Examination and Treatment of the Thoracic Spine and Ribs
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Examination and Treatment of the Thoracic Spine and Ribs
- 1. ! ! ! ! ! ! ! ! ! ! ! M cPhe rson ’s Buildin g Suite 308, 546-566 Collins Stree t `! ! ! ! ! ! ! M elbourne VIC 3000 ! (03) 9939 1289 w ww .m elb ourneosteop athy cent re .c om .a u in fo@m elb ourneosteop athy cent re .c om .au ! Presentation*to*MD*health* Examination*and*Treatment*of*the*Thoracic*Spine*and*Ribs* ! ! Date:!! ! Presenter:!! ! 11th!July!2013! Dr!Shane!Buntman!BSc!(Biochemistry/Genetics),!BSc!(Clinical!Science!–! Osteopathy),!MHOS!(Osteopathy)! Current!Positions:!! Director/Osteopath,!Clinical!Supervisor!at!Victoria!University!Osteopathy!School! Clinic:!!! ! Melbourne!Osteopathy!Sports!Injury!Centre! !! Review*of*Anatomy** K K K K K K ! K Facet!joints!(T1K12),!!! • increase!in!size!from!T1K12!! • alignment!of!the!facet!joints!of!the!thoracic!spine!allows!freedom!of!movement!as!you! twist!back!and!forth!or!lean!side!to!side! • position!on!side!of!vertebral!body! • Sagittal!Facet!Orientation!–!60!degrees!at!T1!increasing!to!70!degrees!at!T12! • Frontal!Facet!Orientation!–!20!degrees!posterior! CostoKvertebral/CostoKtransverse!joints,!CervicalKdorsal!joint,!ThoracoKlumbar!junction,!! Thoracic!Intervertebral!Discs! • Consist!of!Fibrocartilage! • Two!components:! ! Annulus!Fibrosus!–!obliquely!oriented!fibers!composed!of!type!I!collagen! ! Nucleus!Pulposus!–!softer!central!portion!composed!of!type!II!collagen!and!has!a! high!polysaccharide!content!with!88%!water.! • Account!for!25%!of!the!total!spinal!columnar!height! • Attached!to!Vertebral!Bodies!by!Hyaline!Cartilage! • Intradiscal!Pressure!is!dependant!on!position!–!supine!is!lowest!and!sitting!flexed! forward!is!the!highest.!! Nerve!Roots! • In!Thoracic!and!Lumbar!Spine,!central!and!paracentral!disc!herniations!affect!the!nerve! root!of!the!lower!vertebral!level!(eg!L4KL5!=!L5!nerve!root!involvement)! • In!Thoracic!and!Lumbar!Spine,!far!lateral!disc!herniations!affect!the!nerve!root!of!the! upper!vertebral!level!(eg!L4KL5!=!L4!nerve!root!involvement! Ribs:!! • anterior!insertion!on!sternum!via!costal!cartilage!! • posterior!Tx!transverse!process!and!body!vertebra! Diaphragm!(insertion)!! • ribs!7K12!and!costal!margins!! • L1K3!vert!bodies! Scapula!biomechanics!(see!below!table)! !
- 2. ! K K K K ! ! Important!soft!tissue!in!Thoracic!spine:!! • erector!spinae!(rotatores,!multifidus,!iliocostalis)! • lattisum!dorsi,!! • trapezius!(upper,!middle/lower),!! • quadratus!lumborum,!! • intercostals,!! • rhomboids,!! • Serratus!anterior,!! • pectoralis!(major/minor)! Viscera!referring!to!Thoracic!sipne! • Heart! • lung! Sympathetic!Trunk! Spinal!Ligaments:! • Anterior!Longitudinal!Ligament!(ALL)!–!very!strong!and!resists!hyperextension! • Posterior!Longitudinal!Ligament!(PLL)!–!weaker,!hourKglass!shaped!(wide!over!discs)! • Ligamentum!flavum!–!strong,!yellow,!elastic,!connects!laminae,!runs!from!anterior! surface!of!superior!laminae!to!posterior!surface!of!inferior!laminae,!constantly!in! tension,!hypertrophy!=!nerve!root!compression! • Supraspinous!Ligament!–!begins!at!C7!and!lies!dorsal!to!spinous!process! • Interspinous!Ligament!–!lies!between!spinous!process! !
