of the lumbopelvic core (Lee D G, 1999) and the application of
lhis protocol {'or stabilization of the thorax. Chapter 7 is written by Linda-Joy Lee (BScPT,FCAMT)
and demonstrates her phenomenal ability to integrate concepts from many models. She is a superb
clinician, excited by clinical and educational challenges and I thank her for laking on lhis one.
A project such as this does not come together through individual effort and 1 would like to acknowl
edge the production team whose ideas and guidance have resulted in an educational producl that goes
beyond my original intent. Edi Osghian from DV Media Inc. co-ordinated the project and was instru
mental in putting it all together, thank you Edi and yes you were righl- a make-up artisl was a greal
ideal The still photos were taken by a superb photographer, Goran l3asaric whose attenlion to detail
and lighting drove us crazy for two days but in the end - I was impressed with what a little bil of light
in the righl place could dol Steve Sara filmed the video clips with a camera that was almost as big as
he was. No rewinds or reviews were possible - "trust me, [ got it right" - and he did. And none of the
photos or video clips would have been possible without the assistance or our model, Melanie Coffey,
Thanks Mel For saying "Sure, J can do that." Little did she know all that we would expect from her.1
have collaborated on several projects with artist Frank Crymble; and once again he came lo my rescue
redrawing the complicated, combined biomechanics of the thorax meeting my demands for visual sim
plicity, yet accuracy. His patience for my persistence has always impressed me, thank you Frank. And
last, but certai nIy not least, thank you to Laura Galloway for designing the layoul for aII of this materiaI
in such a visually pleasing and easy to read format.
There are many people who have contributed to my educational and personal growth that has ulti
mately allowed me to give this material to you, the clinician. J would like to acknowledge my heartfelt
appreciation to Dr. Andry Vleeming, who challenged me to let go of my biases and see the human expe
rience from a different perspective and to Karen Angelucci, who taught me to explore a different way
of living in my own body through exercise in the method of Pilates. As always, I am especially grateful
for my family, Tom, Michael and Chelsea who allow me the time, and provide the encouragement, so
necessary to continue along lhis path of enquiry.
British Columbia, 2003 D.L.
CONTENTS
CHAPTER 1
...13
..........1 4
OSTEOLOGy ....
....1 4
Vertebromanubrial Region.
Vertebrosternal Region .
....16
. .
Vertebrochondral Region
.......... 18
..........20
ARTHROLOGy ...................
Costal Joints.. ....................
Intervertebral Disc
..........20
Zygapophyseal Joints . .. .
. .
. .
. .
...........20
.....21
..
..
MYOLOGY . .. ...................................
.....22
.....22
.....22
.....22
.....22
.....25
CHAPTER 2
PRINCIPLES OF THE INTEGRATED MODEL OF FUNCTION . . 29
.
. .
...30
INTRODUCTION.
...... 31
......32
.......33
......33
The outer unit - The global system - The slings ........... ... . .
.......36
.....38
.......38
CONCLUSION
.......39
. . .
. . . . . . .
. . . . . .
. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .
CHAPTER 3
... .... 41
..
..
CONTENTS
......... 43
FUNCTIONAL MOVEMENTS
Vertebrosternal Region .........................
F lexion ..................... .
......... 43
. ... ... 43
Extension.. . ...........
........ 46
........ 48
Lateral bending
.......5 1
......53
Vertebrochondral Region
......5 4
Flexion/extension
Lateral bending
....5 4
Rotation
..... 55
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . ..
...55
.....55
. ..56
............ 56
Rotation ...
...........57
RESPIRATION
...................57
SUMMARY
CHAPTER 4
DIAGNOSING THE THORACIC DYSFUNCTION
........... 59
SUBJECTIVE EXAMINATION
......... .60
.......60
......... 60
Pain/Dysaesthesia
Sleep ..
..... ...60
Occupation/Leisure activities/Sports
.... .....60
...........60
...........60
OBJECTIVE EXAMINATION
........60
Postural Analysis .
.....63
.....63
64
Lateral bending..........................................
...6 4
Axial rotation
Respiration ................................................................
........6 4
. .
.......6 4
. .
..
.. .
....6 4
Backward bending
........65
.........66
Rotation .................... .
Respiration
..67
. . . . .
67
CONTENTS
.......67
... ...67
. . ... 68
Zygapophysea/ joints.
..
. . . . .
..
. . . . . . . .
..............69
. .
....70,71
Costotransverse joints
...............72
Lateral translation.
........73
..73
74
.........74
........ 75
........76
..
.........76
Lat.eral translation.
. .
..
. .
. . . . . . . .
. . .
.........76
......... 77
.........77
. . .
. .
...
. . . . . .
.........78
.........78
.........77
.........79
CHAPTER 5
.........81
. . . . . . . . .
.. .............................. .
. . . .
. . . . .
83
83
.........83
..........83
CHAPTER 6
RESTORING FORM CLOSURE OF THE THORAX
..........85
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.........88
.......88
..... 89
.
....90
..90
..
CONTENTS
Vertebrosternal/vertebrochondral region
Thoracolumbar region
..........90
........
. ........ 91
......... 91
Vertebrornanubrial regiol1
......... 91
................. 91
. .
. .
.. .
. . . . . .
. .
. .
. ..
. ........ 92
Vertebrosternal/vertebrochol1dral region
. ......... 92
....... 92
. ....... 93
.....93
. .... 93
.
Vertebrosternal/vertebrochondral regiol1s.....................................................
.......9-+
94
. .. . .. .....95
....... 96
. .
. . . .
. . .
. . .
. . 96
. ..
...... 9 7
..
....9 7
Vertebrosternal/vertebrochondral region
...... 97
. ...... 98
....... 99
CHAPTER 7
RESTORING FORCE CLOSURE IMOTOR CONTROL
OF THE THORAX
. . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
.......... 103
INTRODUCTION ................................................... .
..10-+
..105
.. 105
.. 106
. 10 7
108
. . . .
. . . . . . . . . . . . . . . . . . . . . . . .
Transversus abdo'
. . . . . . .
. .
..
.
. . . . . .
. . . . . . . . . . . . . . . .
. . . . . . . . . . . .
. . . .
..108
. .
.. .
....109
.....109
Deep fibres
.111
.....
..
112
... I j 3
CONTENTS
Neutral spine.
. . .. . ..
.
. .
. .
.....125
.....131
....124
.131
Integrated u
f nctional
.....120
.....129
Trunk-leg dissociation
T horacopelvic
...125
REFERENCES
.....11 4
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .. . . . . . . . . . . . ..
