ashton thoracic

8/16/2019 Ashton Thoracic

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The Importance of Restoring Thoracic

Arthokinematics for Optimal Shoulder Function

Michael Ashton

PT,DPT, ATC, CSCS, COMT, FAAOMPT



Objective

• By the end of this presentation, you will

– Understand the thoracic biomechanics and itsinfluence on ADL’s, shoulder injuries/performance,and lifting mechanics

– Know thoracic arthrokinematics and its relation toexercises

– Know how to apply the appropriate lockingtechniques to emphasis thoracic mobility duringexercise

– Learn exercises to emphasize thoracic mobility inrelation to shoulder function



Biomechanics of the thorax

• Rotation – Hsu et al

• Thorax contributes most to axial rotation, 60% of motion came from thorax

– Willem et al• Thorax contributed most to axial rotation, T4-8 produced 50% of total axial rotation.

Coupling of side-bending and axial rotation highly variable

• Extension – Edmonston et al

• Lateral radiographs and photographic image analysis of thorax during bilateral armelevation shows that the thorax extends, lower region>upper region

– White and Panjabi• T1-5: 4 degrees

• T7-9: 6 degrees

• T10: 9 degrees

• T11-12: 12 degrees

• T6 vertebral level was the most rigid in terms of nervous system mobility. – Butler DS



Thoracic Biomechanics

Level Flexion Flexion/extension

combined

Extension Lateral Bending Axial Twist

T1-2 4 6 9

T2-3 4 6 8

T3-4 4 6 8

T4-5 4 6 8

T5-6 4 6 8

T6-7 5 6 8

T7-8 6 6 8

T8-9 6 6 7

T9-10 6 6 4

T10-11 9 7 2

T11-12 12 9 2

T12-L1 12 8 2



Thoracic Biomechanics Influence on

the Shoulder• Essential for overhead shoulder mechanics

– Bilateral arm elevation• the integrated thorax (all regions) extends when both arms are

elevated overhead.

– Unilateral arm elevation• the thorax rotates and laterally flexes towards the side of the elevating

arm.* – Theodoridis & Ruston9

» Electromagnetic tracking of T2–T7 during unilateral arm elevation.Variable coupling of lateral flexion and axial rotation, most coupledipsilateral

• Position of the thoracic spine affects position of the scapula• Flexed spine could lead to anterior tilting impairing retraction

http://www.tandfonline.com/doi/full/10.1179/2042618615Y.0000000008

http://www.tandfonline.com/doi/full/10.1179/2042618615Y.0000000008



Thoracic Joint Hypomobility

• linked to decreased shoulder flexion,2

increased neck and shoulder pain,as well as

overuse injuries in the cervical and lumbar

spine.



Thoracic Spine Mostly affected by

Joint Hypomobility into Extension• Hypomobility

• Joint(arthrokinematic) motion less than normal

• True collagen shortening in the joint capsule and

surrounding fascia resulting in: – Loss of mobility of the capsule↓roll/glide of joint

• ↓’d gross range of motion

• ↑compression and torque on joint surface and tissue whichover time leads to osteoarthritis of that joint

• Compensatory hypermobility and/or overuse injuries atadjacent joints

– Cervical, shoulder, lumbar



Osteokinematics vs Arthrokinematics

Arthokinematics

• Study of the motion of jointsregardless of the motion of thebones.

• Motions are named according tothe direction the joint surfacesglide relative to each other

• Terminology

– Translatoric glide, roll, spin

• Treatment Examples

– Joint mobilization/manipulation

– Joint mobilizationexercises/mullligan approach*

Osteokinematic Approach

• Study of the motion of

bones regardless of the

motion of the associated joints.

• Angular motions are named

according to the axis about

which they rotate:• Treatment

– Stretching techniques

– ROM



Thoracic hypomobility and shoulder

injuries• Wainner et al.

– Coined the term, ‘regional interdependence’, to describe how impairment in one region, such as the cervicalor thoracic spine, can result in dysfunction elsewhere, such as the glenohumeral joint. Failure to address theoriginal impairment may, therefore, be responsible for the persistence of pain.

• Norlander et al. – 139 laundry workers demonstrated that hypomobility of the cervicothoracic junction could increase the

probability of developing shoulder–neck pain in the following 12 months by 3-fold.

• Sobel et al – pain and dysfunction of the second rib and cervicothoracic junction were identified in 40% of 101 individuals

with NSSP, which was not present in age-matched asymptomatic individuals.