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- 6. ! ! Common*Conditions*in*the*Tx*spine*and*associated*areas* K K K K K ! K K K Sprains!to!costo!vertebral/transverse!joint!! • forced!chest!motion!(coughing/sneezing)! • hyperKrotation!motion! Postural!sprain/strain!complex!! • excessive!sitting!or!standing! Facet!joint!sprains!!! • usually!forced!extension/rotation!motions! Scoliosis!! • rotoKscoliosis! Thoracic!outlet!syndrome:!sites!of!compression! • rib!1! • scalenes! • pec!minor!! Degenerative!disc!disease! Hyperkyphosis! SomatoKvisceral!or!VisceroKSomato!referral! Less*Common*Conditions*in*Tx*spine*and*associated*areas* K K K K K K K K K K ! ! ! Scheuermann’s!Disease!–!usually!in!adolescents! Costochondritis! Disc!herniation! Spinal!Stenosis! Crush!fracture! • osteoporosis! • pathology! Tuberculosis! Spondylosis!–!degeneration! Ankylosing!Spondylitis! Underlying!pathology!–!check!red!flags! Visceral!Referral!! • Heart!attack!(myocardial!infraction)! • Pneumothorax! • peptic!ulcers! • malignancies!(tumours)! !
- 7. Examination*of*the*Tx*spine*associated*areas* Observation:*Standing*and*Sitting* K Sagittal!plane:!! • CD,!! • Tx!kyphosis!(flexion)! • T/L!(starts!to!extend!but!still!in!flexion)!! • humeral!head! K Posterior!Frontal!plane:!! • Shoulder!girdle! • Scapula!positions!(inf!scap,!medial!spine)!–!see!table!below! • iliac!crest!(L4K5)! K Anterior!Frontal!plane:!! • Acromion! • Clavicle! • AC!joint/SC!joint! • Sternum! • Angle!of!Louis!(Rib!2)! • Costal!margin! K Scapula!positions:!! • medial!border!of!spine!of!scapula!–!T3! • inferior!tip!of!scapula!–!T7! • acromion! ! K Scapula*biomechanics:* * Scapula* Medial*Border*of* Inferior*Angle* Acromion* Movements* spine* Hypertonic* Muscles* Upward!rotated! Inferior! lateral/superior! superior! Upper!trap,! Serr!Anterior! Downward!rotated! superior! Medial/inferior! inferior! Rhomboid,!levator! scapulae! Elevated! superior! superior! superior! Upper!trap,! levator!scapulae! Depressed! inferior! inferior! inferior! Lat!Dorsi! Anterior!tilt! anterior! posterior! anterior/inferior! Pec!minor! Abducted! lateral! lateral! lateral! Sub!scap,!Serr!ant! Adducted! medial! medial! medial! Rhomboid,!traps,! lev!scap! Winging! lateral/posterior! lateral/posterior! ! ! ! ! ! ! ! !