. .
. .
....133
... .134
....137
..
ANATOMY OF
THE THORAX
I!I
C I I APTER I
ANATOMY OF TH E THORAX
INTRODUCT ION
OSTEOLOGY
Vertebromanubrial Region
The first thoracic vertebra is atypical (Figs. 1.2,
1.3. 1.4). I t has a large, nonbifid spinous process,
clublike at its end. The superior aspect of the
spinous process tends to lie in the same trans
verse plane as the Tl-2 zygapophyseal joints. The
facets on the superior articular processes lie in
the coronal body plane while those on the inferior
articular process present a gentle curve in both
the transverse and sagittal planes. The transverse
processes are long and thicle They are located
betvveen the superior and inFerior alticular processes
at the dorsal aspect of the pedicle and are ideally
situated For palpation of intervertebral motion.
On the ventral aspect or the transverse process
there is a deep, concave Facet which articulates
with a convex racet on the first rib to rorm the
costotransverse joint. In the normal upright posture,
the orientation of this joint is anteroinrerior.
CIIAPTER I
Vertebrosternal Region
The vertebrae in this region (T3 to T7) have long,
thin, overla p ping spinous processes. The tip of
the spinous process can be three finger widths
inferior to the transverse p rocess of the sa me
vertebra and frequently deviates from the midline.
Consequently, it is an unreliable point for palpating
intervertebral motion.
Figure 1.6. The manubrium.
Figure 1.11. Posterolateral view of the articulated thorax, vertebrosternal region. Note the curvature of the fifth costotransverse
joint (arrow).
..
Vertebrochondral Region
The vertebrae in this region (Fig. 1. 14) (T8, 9,
10) differ from the vertebrosternal region in the
following aspects. The spinous process is shorter,
although still c1irected inferiorly such that the tip
lies close to the transverse plane of the transverse
process of the inferior vertebra. The facet on the
ventral aspect of the transverse process is flat and
faces anterolateral and superior ( F ig. 1. 15) .
Therefore, when the tubercle of the rib glides
superiorly, it also glides posteromeclially with
minimal conjunct rotation. When the tubercle
of the rib glides inferiorly, it also glides antero
laterall y following the plane of the costotrans-
with the eighth rib as well as the large superior demi-facet for
articulation with the head of the eighth rib and the small demi
facet for articulation with the head of the ninth rib.
CHAPTER I
Thoracolumbar Region
Figure 1.17. The eleventh and twelfth thoracic and the first
lumbar vertebrae. Note the orientation ofthe zygapophyseal
joints.
ARTHROLOGY
ZygapophysealJoints
Costa/Joints
The costotransverse joints are synovial and also
contain small intra-articular Folds (Giles & Singer
2000). 1l1e lateral costotransverse ligament SUPPOltS
the lateral aspect of the joint and is transversely
oriented (Fig. 1.22). It attaches to the tip or the
transverse process and inserts into the non-articular
portion of the tubercle of the rib. The superior
EI
RL=radiate ligament
MYOLOGY
Intervertebral Disc
The intervertebral discs of the thoracic spine are
narrower than those in the cervical and lumbar
regions and constitute approximatel y one-sixth
of the length of the thoracic vertebral column.
Since the ratio of the height of the disc to the
vertebral body is 1:5, motion bet\,yeen the segments
of the thorax is small. There is a linear increase
in the cross-sectional area of the disc in the lower
thorax reflecting an increase in the weight bearing
function of these levels.
IJII
while spinalus
(M).
(Reproduced
III
C I I APTER l
111
C I IAPTER 1
III
FUNCTION
2
PRINCIPLES OF
THE INTEGRATED
MODEL OF
FUNCTION
INTRO DUCTION
2.
3.
emotions.
t7
tJ
FUNCTION
2002.
..
..
Load
R2
.'
.
.
.
.
.
.
.
'
Elastic
zone
.
. '
.
.
R1
Range of motion
Panjabi 1992
Displacement
CHAPTER 2
III
CIIAPTER 2
Lee 2001).
III
CHAPTER 2
iii
Ell
TH IR D COM PONENT
M O TOR CONTROL
CONCLUS ION
\"
T1
T2
3
BIOMECHANICS
OF THE THORAX
EI
TER MINOLOGY
To fac ilitate the s u bsequen t d i sc u ss ion, the ter
Flexion
Anterior Translation
VI
z
-
-----
Figure 3.2. Flexion around the X axis induced anterior translation along the Z axis and slight distraction along the Y axis. Anterior
translation along the Z axis induced forward sagittal rotation around the X axis and slight compression along the Y axis ( Panjabi
et aI1976).
CHAPTER 3
......
..
..
.
'
.
.'
....
.....
............
..
..
..
..
..
....
Flexion
....
....
.
..
...... .
con s i d e r a b l e i n d e p e n d e n t m o ve m e n t o f t h e
ste rn u m and t he spine i s possible, "th us allowing
mob i l ity of the spi n e without forcing concomi
tant movements of (the) rib cage". T h i s i s supported
cl i n ica lly i n t h at th ree move m e n t patterns a re
apparent i n t h is region of t h e t horax and depend
on the relative flexibility between the spinal column
and t he rib cage. [n t he very you n g, (less t han 12
years of age) the head of t h e rib does not fu lly
art iculate with the i n ferior aspect of t h e s uperior
vertebra (Wi l liams et al 1 989) . In other words,
the superior costovertebral joint is not com pletely
developed prior to puberty. The secondary ossi
fica t i o n centres for the head of the r i b d o n o t
deve lop u ntil puberty; therefore, the you ng chest
CI-IAPTER 3
Extension
Posterior Translation
Figure 3.5. Extension around the X axis induced posterior translation along the Z axis and slight distraction along the Y axis.
Posterior translation along the Z axis induced backward sagittal rotation around the X axis and slight compression along the Y
axis (Panjabi et aI1976).
'
.
, .
, .
, .
.'
.'
.
.
.
.
.
.
.
.
.
.'
.'
.'
-.
..
..
: J:'*
. .
. _,
f
.. .
...
...
..
.
'
.
.
.
.
.'
.
.
.
.
.
.
III
CHAPTER 3
respi ration ,
Lateral bending
III
Right Translation
Figure 3.B. Right sideflexion around the Z axis induced left rotation around the Y axis and right translation along the X axis.
Right lateral translation along the X axis induced right sideflexion around the Z axis and left rotation around the Y axis
(Panjabi et aI1976).
Figure 3.9. As the thorax sideflexes to the right, the ribs on the
right approximate and the ribs on the left separate at their
lateral margins. The costal motion stops first, the thoracic
vertebrae then continue to sideflex slightly to the right.