• Multiple references – Biomechanical links can be made between different anatomical regions and concurrent symptoms such as

the thoracic spine facet joint and referral of pain to the neck and shoulder

• Multiple references – impairment of the cervicothoracic spine and ribs may increase an individual's risk of developing neck–

shoulder pain and may contribute to an overall worse prognosis

• Multiple References – Individuals with a shoulder impingement have statistically less thoracic mobility and a more kyphotic

thoracic spinal posture than individuals with healthy shoulders



Osteokinematics vs Arthrokinematics:

Thoracic Extension

Osteokinematics

• the superior vertebra

extends relative to the

inferior vertebra (all fourregions).

Arthrokinematics

• Facet joint surfaces

considered planar joints

• the inferior articular processof the superior vertebra

should glide inferiorly and

slightly posterior following

the joint's orientation,

which may be variable both

regionally and between

sides of the same segment.



Difference between Thoracic and

Shoulder Arthrokinematics



Major Disruptor to thoracic mobility?



Upper Crossed Syndrome

• Forward Head Posture

(FHP)

• Rounded Shoulders



Thoracic

Extension????

Scapular

Retraction???



Affects of UCS/Forward Head Posture

• Mid-cervical Spine C3-6 – Hyperextension leading to

• Diminished intervertebral foraminal size and together withdegenerative changes causes ischemia and neuropathic

symptoms – Apex is usually C5-6

• Neurologically affects• Shoulder

• elbow

• Cervico-thoracic Spine – CT and upper thoracic spine are fixed into flexion

• Hypomobile into extension, sidebending and rotation



Affects of UCS/FHP

• Shoulder Girdle

– Shoulders are rounded bring the scapula in a

protracted and internally rotated position

– Glenoid is facing more anterior, lateral and inferior

– Biomechanics of the GH, AC and SC joints are

compromised

• Proximal end of clavicle close packed against sternum• Distal end of clavicle close packed against acromion



Lifts affected: vertical and horizontal

push and pull activities



Upper Crossed Syndrome

• Typical Corrective Approach

– Self myofascial release

– Stretching (static,dynamic,neuromuscular)

– Positional Isometrics/isolated strengthening

– Integrated dynamic movement/function

• What’s Missing from the Tradition Approach?

– Specific Joint Mobility of the Thoracic Spine

• Osteokinematic Approach vs Arthrokinematic Approach



Research proves thoracic mobilization has a

positive affect on shoulder performance!!!



Regional interdependence and manual therapy

directed at the thoracic spine

• Treatment to the thoracic spine maybiomechanically restore the 15° of thoracicextension required to achieve full shoulderelevation, improve the recruitment of muscles in

the shoulder girdle or have a neurophysiologicaleffect on pain and dysfunction.

• Additional effects on the shoulder girdle regionafter thoracic manipulation include increased

middle trapezius activity in individuals withrotator cuff tendinopathy and increased lowertrapezius strength in asymptomatic individuals.



Thoracic Manual Therapy in the Management of Non-

Specific Shoulder Pain: A Systematic Review

• Thoracic manual therapy accelerated recovery

and reduced pain and disability immediately

and for up to 52 weeks compared with usual

care for NSSP.



The Effects of Self-Joint Mobilization on Thoracic Extension

Utilizing a High Density Foam Roller

• The aim of this study was to determine the effect of thoracic self-joint mobilization

on active thoracic extension using a high density foam roller. Thoracic extension

was defined by the distance between C7 and T12

• Twenty-three healthy college students participated in the study. Subjects were pre-

tested for maximum thoracic extension. Subjects were randomly assigned to one

of two groups, the intervention group or the control group• The protocol consisted of two self-mobilization sessions each day for 14 days using

a high density foam roller. Following completion of the protocol, both groups were

again measured for maximum thoracic extension.

• Results revealed significant increase in thoracic extension for the intervention

group after the 14 day protocol



Specificity is key



Locking techniques

• Coordinative locking

• Ligamentous locking

•

Artificial locking• Joint Locking Locking



Artificial Locking

• Use of external devices to prevent motion

from occurring

– Wedges, tables, tennis balls, bolsters, foam, floor,

wall, hand towel, etc.

• Example



Ligamentous Locking (Counter

Curve)

• Take up maximal tension on collagen into a

particular direction to prevent motion

• Usually taken up in one plane of motion

proximal and/or distal to the area being

trained

• Performed when collagen is healthy and can

tolerate stretching



Coordinative Locking

• Person actively prevents motion into an area

• Provides the least amount of real protection

during an exercise, as no real resistance is

present to prevent motion

• Most difficult. Would be considered the final

progression of locking techniques

• Example: Simply instruct the person to not

allow the lower back to arch



Joint Locking

• Joint Surfaces are compressed to take tension

of capsule and ligaments to prevent the

segment(s) form participating in the exercise

• Indicated for Hypermobile segments



Practical Guidelines

• When to perform

– Immediately after soft tissue work and before dynamic movements

– In between exercises

– Cool Down

• When not to perform – In the presence of a hypermobility in the thoracic spine

– individuals who are not comfortable performing the self-mobilization i

– In the presence of pain

– In the presence of a known pathology that could be exacerbated by

the exercise

• suspected fracture

• neurological symptoms



Practical Guidelines

• Do not re-create the compensatory and

structural deficit

– Compensatory

• Transition areas of the spine tend to be the most

mobile (will travel the path of least resistance0

– C7/T1

– T11-L2

• Glenohumeral joint (already mobile in nature)