- 8. Motion*in*the*Thoracic*spine:* K K K K Limited!primarily!by!the!connection!with!the!ribs,!the!!orientation!of!the!facets,!and!the!long! spinous!processes!that!overlap!in!the!back.!! Flexion!and!Extension!combined!is!3°!to!12°,! • very!limited!motion!in!the!upper!thoracic!(2°!to!4°)!! • increases!in!the!lower!thoracic!to!20°!at!the!thoracolumbar!junction!! SideKBending!2°!to!9°!! • upper!thoracic!2°!to!4°! • lower!thoracic,!it!may!be!as!high!as!9°!! Rotation!2°!to!9°.!! • upper!levels!9°! • lower!levels!2°! ! Fryette’s*Laws*of*Physiologic*Spinal*Motion! ! Fryette!presented!his!ideas!of!coupled!motions!between!facets!in!both!a!neutral!position!and!out!of!a! neutral!position.!He!presented!three!laws!that!determine!coupling!motions!of!the!spine.”(Houglum,! 563).! ! Law$1:!If!the!upper!segments!of!vertebrae!are!moving,!the!lower!segments!will!have!an!opposite! direction!of!movement!provided!that*the!spine!is!neutral.! ! “Fryette’s!First!Law!states!that!when!the!lumbar!or!thoracic!spine!is!neutral,!sideKbending!occurs!to! the!opposite!side!of!the!vertebral!rotation.!For!example,!in!neutral!position,!if!the!spine!is!laterally! flexed!to!the!right,!it!will!also!rotate!to!the!left.!(Therapeutic!Exercise!for!Musculoskeletal!Injuries!by! Peggy!A.!Houglum,!563).! ! Law$2:!If!the!trunk!is!in!flexion!or!hyperextention,!the!movements!of!all!the!segments!are!the!same.! ! “Fryette’s!Second!Law!deals!with!pathological!positions!and!coupled!motions.!Fryette!indicated!that! when!the!spinal!alignment!is!either!in!flexion!or!extension,!the!sideKbending!and!rotation!of!the! vertebrae!will!be!toward!the!same!direction.!For!example,!if!the!lumbar!spine!is!placed!into!a!lordotic! position,!and!sideKbending!to!the!left!is!performed,!rotation!to!the!left!will!also!occur!at!the!vertebral! level.”!(Houglum,!563).! ! Law$3:!If!only!a!segment!of!the!vertebra!is!moving!the!movements!of!the!other!segments!are!reduced.! ! “Fryette’s!Third!Law!states!that!if!motion!in!one!place!occurs!in!the!spine,!motion!in!the!other! direction!is!diminished.!For!an!example!of!this,!stand!erect,!rotate!the!spine!to!the!left,!and!note!the! amount!of!rotation!that!occurs.!Next,!forward!flex!at!the!trunk!and!then!in!that!position,!repeat!the!left! rotation!motion.!You!will!find!that!the!amount!of!rotation!you!are!able!to!perform!is!less!than!in!erect! standing.”!(Houglum,!563).! ! * *
- 9. Active*Range*of*Motion*(ROM)–*Standing*and*Sitting* K K K K K K Flexion! • view!in!sagittal!plane!and!from!behind! • look!for!rotations!or!sidebending!on!motion! • look!for!rib!humping!between!left!and!right!sides! Extension!! • look!for!rotations!or!sidebending!on!motion! Rotation!–!Left/Right! Sidebending!–!Left/Right! Things!to!look!for! • Observe!pivot!points! • Looking!for!joint!dysfunction!–!segments!with!less!motion!! • Reduction!in!motion! • Identify!segments!that!move!in!groups! • Reproduction!of!pain! Scapula!Motion!–!GH!flexion/abduction! ! Passive*ROM*L*seated* K K ! Should!be!performed!in!the!seated!position! Test!in!all!motions!and!feel!end!feel! • Flexion!