Rotation
..
IjI
CHAPTER 3
. "
Figure 3.13Q The costocartilage ofthe left sixth rib was removed
..
Figure 3.14. The osteokinematic and arthrokinematic motion proposed to occur in the vertebrosternal region during right rotation
of the trunk.
At t he zyga p o p hysea l j o i n t s, t h e l e f t i n fe r i o r
articular process of t h e s u perior vertebra gl i des
superolateral ly, the right i nferior art i c u l ar process
gl ides i n feromed i a l l y to f ac i l i tate right rota t i o n
and right s ideAexion of t h e t horacic vertebra.
Vertebrochondral Region
/..
::::::
:'7
::: .
6th
{'.){!.;:::.,
"""
ID
C HAPTER 3
Flexion/extension
Lateral bending
..
t h e c o s t a l e l e m e n t s . The c o u p l e d m ove m e n t
pattern for rotation here c a n b e i p s i latera l side
Aexion or contralateral s ideAexio n . The coronally
orie nted facets of the zygapophyseal joints do not
dictate a coupl i ng of si deAexion when rot ation is
i nd uced. The small superior costovertebral joint
a n d t h e lack of a d i rect a n terior attac h me n t of
t h e assoc i ated r i b s fac i l i tates t h i s flex i b i l i ty i n
motion pattern i ng.
Rotation
Vertebromanubria/ and
Thoraco/umbar Region
Flexion/Extension
C HAPTE R 3
B IOMECHANICS OF T H E THORAX
Lateral bending
Rotation
C o n s i d e ra b l e flex i b i l i t y of m o t i o n cou p l i ng i s
a p p a re n t i n t h e t h o ra c o l u m b a r j u n c t i o n .
Anatomical ly, t h e lower thoracic levels (T J 0, T I J )
a re designed to rotate wit h m i n i m al resl rict ion
from the ri bs. Passively, the T1 J - J 2 segment can
b e p u re l y rotated about a vertical axis w i t h no
restriction from the zygapophysea l joi n l s or l he
ribs. Act i vely, t h e coupled movemenl pat tern for
rotation in t h is region can be ipsi lateral s ideflex
i o n or co n l ra l a le ra l s i d e fl exion. The coro n a l l y
oriented facets of the zyga pophyseal joints do not
d ictate a specific cou p l i n g of sideflexion when
r o t a t i o n is i n d u c e d . T h e a b s e n c e o f a c o s l o
transverse joint and t h e lack of a d i recl anterior
attac h m e n t of the assoc iated ribs fac il itates t h is
flex i b i l ity i n motion p a t t e rn i n g at t he eleve n t h
and twe l ft h segmenls.
RES P IRATIO N
SU M MARY
4
DIAGNOSING
THE THORACIC
DYSFUNCTION
SUBJECTIVE EXAMINATION
OBJECTIVE EXAMINATION
----
Mode of Onset
Postural Analysis
a recurring problem?
Pain/Dysaesthesia
Sleep
Are the symptoms interfering with sleep? What
kind of bed is being slept in and what position is
most frequently adopted? Does rest provide relief?
Occupation/Leisure activities/Sports
therapy?
General Information
Age
Name
Dr.
I l""U'Iil",;mr; ro.l'.ili,
Past Treatment
Past History
;/;rr;rJ'..I'f' ':+Hif:+if'
Location
IIA
Imm
Surface/Position
fl/, ,
Aggravating Activities
Bowel/bladder symptoms
Status in a.m.
Night Wakening
Medication
Adjunctive Tests
Distal paraesthesia
Relieving Activities
Occupation/sport/hobbies
'*'
secondary to osteoporosis.
Lateral bending
Axial rotation
Respiration
With the patient standing or sitting she is instructed
to take a deep breath in and a long breath oul.
Any asymmetry of chest expansion and release is
nOled and when presenl requires further specific
mobility testing to determine the cause.
Functional Movement Tests
Segmental Tests
Forward bending
Backward bending
The following test is used to determine the
osteokinematic function (active mobility) or lWO
adjacent thor acic vertebrae during backward
bending of the head/trunk. The transverse processes
of two adjacent vertebrae are palpated with the
index fingers and thumbs o f both hands (Fig.
4.12a,b). The patient is instructed to backward
Lateral bending
T h e fo l l ow i ng t e s l i s used t o d et e rm i n e t he
osteokinem a t i c function (act ive mobi l i ty) of two
adjacent t horacic vertebrae during lateral bend ing
of t h e h ead/trunk. The t ra n sverse processes of
two adjacent vertebrae are palpated with the index
fingers and t h umbs of both hands. The patient is
instructed to lateral bend the head/t runk and t he
quant i ty and d i rect ion of motion is noted. I n the
Rotation
The fo l l ow i n g t e s t i s u s e d t o d e t e rmi n e t h e
osteoki nematic function o f two adjacent t horaci c
vertebrae d u ring rotation of t he head/tru n k . The
tran sverse processes of two a djacent vertebrae
are pal pated with t he index finge r a n d t h umb of
bot h h a n d s . The patient is i n st ructed to rotate
the head/t r u n k and the quant ity and direct io n of
motion is noted. 1 n the u pper t horax (vertebro
ma n ubri a l ) and th e vertebrosternal regions, the
supe rior t h o racic vertebra should l ateral be n d
and rotate to t h e same side such that t he superior
t ran sverse p rocess on the side of t he concavity
move s d o rs a l ly a nd i nfe r i o rly. Be l o w T7, the
d irection of the conj unct lateral ben d i s variable.
It may be eit her to the same s i de as t he rotat ion
or to t he oppos ite side.
Th e fo l l ow i n g test i s u s e d t o d e t e rmi n e t h e
osteokinematic fun c t i o n of a rib a n d the vertebra
of t h e s a m e n u mber d u r i n g ro t a t i o n of t h e
head/t r un k . The transverse p rocess i s pal pated
with the t h u mb of one h a n d . The rib i s pal pated
just l a teral to the tubercle and med i a l to the angle
w i t h t h e t h u mb o f t he o t h e r h a n d . The i n dex
finger of t h i s hand rests a long t he shaft of the rib.
The patie n t is instru cted to rotate the head/t ru n k
a n d t h e relative motion between t he transverse
p rocess and the rib is noted .
Respiration
T h e follow i n g t e s t i s u s e d t o d e t e r m i n e t h e
osteoki n e ma t i c fun c t i o n of a r i b relative to t h e
vertebra o f t h e same number d u r i n g respi rati on.
