!!!!!!!!!!

Presentation*to*MD*health*

Examination*and*Treatment*of*the*Thoracic*Spine*and*Ribs*!Date:!! ! ! 11th!July!2013!Presenter:!! 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 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!

K CostoKvertebral/CostoKtransverse!joints,!CervicalKdorsal!joint,!ThoracoKlumbar!junction,!!K 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.!!K 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!

K Ribs:!!• anterior!insertion!on!sternum!via!costal!cartilage!!• posterior!Tx!transverse!process!and!body!vertebra!

K Diaphragm!(insertion)!!• ribs!7K12!and!costal!margins!!• L1K3!vert!bodies!

K Scapula!biomechanics!(see!below!table)!! !

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McPherson’s Building

Suite 308, 546-566 Collins Street

Melbourne VIC 3000

(03) 9939 1289

www.melbourneosteopathycentre.com.au

info@melbourneosteopathycentre.com.au

!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)!

K Viscera!referring!to!Thoracic!sipne!• Heart!• lung!

K Sympathetic!Trunk!K 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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Common*Conditions*in*the*Tx*spine*and*associated*areas*K Sprains!to!costo!vertebral/transverse!joint!!

• forced!chest!motion!(coughing/sneezing)!• hyperKrotation!motion!

K Postural!sprain/strain!complex!!• excessive!sitting!or!standing!

K Facet!joint!sprains!!!• usually!forced!extension/rotation!motions!

K Scoliosis!!• rotoKscoliosis!

K Thoracic!outlet!syndrome:!sites!of!compression!• rib!1!• scalenes!• pec!minor!!

K Degenerative!disc!disease!K Hyperkyphosis!K SomatoKvisceral!or!VisceroKSomato!referral!

!Less*Common*Conditions*in*Tx*spine*and*associated*areas*

K Scheuermann’s!Disease!–!usually!in!adolescents!K Costochondritis!K Disc!herniation!K Spinal!Stenosis!K Crush!fracture!

• osteoporosis!• pathology!

K Tuberculosis!K Spondylosis!–!degeneration!K Ankylosing!Spondylitis!K Underlying!pathology!–!check!red!flags!K Visceral!Referral!!

• Heart!attack!(myocardial!infraction)!• Pneumothorax!• peptic!ulcers!• malignancies!(tumours)!

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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*

Movements*

Medial*Border*of*

spine*Inferior*Angle* Acromion*

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! ! !

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Motion*in*the*Thoracic*spine:*K Limited!primarily!by!the!connection!with!the!ribs,!the!!orientation!of!the!facets,!and!the!long!

spinous!processes!that!overlap!in!the!back.!!K 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!!

K SideKBending!2°!to!9°!!• upper!thoracic!2°!to!4°!• lower!thoracic,!it!may!be!as!high!as!9°!!

K 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).!!* *

Active*Range*of*Motion*(ROM)–*Standing*and*Sitting*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!

K Extension!!• look!for!rotations!or!sidebending!on!motion!

K Rotation!–!Left/Right!K Sidebending!–!Left/Right!K 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!

K Scapula!Motion!–!GH!flexion/abduction!!

Passive*ROM*L*seated*K Should!be!performed!in!the!seated!position!K 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 Upper!ribs!–!pump!handle!K Lower!ribs!–!bucket!handle!K Rib!11K12!ribs!(floating)!–!moves!anterior!and!posterior!K Examine!anterior,!posterior!and!lateral!aspect!of!rib!cage!K 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!

K 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!* *

*

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!

• 1st!rib!superior!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!

!K Assess!Diaphragm!!

• Supine!• Knees!up!• Place!thumbs!under!costal!margin!• Gentle!apply!pressure!• Get!patient!to!breathing!!• Assess!tenderness,!restriction!in!motion!

!Special*Test*

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!

K 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!

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!

K 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!

K 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!

!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!

• 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!

• 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!