–!springing!–!ligamentous/muscular! • Extension!–!hard!–!bony! • Sidebending!K!Left/Right!K!!springing!–!ligamentous/muscular! • Rotation!K!Left/Right!K!!hard!–!bony! • Reproduction!of!pain! • Restriction!of!movement! • Incorrect!End!Feel!! Rib*Cage*and*Rib*Motion*–*Standing,*Sitting,*Supine* K K K K K K * Upper!ribs!–!pump!handle! Lower!ribs!–!bucket!handle! Rib!11K12!ribs!(floating)!–!moves!anterior!and!posterior! Examine!anterior,!posterior!and!lateral!aspect!of!rib!cage! Palpate!along!rib!angle! • Altered!ROM! • Feeling!for!any!restriction!on!both!inspiration!and!expiration! • Tenderness!and!pain! • Asymmetry! • Tissue!texture!abnormality! • Width!of!intercostal!space! Rib!motion! • Patient!breathes!as!normal! • Examiner!assess!motion!in!all!position! • Altered!ROM! • Feeling!for!any!restriction!on!both!inspiration!and!expiration! • Tenderness!and!pain! • Inhalation!restriction!–!rib!that!stops!first!on!inhalation!compared!to!the!rib!below!or!on! the!other!side! • Exhalation!restriction!–!rib!that!stops!first!on!exhalation!compared!to!the!rib!below!or! on!the!other!side! *
- 10. * K Findings* Anterior!translated!! o Rib!angle!less!prominent! o Tender!rib!angle!(tension!on!iliocostalis)! o Prominence!of!anterior!rib!on!anterior!rib!cage! o Restricted!in!both!inhalation!and!exhalation! • Posterior!translated! o Rib!angle!more!prominent! o Tender!rib!angle!(tension!on!iliocostalis)! o Less!prominence!of!anterior!rib!on!anterior!rib!cage! o Restricted!in!both!inhalation!and!exhalation! • Lateral!Flexed!! o prominent!rib!shaft!in!mid!axilliary!line! o restricted!in!exhalation! o tenderness!in!intercostal!space!of!the!rib!above! st!rib!superior! • 1 o palpation!of!1st!rib!superior!to!upper!trap! o tenderness!on!superior!aspect! o restriction!of!exhalation! o hypertonic!scalenes! • External!rib!torsion!(superior!and!inferior)! o Superior!border!of!dysfunction!rib!more!prominent! o Inferior!border!of!dysfunctional!rib!more!prominent! o Tenderness!and!tension!on!rib!angles! o Restriction!in!exhalation! ! Assess!Diaphragm!! • Supine! • Knees!up! • Place!thumbs!under!costal!margin! • Gentle!apply!pressure! • Get!patient!to!breathing!! • Assess!tenderness,!restriction!in!motion! • K ! Special*Test* K K Quadrant!Test!(Facet!Joint!compression)!! • Seated!or!Standing! • Patient!move!into!full!extension!and!then!rotates!to!affected!side! • Apply!over!pressure!thorugh!the!shoulders!into!hyperextension!! • Guide!patient!into!positions! • Maintain!control!of!patient!throughout!whole!test! • Positive!is!reproduction!of!patient!symptoms!! o Radicular!pain!indicates!compression!of!the!intervertebral!foramina!that! impinges!on!the!lumbar!nerve!roots! o Local!pain!(not!radiating)!indicates!facet!joint!pathology! o Symptoms!isolated!to!the!area!of!the!PSIS!may!indicate!SI!joint!dysfunction! Valsalva! • Patient!seated! • Examiner!next!to!patient! • Patient!takes!a!deep!breath!while!bearing!down!(like!having!a!bowel!movement)! • Increased!pain!and/or!radicular!pain!(increased!intradiscal!pressure)! • Testing!for!disc!problems!