The transverse process is palpated with the thumb
of one hand. The rib is palpated just l ateral to t he
t u bercle a n d medial to the angle w i t h t he t h umb
of the other h a n d . The index finger of t h is h a n d
res t s a l o n g t h e s h a ft of t h e rib. Th e pat i e n t i s
in s t r u c t e d t o b re a t h e i n fu l l y a n d t h e r e l a t ive
mot i o n between the t ran sverse p rocess a n d t he
r i b i s n o t e d . The p a t i e n t i s t h e n i n s t ru c t e d t o
breathe out fully and t h e relative mot ion between
the t ran sverse p roc ess a n d the rib is n oted .
Articular Function - Form Closure
Figure 4.1SU,b. Articular function - form closure. Passive mobility test of arthrokinematic function- points of palpation to test the
superior glide of the right T4-5 zygapophyseal joint.
PI
Figure 4.16a,b. Articular function- form closure. Passive mobility test of arthrokinematic function - points of palpation to test the
inferior glide of the right T4'5 zygapophyseal joint.
Figure 4.17a,b. Articular function - form closure. Passive mobility test of arthrokinematic function - points of palpation to test the
inferior glide of the right fifth costotransverse joint.
Figure 4.18a,b. Articular function- form closure. Passive mobility test of arthrokinematic function - points of palpation to test the
anterolateroinferior (arrow) glide of the right 9th rib.
Figure 4.19a,b. Articular function- form closure. Passive mobility test of arthrokinematic function - points of palpation to test the
inferior glide of the right 1st costotransverse joint.
III
Figure 4.2oa,b. Articular function - form closure. Passive mobility test of arthrokinematic function - points of palpation to test
the superior glide of the right fifth costotransverse joint.
III
CI-IAPTER
Figure 4.210,b. Articular function - form closure. Passive mobility test of arthrokinematic function - points of palpation to test the
posteromediosuperior glide ofthe right 9th rib. The T9 transverse process is glided anterolateroinferior.
Figure 4.220,b. Articular function - form closure. Passive mobility test o farthrokinematic function- points o fpalpation t o test the
superior glide ofthe right first costotransverse joint.
III
Figure 4.26a,b. Articular function - form closure. Passive stability test for arthrokinetic function - points of palpation to test
anterior translation (spinal).
111
Figure 4.29a,b. Articular function - form closure. Passive stability test for arthrokinetic function - points ofpalpation to test
anterior translation (posterior costal).
III
Figure
4.30a,b. Articular function - form closure. Passive stability test for arthrokinetic function- points ofpalpation to test
m ove ; t h i s i s a n o r m a l biom e c h a n i c a l c o ns e
quence. Therefore, when i nterpreting t he f i n d i ngs
from t h i s t e s t i t i s i m port a n t t o o bse rve w h a t
h appe n s i n t h e t h o rax d u r i n g t he m o m e n t t he
arm begi ns to l i ft . The provocation of a ny pa i n is
also noted a t t h is ti me. The t horax is t he n com
pressed pass ively ( F ig. 4 . 3 4 ) by approxi m a t i n g
the ribs ( noted t o b e mov i n g d u ring t h e fi rst pa rt
III
FORCE CLOSURE
5
CLASSIFYING
THE THORACIC
DYSFUNCTION
III
INTEGRATED MODEL OF
FUNCTION CLASSIFICATION
Functionally, motion of the thorax can become
restricted or poorly controlled due to either excessive
or insufficient articular compression. In keeping
with the integrated model , the causes for the
thoracic impairment can be due to dysfunction of:
6
RESTORING
FORM CLOSURE
OF THE THORAX
t h e d egree o f p h ys i c a l a c t i v i t y w h i c h tends to
aggravate it a n d the a m o u n t of rest req u i red to
relieve it. The intervertebral d isc herniation causes
excessive compression of t he thorax due to secondary
m usc l e spasm/h ype rt o n i c i t y. Spe c i fi c a n d/or
regional d istraction tec h n i q ues as wel l as m usc le
release/decompression techniques are often helpful
for relievin g pain . In addition, postu ra l education,
t aping for support and t i me complete the man
age m e n t of this con d i t io n .
EXCESSIVE ARTICULAR
COMPRESSION - STIFF JOINT
m i d s t o f a n o t h e r w i s e n o r m a l c u rve .
Mu lli segm e n t a l s t i ffness tends to a l t e r t he
primary l horac ic curve and can be exaggerated
(kyphosis), reduced (lordos is) or twisted (roto
scoliosi s ) .
Bot h t he segmental s t i ff j o i n t a n d t h e m u l t i
segm e n t a l s t i ff region p resent w i t h a consis
tent pattern of restriction on segmental passive
m o b i l i t y le s t i ng. I n c re a s e d s t i ffn ess i n t h e
neutral zone and a harder e n d feel i n t he clastic
zone a re noted on passive tests for a rt h rokine
matic fu nction. The stiff join t has a solid stop
which does not vary w i t h the speed of t he test .
iii
6.
Adjunctive tests.
Figure 6.1. Bil ateral fiexion restriction - vertebromanu brial region. Longitudinal traction - supine.
IE'
A l t e r n a t e l y, d i s t rac t i o n c a n be d o n e w i t h t h e
pat ient e i t her silt i ng or st and i ng w i t h bot h hands
beh i n d t he neck, flllgers i n terlaced. The t herapist
w i nds bot h of t he i r arms benea t h t he pat i e n t 's
ax i l l ae t h rough t h e t ri a n gu l a r space c reated by
t h e Aexed e l bows. The fingers are i nterlaced and
p l aced ove r t he pa t i e n t 's h a nds ( F ig. 6.2) . The
t h o rax is gen t ly gripped by adduct ing the arms.
The pati e n t is i nst ructed to look forward and t he
t herapist e nsu res that the l igame n t u m n uc hae is
not on fu l l st re t c h . From t h i s posit ion, a Grade
3 to 4 longi t u d i n a l t raction tec h n ique is applied
by roc k i n g t h e pat ient bac kwa rds a n d forwards
u ntil a pen d u lar type mot ion is prod uced. Gravity
provides the dist ract ive force. A h igh ve loc ity, low
a m p l i t ude t h rust tec h n i q u e (Grade 5) c a n be
a pp l i e d at t h e apex o f t h e desc e n t w h e n t h e
pat ient's body weight is d ropping.
To m a i n t a i n t he mob i l i t y ga i ned, t he pat ient is
inst ructed to perform t he following exercise. With
the fi nge rs i n t e rl aced beh i nd t he neck and the
i ndex fingers in t he appropriate interspinous space.
t h e pa t i e n t is i nstructed to Flex t h e head/neck.