Simple Warm Up Progression



References

• Sobel JS, Kremer I, Winters JC, Arendzen JH, de Jong BM. The influence of the mobility in thecervicothoracic spine and the upper ribs (shoulder girdle) on the mobility of the scapulohumeral joint. JManipulative Physiol Ther. 1996;19(7):469–74.

• Sobel JS, Winters JC, Groenier K, Arendzen JH, Meyboom de Jong B. Physical examination of the cervicalspine and shoulder girdle in patients with shoulder complaints. J Manipulative Physiol Ther.1997;20(4):257–62.

• Norlander S, Aste-Norlander U, Nordgren B, Sahlstedt B. Mobility in the cervico-thoracic motion segment:an indicative factor of musculo-skeletal neck-shoulder pain. Scand J Rehabil Med. 1996;28(4):183–92.

•

Norlander S, Gustavsson BA, Lindell J, Nordgren B. Reduced mobility in the cervico-thoracic motionsegment – a risk factor for musculoskeletal neck-shoulder pain: a two-year prospective follow-up study.Scand J Rehabil Med. 1997;29(3):167–74.

• Norlander S, Nordgren B. Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility inthe cervico-thoracic spine. Scand J Rehabil Med. 1998;30(4):243–51.

• Picavet HS, Schouten JS. Musculoskeletal pain in the Netherlands: prevalences, consequences and riskgroups, the DMC(3)-study. Pain. 2003;102(1–2):167–78

• Bergman GJ, Winters JC, Groenier KH, Pool JJ, Meyboom-de Jong B, K, et al. Manipulative therapy inaddition to usual medical care for patients with shoulder dysfunction and pain: a randomized, controlled

trial. Ann Intern Med. 2004;141(6):432–9• Butler DS.: Mobilization of the nervous system. Melbourne: Churchill Livingstone, 1991, pp 32–49

• Peek A, Miller C.,& Heneghan N. Thoracic manual therapy in the management of non-specific shoulderpain: a systematic reviewJournal of Manual & Manipulative Therapy. 2015;23(4):176-187

• Cross KM, Kuenze C, Grindstaff TL, Hertel J. Thoracic spine thrust manipulation improves pain, range ofmotion, and self-reported function in patients with mechanical neck pain: a systematic review. J Orthop Sports PhysTher. 2011;41(9):633–42.

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References

• Cleland, J. A., M Childs, J. D., McRae, M., Palmer, J. A., & Stowell, T. (2005). Imme-diate Effects of Thoracic Manipulation in

Patients with Neck Pain: A Randomized Clinical Trial. Manual Therapy, 10(2), 127-135.

• Edmondston, S. J., & Singer, K. P. (1997). Thoracic Spine: Anatomical and Biome-chanical Considerations for Manual Therapy.

Manual Therapy, 2(3), 132-143.

• Houglum, P. A. (2001). Manual Therapy Techniques. In L. D. Robertson, E. Mustain, R. T. Pyrtel, A. M. Augspurger, B. J.

Bentley, J. Sexton & K. Bojda (Eds.), Therapeutic Exercise for Musculoskeletal Injuries (2nd ed., pp. 173-191). United States:

Library of Congress.

• Johnson, K. D., & Grindstaff, T. L. (2012). Thoracic Region Self-Mobilization: A clini-cal suggestion. International Journal of

Sports Physical Therapy, 7(2), 252-256.

• Overuse Injuries of the Spine. (1994). In M. Harries, C. Williams, W. D. Stanish & L. J. Micheli (Eds.), Oxford Textbook of Sports

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• Prentice, W. E. (2004). Joint Mobilization and Traction Techniques in Rehabilitation. In T. Dorwick, V. Malinee & M. Turenne

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McGraw-Hill.

• Pat Roiger, John De Cleene, Janet Johnson, DPT, ATC, and Seth Paradis, PhD . The Effects of Self-Joint Mobilization on

Thoracic Extension Utilizing a High Density Foam Roller. Bethel University .The Department of Human Kinetics and Applied

Health Science The Biokinetics Program• Crawford HJ, Jull GA. The influence of thoracic posture and movement on range of arm elevation. Physiotherapy Theory and

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References

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http://www.tandfonline.com/author/Cleland,+Josh

http://www.tandfonline.com/author/Mintken,+Paul

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http://ajs.sagepub.com/content/26/2/325.abstract

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