- 11. K K K Straight!Leg!Raise! • Patient!supine! • Examiner!raises!leg!slowly!–!hip!flexion! • Patient!knee!is!fully!extended! • Positive!–!radicular!pain! • Testing!for!nerve!root!impingement!and!disc!problems! Slump!Test! • Patient!sits!on!edge!of!table! • Patient!slumps!forward!along!thoracolumbar!spine,!rounding!the!shoulders!while! keeping!cervical!spine!neutral! • Patient!flexes!cervical!spine;!Clinician!holds!patient!in!this!position! • Knee!is!actively!extended! • Ankle!is!actively!dorsiflexed! • Repeat!on!opposite!side! • Positive!K!Sciatic!pain!or!reproduction!of!other!neurological!symptoms! • Testing!K!Impingement!of!the!dural!lining,!spinal!cord,!or!nerve!roots! Spring!test! • Patient!is!prone! • Examiner!stands!with!thumbs!or!hypothenar!eminence!over!the!spinous!process!of!a! vertebrae! • Apply!a!downward!“springing”!force!through!the!spinous!process!of!each!vertebrae!to! assess!anteriorKposterior!motion! • Positive!K!increased!or!decreased!motion!at!one!vertebrae!compared!to!another! (hypermobility!or!hypomobility)! * Techniques* ! K Highly!recommend!the!application!of!HVLA!for!the!Thoracic!spine!and!rib!problems! General*rule*for*treating*ribs* K Should!treat!the!thoracic!spine!first!especially!if!bilateral!rib!pain! K Address!the!structural!rib!dysfunction!prior!to!treatment!of!the!respiratory!dysfunction! ! Ribs:* Seated!Anterior!translation! • Practitioner!stands!behind!patient!seated!on!table! • Patient!place!hand,!of!affected!side,!on!opposite!shoulder! • Practitioner!places!thumb!on!shaft!medial!to!rib!angle!of!affect!rib! • Practitioner!lifts!elbow!to!localize!forces! • Practitioner!applies!a!posterolateral!pull!force!on!shaft! • Patient!pulls!elbow!laterally!and!inferior!for!3K5!seconds!! • Practitioner!resist!rib!motion!and!take!up!the!slack!between!each!contraction! • Repeat!3!times! ! Seated!Posterior!translation! • Practitioner!stands!behind!patient!seated!on!table! • Patient!place!hand,!of!affected!side,!on!opposite!shoulder! • Practitioner!places!thumb!on!shaft!lateral!to!rib!angle!of!affect!rib! • Practitioner!lifts!elbow!to!localize!forces! • Practitioner!applies!a!anteromedial!push!force!on!shaft! • Patient!push!elbow!superior!and!towards!opposite!shoulder!for!3K5!seconds!! • Practitioner!resist!rib!motion!and!take!up!the!slack!between!each!contraction! • Repeat!3!times!
- 12. ! Seated!External!rib!torsion!–!superior! • Practitioner!stands!behind!patient!seated!on!table! • Patient!place!hand,!of!affected!side,!on!opposite!shoulder! • Practitioner!places!thumb!on!angle!of!affect!rib!in!vertical!fashion! • Practitioner!lifts!elbow!to!localize!forces! • Practitioner!applies!a!anterior!force!on!the!superior!border! • Patient!pulls!elbow!to!the!lap!(internal!torsion!motion)!for!3K5!seconds!! • Practitioner!resist!rib!motion!and!take!up!the!slack!between!each!contraction! • Repeat!3!times! ! Seated!External!rib!torsion!–!inferior! • Practitioner!stands!behind!patient!seated!on!table! • Patient!place!hand,!of!affected!side,!on!opposite!shoulder! • Practitioner!places!thumb!on!angle!of!affect!rib!in!vertical!fashion! • Practitioner!lifts!elbow!to!localize!forces! • Practitioner!applies!a!anterior!force!on!the!superior!border! • Patient!push!elbow!to!the!ceiling!