The fingers may assist t he motion by applying a
..
vertebromanubrial region.
s ligh t l y e x t e n di n g t h e s u pe r i o r v e r t e b r a . T h e
techn i que c a n be graded from 1 to 4 .
..
Vertebromanubrial region -
Thoracolumbar region -
Th i s d y s Fu n c t i o n w i l l re s t r i c t flex i o n of t h e
head/nec k . Rot a t ion a n d lateral be n d i n g o f t he
head/neck to t he opposite s ide of t h e rest r i c ted
rib and fu l l i n s p i ra t i o n w i l l a lso be l i m i ted . The
i n ferior glide of the first rib at t he costotransverse
j o i n t w i l l be restricted.
EXCESSIVE ARTICULAR
COM PRESSION -
----===
Th i s dysFu n ct i o n i s s e e n w h e n t h e costotran s
verse joint i s restricte d . It is com mon to see both
a n t erior a n d posterior rot a t i o n restricted w h e n
t h i s joi n t i s brotic a n d d istraction of t h e j o i nt i s
t h e m ost effective tec h n i q u e For mob i l izatio n .
O n c e a ga i n , t h e p a t t e r n of re s t r i c t i o n o n
segme n t a l p a s s i v e m o b i l i t y t e s t i ng c a n b e
'
variable with joi nts wh ich are bei ng compressed
by the n e u romyofascial system. Wh i le u n d e r
com p ress i o n , i n c reased s t i ffn ess i s p a l p a b l e
within t he neutral zone a n d while the stiff j o i n t
h a s a solid end fee l w h i c h does n o t vary w i t h
the speed o f t h e test, the compressed j o i n t i s
somewhat softer and t h e a m p l i t ude o f motion
can vary w i t h the speed of the test . When the
glide is appl ied rapid ly, t he amplitude of motion
may be l ess t h a n if t he glide i s appl ied s low ly.
This rdlects t he neuromyofasc ial cause of t h e
a rt ic u l a r c o m p ress i o n . T h e passive t e s t s for
arthrok i net i c fu nct ion ( pass ive s t a b i l i ty) a re
oft e n , but not always, norm a l .
C HA PT E R 6 R E STO R I N G F O R M C L O S U R E OF T H E T H O RAX
6.
Adjunctive tests .
Fixation ofthe
costotransverseJcostovertebraljoint
Vertebromanubrial region superior fixation right 1 st rib
Vertebral Body---,
Superior
Costovertebral Joint
Rib
Inferior
Costovertebral Joint
Horizontal
Intra-discal Cleft
or t h e s u p e r i o r vert e b ra occ u rs w h e n t h e l e ft
lateral translat ion exceeds the physiological motion
barrier and t he vertebra i s u nable to ret u rn to its
n e u t ra l pos i t i o n . For t he f'ixat i o n to occ u r i t i s
p ro posed t h a t a h o r i zo n t a l c l eft t h ro u gh t h e
posterior 1 /3 o r the i ntervertebral d i sc must occu r
( F ig. 6 . J 9 ) .
I . Postura l
6.
Adjunctive t ests.
the left and right sixth ribs i n a motor vehicle accident one
month prior. Note the complete block of right rotation at the
fixated segment.
Em
C H A PT E R 6 R E STO R I N G FO R M C LO S U R E O F T H E T H O RAX
Figure 6.21. M a n i p u lation tec h n i q u e for a left lateral shift of the sixth ring. Strong d istraction m u st be maintained throughout
R E STO R I N G FO R M C LO S U R E O F T H E T H mAX C H A PT E R 6
THE
(OMPRElIOR"
0;;;-
--...._,
""' ......
.::
7
RESTORING
FORCE CLOSURE/
MOTOR CONTROL
OF THE THORAX
Written by Linda-Joy Lee
C HAPTE R 7
INTRODUCT ION
m e n t a n d t i m i n g . T h e re fo re , w h e n p l a n n i ng
exerc i se i nterve n t ion c l i n ic ians m u s t re m e m be r
t h at "exe rc ise A" does not guarantee t h e use of
"musc le A". I t is u p to t h e c l i n ic ia n to obse rve,
assess, and decide if "exerc ise A" i s reac h i ng the
goa l of t ra i n i n g " m u s c l e A " ( w i t h a p p ro p r i a t e
rec ru i t me n t , t i m i ng, e n d u rance, e t c . ) for each
pat i e n t . The key t o c o r rec t i ng d y s fu n c t i o n a l
patterns of muscle activation is teaching awareness
of movement; t h i s req u i res m i n dfu l ness on t h e
part of bot h the t h e rapist and the pat i e n t .
Wi t h respect t o t h e t horax, i t i s the coordi n a ted
action between t he local and global m uscle systems
t hat ensures sta b i l ity without rigidity of pos t u re
and wit hout episodes of colJapse. Th i s is the goa l :
"Mobil ity o n Sta b i l i t y" . The exerc ises p resen ted
i n t h i s chapter foc us on ba l a nc i ng tension a n d
com pression forces and i nvolve an extens ive use
of i mage ry. I n t h i s man ner, i n d i v i d ua1 m u scles
are recruited and appropriately t imed for the coor
d i n a t e d exe c u t i o n a n d c o n t ro l of fu n c t i o n a l
move men t .
The t h orax i s a c e n t ra l a re a i n t h e s p i n e t h a t
t ransfers loads between the lower quadrant ( lower
ext re m i t ie s a n d l u m b ope l v i s), a n d t h e u p p e r
q u a d r a n t ( u p p e r e x t re m i t i es a n d n e c k ) . T h i s
fun c ti o n i s h ighl ighted i n athletic act i v i t i es such
Multifidus
Sacrum
Diaphragm
Pelvic Floor
foc u s m o re a n t e r i o r (vagi n a l o r u re t h ra l ) t h a n
p o s t e r i o r ( re c t a l ) . H owever, i t i s i m po rt a n t t o
recogn ize t h a t i F a s u ccessFu l i solated TA con
t ract ion occ u rs with verbal c u e i n g of t h e pelvic
floor, it can not be gua ra nteed t hat a proper con
t rac t i on of t h e pelvic floor has occ u rred, espe
cia l l y i n t hose pat i e n t s w i t h speci fic pelvic f l oor
dysfunction (eg. stress i ncontinence, pain syndromes,
t ra u m a ) . B u m p et al (199]) fou n d t hat only 49%
of female patients prese n t i ng in a gynecological
and urodynamic laboratory could perform a correct
p e l v i c floor c o n t ra c t i o n w h e n given verba l or
written i nstruct ions. Thus, i f the t herapist suspect s
either hyperton i c i t y or poor recru i t me n t of' t h e
pelvic noor m u s c u l at ur e , a refe rra l to a t h e ra p i st
spec ial izing in pelvic f loor dysfu nction and manual
assessment of the floor is reco m mended.