(external!torsion!motion)!for!3K5!seconds!! • Practitioner!resist!rib!motion!and!take!up!the!slack!between!each!contraction! • Repeat!3!times! ! Supine!1st!rib!MET!inferior! • Practitioner!stands!at!the!end!of!the!table!behind!patient!lying!supine! • Practitioner!places!thumb!into!supraclavicular!fossa! • Other!hand!controls!head!motion! • Apply!an!inferior!force!onto!first!rib!! • Move!neck!into!cervical!flexion!and!sidebending!into!affected!side! • Get!patient!to!take!a!deep!breath!in!and!hold!for!3!K5!seconds!whilst!continuing!to!hold!thumb! pressure!on!1st!rib! • At!the!same!time!get!patient!to!move!head!into!opposite!sidebenidng! • Practitioner!resist!rib!motion!and!take!up!the!slack!between!each!contraction! • Repeat!3!times! ! Prone:* Prone!Springing!Mobilisation!into!extension!(anterior/posterior)! • Direct!on!spinous!process! Prone!Springing!Mobilisation!into!rotation!–!short!lever! • Contact!on!transverse!process! • Take!up!tissue!tension!slack! • Apply!downward!pressure! Prone!Mobilisation!of!Rib!11K12!–!short!lever! • Contact!on!ASIS!with!one!hand!and!lower!ribs!other!hand! • Pull!into!pelvic!rotation!and!opposite!thoracic!rotation! Prone!Mobilisation!of!Rib!11K12!–!long!lever! • Stand!opposite!side!to!affected!rib! • Contact!lower!ribs!with!one!hand! • Bend!knees!into!90!degrees!flexion!and!contact!feet!with!other!hand! • Pull!feet!into!pelvic!rotation!and!apply!opposite!thoracic!rotation!with!other!hand! • Can!be!turned!into!a!MET!or!articulation!and!manipulation! Prone!Upper!Tx!(hands!under!forehead)!–!long!lever! • Extension!! • Sidebending!bilateral!
- 13. • Rotation!bilateral! Prone!localised!sidebending/gappinh! • Contact!thumbs!on!side!of!sp’s! • Apply!a!lateral!force!to!gap!the!joint! ! Supine:* Supine!Rib!Raising!(all!levels)! • Contact!finger!tips!medial!to!the!rib!angle!on!affected!side! • Apply!scooping!motion!in!a!superiolateral!motion! • Do!this!is!rhythmically! • Feels!change!in!motion!and!tissue!texture! Supine!Diaphragm!Inhibition/Release! • Knees!bent! • Use!thumbs! Supine!Diaphragm!Inhibition/Release! • Knees!bent! • Use!finger!tips! Supine!Anterior!rib!mobilization!–!short!lever! • Use!breathing! • Contact!sternum! • Other!hand!costal!margin! • Use!springing!motion! Supine!Anterior!rib!mobilization!–!long!lever! • Use!breathing! • Arm!above!head! • Contact!thenar!eminence! Supine!lateral!stretch!(ribs,!fascia,!lats)! • Stand!at!head!of!table! • Patient!places!arms!around!your!waist!(or!use!towel!if!arms!are!to!short)! • Lean!back!to!apply!traction! • Transfer!weight!to!one!side!until!stretch!is!felt! • Can!be!used!to!articulate!into!ext! Supine!upper!Tx!mobilisation!into!extension! • Stand!at!head!of!table! • Place!fingers!under!CD!junction! • Apply!extension!to!joint! ! Seated:* Seated!side!stretch!(lateral!fascia/lat!dorsi)!–!short!lever! • MET! • Articulation/mobilisation! Seated!side!stretch!(lateral!fascia/lat!dorsi)!–!long!lever! • MET! • articulation/mobilisation! Seated!rib!articulation!–!short!lever! • using!breathing! Seated!rib!articulation!–!long!lever! • using!breathing! Seated!Spinsters!Thrill!–!upper!Tx! • MET! • articulation/mobilisation! Seated!Spinsters!Thrill!–!mid/lower!Tx!
- 14. • MET! • articulation/mobilisation! Seated!Tx!MET! • Rotation! • Sidebending! • Flexion! • Extension! • Combined!motions! Neural!Stretch!–!slump,!SLR! ! ! Sidelying:* Sidelying!Tx!gapping!–!short!lever! • using!breathing! Sidelying!Tx!gapping!–!long!lever! • using!breathing! Sidelying!rib!gapping!–!short!lever! • Inhalation! • expiration! Sidelying!rib!gapping!–!long!lever! • Inhalation! expiration!