Pelvic floor
Sapsf'ord et a I (200 1 ) have shown t hat act ivat i o n
of' the abdom inal muscies should accompany con
t ract ion of' the pelvic floor mu sc les and vice versa.
I mages and explanat ions that i nvolve contraction
of the an terior pelvic f l oor (pu bococcyge u s ) are
usel'u l rac i l i t a t ion tech n i q u es f' o r obt a i n i ng a n
isolated t ransve rsus a bdom i n i s (TA) contraction
and are descri bed below. Sapsrord et a I 's research
su pports u s i ng a su bmaxi mal con t rac t i o n of t h e
pelvic noor i n a pos i t ion o f n e u t ra l pelvic t i l t to
best fa c i l i t a t e c o n t rac t i on of TA . Tra i n i n g t h e
tonic fu nct ion o f the pel\ric noor m uscles i nvolves
a s l ow, ge nt le, s u b m axi m a l con t ra c t i o n , w i t h a
Transversus ahdominis
Patie nt pos i t i o n : The i ni t i a l posi t ion chosen to
m e d i a l t o a n d s ligh t l y i n fe r i o r t o t h e A S I S
( a n terior s u perior i liac s p i ne ) b i latera l ly (see
F igure 7 . 2 ) . The pat ient should be taught how
to p a l pa t e h e re for a p roper c o n t rac t i o n . I n
sidelyi ng, t h e t herapist can also ge ntly c u p t he
l o w e r a b d o m e n w i t h t h e p a l m t o p ro v i d e
feed back o f wh ere t h e contraction should be
i n i t i a t e d . O b s e rve t h e a bd o m i n a l wa l l a n d
tru n k for signs o f proper isolation without global
m u scle activa t i o n .
a d d i n g t h e g l o b a l m u scles w h i l e
m a i n ta i n i ng a n e u t ral s p i ne pos i t i on
moving out of neutral spine pos i t ion with
global m uscle activity
i ntegration i nto fu nctional act ivit ies
Breathing
Optimal d i a p h ragmatic breat h i ng i nvolves both
abdom inal and lower ri bcage expansion ( Detroyer
1 9 8 9 ) . The most com m o n c o m p o n e n t l o s t in
'D
where the patient needs to d i rect their breath, and releases this
pressure as the patient begins inspi ration. In this example, the
patient is using one hand to monitor for excessive apical chest
movement. The hand can also be placed on the lower
abdomen to monitor excessive movement there.
" As you brea the o u t , let the air fal l out of you
and re lax yo u r stomach"
" I magine I a m slowly p u ll i ng the air out of you "
"Thi n k of sighing t h e air o u t as you breathe
out"
Neutral spine
S i t t i n g ( see F i gure 7 . 4 , Video C l i p
7.5)
III
" I m ag i n e t ha t you r s t e rn u m i s be i ng ge n t l y
l i fted"
For a decreased l u m b a r l ordosi s ( fl exed l u m ba r
spi ne) :
" I magi n e a s t r i n g att ached t o your t a i l bone,
and someone e l se i s gen t l y p u l l i n g t h e s t r i ng
u p to heave n"
hG row t a II From t h e tai I bone"
control are the stern u m and the l u m bar spine. Patient points
of control are the sternum and the superior pubic bone. The
therapist's hand helps the patient create a "sinking" or
I l i a c c re s t s a n d h i p fo l d s ( t o fac i l i t a t e
a n terior pelvic t i l t over h i ps )
A s t he verbal c ues are given, t he t herapist uses
the po i n t s of c o n t rol to c reate t h e ideal c u r
vat ures. To faci l itate i ncreased thoracic kyphosis,
the h a n d on t h e ste rn u m c reates an i n ferior
and posterior pressure. To decrease an excessive
kyphos i s , the h a n ds l i ft t h e rib cage from t he
s i d e s or give a superior a n d s l igh t ly a n terior
p res s u re at t he l evels of excessive c urve. To
correct a flat l u m ba r s p i ne, t h e fi nge rs p u s h
gen t ly anterior and superior, c reat i ng a " l i ft i ng"
sensat ion . For a n excessive l u m ba r lordos i s at
one or two segm e n t s , foc u s on Fac i l i t a t i ng a
lordosis at levels above or below t hat are f l exed,
and then "lengthening" or "stretc h i ng" the curve
at the hyperextended segme n t ( s ) .
The b re a t h c a n be u sed t o ra c i l i t a t e t h e
proper c u rves as we l l - " breathe deeply and
a l low t he a i r to f i l l the spacc : "
Between you r s h o u l d e r b l a d e s ( i r
m idt horax i s lordot i c )
R E STO R )
7.6)
O n c e t he s p i n a l c u rves a re corrected i n t he
sagi ttal plane, correc t ions can be made to any
rotat ion/sidebe n d i ng Fa u l t s . It i s i m port a n t to
rea l i ze t h a l t he pos i t i o n of t h e sc a p u l a a n d
altered activity or lengt h/strength relat ionsh i ps
of the scapu lot horac ic m uscles can have a s ig
n i ncant i m pact o n the posit ion a n d fu nct ion
of t h e t horacic s p i ne.
excessive a c t i v i t y i n t h e globa l m u s c l e s ( t o
re lease braCi ng) a n d a l l ow you to move a n d
s u p port t he t horax i n to a n opt i ma l pos i t i o n .
T h e ra p i s t Fa c i l i t a t i o n : M a n u a l a n d Ve r b a l
C ue s : H a nd s on t h e latera l aspect of t h e r i b
cage. Fac i l itate a " l i Ft" a n d "lengtheni ng" o f the
rib cage on the side of the sidebending concavity.
G ive left or right lateral pressure to correct a
s h i fl . U sc w i ggl i n g of t h e t h o rax t o release
O n e h a n d u n d e r scapula, o n e h a n d on i l iac
c rest; ask the patient to " I magi ne t hat the
d istance between my hands i s lengthen i ng" ,
"open t h e s pace between my h a n d s . "
E n c i rc le t he rib cage w i t h o n e arm a n d usc
the other hand to s up port t h e s ide c losest
to you . P rov i d e ge n t l e t ra c t i o n (" Let m e
s u p po r t yo u r r i b cage " ) a n d l a t e ra l l y
t ra n s late/rotate t h e rib cage i n to a n e u t ra l
pos i t i o n ( Sec Video C l i p 7 . 6 ) .
Ask t he patient t o maintain t h e new pos it ion
a n d b rea t h e normally ( see c o n s i de ra t i o n s
a bove) .
Figure 7.7 Neutral Spine: Standing Forward Lean on Wall. This i s a useful position to train the abi lity o fthe thorax t o transfer
loads through a weight bearing u p per extremity. Prior to adding arm movement, the patient must be able to atta in and m a i ntain
control of a neutral spine position. I n this example, the therapist uses one arm to support and gently traction the lower thorax.
Subsequently, an inferior-posterior force is applied, thus faci l itating an ideal thoracic kyphOSiS. The caudal hand provides a gentle
cranial and anterior pressure to facil itate a lumbar lordosis i n the flexed l u m bar segments. Verbal cues are given concurrently with
the manual fac i l itation.
""
C I I A PT E R 7
7. 8 )
Figure 7.8 Neutral Spine: 4 Point Kneeling. This position i s more challenging and a progression from the Standing Forward Lean on
Wall position. Prior to adding arm or leg movement, the patient m u st be able to attain and maintain control of a neutral spine
position. In this example the therapist uses the cranial arm under the rib cage to produce a thoracic kyphosis at the desired levels with
a posterior force (lifting the rib cage) . The caudal hand produces a cranial and anterior pressure in the lumbar segments to create a
lordosis, while the verbal cues oflengthening through the low back, letting the buttocks go wide and releasing the hips are given.
M a n u b r iost e rn a l sy m p h y s i s ( fo r l os s o f
up per t horac ic kyphos i s )
S u pport u n d e r l o w e r r i b cage ( ['o r l o s s of
lower t horac ic kyp hos i s )
Posterior t horax along s p i ne ( for excessive
t horacic kyp hos is)
Lu m bar s p i n e s p i nous processes (at leve l
wh ere more lordos is is req u i red or where
c u rve needs lengt h e n i ng)
I l i ac c rests ( to fac i l i tate more even l u mbar
lordosis/lengthe n i ng t h rough spi ne, an terior
pelvic t i l t over h i ps)
I J i p c reases ( t o fac i l i t a t e h i p Fo l d i n g a n d
widening o f b u t t ocks)
C I I A PT E R 7
pa l p a t e b i l a terally a n d c l o s e t o t h e s p i no u s
p rocesses a t t h e leve l y o u w a n t t o fac i l i t a t e .
O n e hand w i l l fac i l i tate t h e segm e n t a l con
t raction by lett i ng t he fi ngers or t h u m bs s i n k
t i o n w i t h rhom b o i d s a n d m i d d l e t ra pe z i u s
m u sc les. You should see no erector s p i nae o r
sca p u l a r m u scle activi ty.
Progress i o n s/Ot her c o n s i derat ions:
" C o n n e c t a l i n e from m y fi n ge r h e re to m y
fi nge r here"
M a n u a l c u es/Key p o i n t s of c o n t ro l : P rovide
Table 7.1
Program for Stabilization
ofthe Thorax
I!!I
C H A PT E R 7
Exercise Progression -
7.3)
I ntrathoracIc
Thoracopelvlc
TQble 72
Adding the Global
Muscle System
Foc u s on l ow load a n d c o n t ro l of
movemen t .
U se " Key Po i n t s o f Control" to p rovide
tactile feedback and assist control at the
level s where segmental hypermobi l i ty or
m u l t i segmental c o l lapse occurs.
Avoid fast ballistic movements.
Progress from stable to u nstable surfaces
to i n c rease proprioceptive i np u t a n d
challenge .
M o n i t o r b rea t h i ng p a t t e r n a n d avoi d
bracing/rigi d ity.
I ncorporate local muscle co-con t raction
i n to daily fu n c t i o n a l activities as early
and as often as possible.
Foc us on co-contraction and contro l of
pos i t ion i n stead of s i ngle m uscle
stre ngthen ing.
Uppe r/m i d d l e t h orac i c dysfu nc t i o n :
ensure i ntegration with arm movements;
midd l e/lower t ho rac ic dysfu nc t i o n :
e nsure i ntegration w i t h l e g movements;
m a ny fu n c t i o n a l a c t i vi t ies regu i re
i n tegrat ion of whole kinetic c h ai n .
I f h igh load and h igh speed activities are
reg u i red, add at e n d s t ages . C o n t i n u e
w i t h concurren t l o w load exercises.
Design exerc ise progressions based on
i n d iv i d u a l pat i e n t prese n t a t i o n and
fun c t ional reg u i rements.
Tab/e n
III
1 ) S u pi ne
Patient position : C rook lying i n neutral spine
on a flat s u rface; can p rogress to l y i ng on a 1 12
r o l l or other u n s u pported su rface. A r m s a re
P rogress from b i l a t e r a l t o u n i l a t e r a l
move m e n t s of t h e a r m s . B i l at e ra l
movements w i l l provide more c h a l l e nge t o
nexion/exte nsion control i n t he thorax, while
u n i lateral movcments w i l l provide challenge
to rotational contro l .
2 ) S it t i ng
Pat i e n t pos i t i o n : S i t t i ng on a firm s u rface,
Figure 7.12 Maintaining Neutral Spine while adding Load: Trunk-Arm Dissociation. Supine.
The therapist mon itors control of lateral shift at the rib cage and observes for rotation of the thorax as the patient moves the right
arm into abduction.
EI
d e m o n s t rates a p rogre s s i o n of t h e
exerc i se to u n i latera l p u l l dow n s .
Video C l i p 7 . 1 4 T h e pat ient is s i t t i ng o n
a ball with t he t horacic spine i n a start i ng
pos i t i on of r i g h t s i d e be n d i n g a n d left
l a t e r a l s h i ft . The t he ra p i s t m a n u a l l y
fac i l i t a t e s a n e u t ra l s p i n e pos i t i o n by
correc t i n g t h e r i gh t s i d e b e n d a n d
exten s i o n . The pati e n t connects to the
local stab i l i zers and t h e n p u l l s t he arm
i n t o a d i ago n a l flex i o n pa t t e rn . The
t herapist con t i n ues to prov ide feedback
t o p reve n t col l a pse o f the t h o rax i n t o
right s idebe nd i ng d u r i n g the exerc ise.
3 ) S u p ported S t a n d i ng/ Stand i ng
The same arm m ove m e n t s descri bed a bove
for t he sitting posi t ion can be used in supported
s t a n d i ng ( w i t h t h e b a c k aga i n s t a wa l l ) o r
s t a n d i n g (see F igure 7 . 1 5 ) . To c h a l l enge t h e
base of s up port fu rt her, c h a nge t h e pos i t ion
of the feet to a l u n ge stance, t hen to stan d i ng
on one leg, w h i l e m a i n t a i n i ng neu t ra l s p i n a l
al ignment and perform i ng t he arm movements.
4 ) Prone on Ball ( F igu re 7 . 1 6 )
Pat i e n t pos i t i o n : K n ee l i ng prone over a ball
w i t h t h e t horax posi t ioned so t hat the c u rve of
t he ball fac i l i tates mai ntenance of t he n e u t ral
t horacic kyphos i s . If add i t ional su p port in the
thorac ic c urve is needed (for excessively lordot ic
c u rves) a towe l rol l can be p l aced vert i c a l l y
u nder t he stern u m .
Exercise i n struction: C u e t h e image t hat facil
PI
slowly lifts the arm. The arm does not have to move th rough
aberrant movements as the patient lifts the arm from the floor.
5 ) U p p e r Ext re m i t y We i g h t B e a r i n g ( C l osed
Ki net i c C h a i n )
Patient pos i t i o n : The Stand i ng Forward Lean
on Wa l l pos i t i o n is t h e s t a rt i n g pos i t io n For
t ra i n i ng load t ransfer t h rough a weight bearing
u p per extre m i ty.
Exercise i nstruction: Th e t herapist Fac i l i tates
a n e u t ra l s p i n e p os i t i o n a n d t h e n c u e s t h e
segm e n t a l m u s c l e c o n t rac t i o n . S t a rt w i t h
b i l at e ra l control b y i ns t ruc t i ng t h e p a t i e n t to
pe rform a push u p action; ask t h e pat i e n t to
keep the thorax still (no collapsing i nto extension)
and let the move m e n t occur as a h inge from
the feet so t ha t t h e s p i n e s tays connected as
one u ni t .
Progre s s i ons/Other c o n s idera t i o n s :
P rogre s s fro m t h e wa l l to Fo u r Po i n t
Knee l i ng; sec F igu re 7. 1 8.
For t he one arm l i ft , s t a rt w i t h t h e hands
p l aced c l ose t oge t h e r ( n a rrow ) , t h e n
progress to h a n d s wider apart .
If t he exercises can not be controlled in the
Sta n d i ng Forward Lea n on Wa l l pos i t ion,
do not progress to Fou r Po i n t Knee l i ng.
1 ) S u p i ne
Leg load i ng exerc ises a n d t h e i r p rogress i o n s
have been descri bed as exerci ses to t ra i n l u m
bope lvic control ( Lee 200 1 , Richard son et a i ,
1 999, Sahrmann 200 1 ) ; examples incl ude heel
s l i des, bent I nee fal l-outs, and one leg alter
nat i ng leg lifts performed from t he start position
of c rook lyi ng. These exerc ises c a n be c h a l
lengi ng for pat ients w i t h thorac ic dysfu nction ,
especially when t he dysfu nction is in the middle
to lower thorac ic regions. Compensatory shifts
and loss of cont rol of t he neutral spine position
ca n be observed . Fo r a descri p t i o n of t h ese
exerc ises the reader i s referred t o the above
sources. The key to applyi ng t hese exerc i ses
to t horaci c stabil ization is the focus on t horac ic
segmental cont rol and maintain i ng t he correct
relat i on s h i p between t h e l u m bope l v i s a n d
t horax ( n e u t ra l s p i ne ) d u ri ng l e g movements.
2 ) S i tL ing
I n this posit ion Tru n k Leg Dissoc iation exercises
can focus on eit her a) movement of t he tru n k on
the h i ps or b) movement of the legs u nder the
trun k .
-
mJ
C H A PT E R 7
4 ) U p p e r E x t re m i ty We i g h t B ea r i n g ( C l osed
K i ne t i c C h a i n )
Pat i e n t pos i t ioning a n d c u e i ng is t h e same as
For Tru n k-Arm D i ssoc ia t i o n ( p ro n e on b a l l ,
fou r poi n L knee l i ng), but the exercise movement
i nvolves I i h i n g one leg at a t i me i nto extension
or d iagonal extension movements.
Exerc i se i n s t ru c t i o n : C u e lu mbopelvic a n d
segmental t horacic local m uscle recru i t m e n t ,
a n d i n struct t he pat ient to keep t h e l e g st i l l
and the knee I'orward w h i Ie rotat i ng the pelvis
and t ru n k as one u n i t over t he leg (spin pe lvis
over re mora l head ) . C ue t h e i n i t iat ion of t he
rot a t i o n move m e n t com i ng from j u s t i n s i d e
the AS I S .
Progressions/Ot he r considera t i o n s : Do not
a l low any lateral or posterior pelvic t i l t i ng as
t he pe lvis rot ates. M on i tor the knee and give
tact i l e cueing to keep the knee fac i ng forward .
M o n i t or t h e t h orac i c level of poor c o n t ro l ,
specifrcally watching for rotation andlor sidebend
ing. Progress to perform i ng the exerc ise w h i le
weight bea ring o n ly on t h e Front leg.
II1II
facil itation of the 'guy-wire' i m age for the right side (the side
longer req u i red. The starting position for the right hand is in
thoracic level.
3) Wa l l S i d e B e n d ( s e e F i gu res 7 . 2 9 , 7 . 3 0 ) :
Th i s exerc i se t ra i n s control o f p u re s idebend
i ng wit hout segmental lateral shift i ng, h i ngi ng,
or rotat ion. The wal l provides tac t i l e feedback
so t he pat ient can monitor if t he pelvis or thorax
rotates away [rom the wa l l . The t h e rapist can
add manual feedback at the rib cage or pe lvis
to e n c o u rage move m e n t o r c o n t ro l a t
des i red leve l s .
Thoracopelvic
mI
lSI
REFERENCES
REFERENCES
230 (60) 20
programs. In: The thoracic spine and rib cage. Ed. Flynn T
\11.1 Butterworth-Heinemann
165:322
2 1: 1 17
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p76
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New York
Perth, Australia
Spine I 1(7):732
Champaign, Ilinois
Mens J M A, VleemingA, Snijders C J, Koes 13 J, Stam 1-1 J
200 I Reliability and validity of the active straight leg raise
test in posterior pelvic pain since pregnancy. Spine
26(10) 1167
-,
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131 :373
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