Paperback, eBook
978-1-912085-05-7
1
280
About 50 colour drawings and 250 clinical photographs
246 x 189
Not yet published
5 November 2018
Handspring Publishing

£64.50 GBP / $79.95 USD

Physical Therapy, Massage Therapy, Movement




The Thorax

An integrated approach

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Diane LEE

Diane is an orthopaedic musculoskeletal physiotherapist (FCAMT)

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This clinical textbook will update the reader on the relevant anatomy, known biomechanics, clinical assessment, musculoskeletal conditions and treatment of the thorax and how these relate to the function of the whole body. An integrated biopsychosocial model (the Integrated Systems Model – ISM) will be highlighted in this text and used as a foundation for clinicians to organize their knowledge from multiple sources. The text emphasizes the current suggestion from the evidence that treatment be individualized and that clinical reasoning form the basis for treatment decisions.

Richly illustrated with 3D-rendered colour anatomical drawings, and over 250 clinical photographs, The Thorax – an integrated approach is the definitive manual on the thorax for all bodyworkers helping patients improve mobility and control of the trunk.

 

Chapter 1 – ANATOMY OF THE THORAX

Regions and Osteology of the Thorax

Vertebromanubrial region

Vertebrosternal region

Vertebrochondral region

Thoracolumbar region

Arthrology of the Thorax

Zygapophyseal joints

Costal joints

Intervertebral discs

Manubriosternal symphysis

Sternoclavicular joint

Myology of the Thorax

Deeper muscles of the thorax

Transversus thoracis

                                    Transversus abdominis

      Diaphragm

      Rotatores thoracis

      Multifidus

      Levator costarum

      Internal and external Intercostals

Superficial muscles of the anterior thorax

  • Serratus anterior
  • Pectoralis major

Pectoralis minor

  • Subclavius
  • External oblique
  • Internal oblique
  • Rectus abdominis

The anterior fascial connections

Width of the linea alba – the inter-recti distance

The posterior fascial connections

Superficial muscles of the posterior thorax

  • Semispinalis thoracis
  • Spinalis thoracis
  • Longissimus thoracis
  • Iliocostalis thoracis
  • Iliocostalis lumborum
  • Serratus posterior superior
  • Serratus posterior inferior

Neurology of the Thorax

Thoracic spinal nerves

Sympathetic trunks

Surface Anatomy – Land Marking the Thorax

Thoracolumbar junction

Vertebrochondral region

Vertebrosternal region

Vertebromanubrial region

Conclusion

Chapter 2 – BIOMECHANICS OF THE THORAX

Introduction

Terminology

Research Evidence

Clinical Expertise

Forward bending of the trunk

  • Thoracic spine osteokinematics
  • Thoracic spine arthrokinematics

Palpation of thoracic spinal osteokinematics and arthrokinematics

Costal osteokinematics

  • Costal arthrokinematics
  • Palpation of the thoracic costal osteokinematics and arthrokinematics

Backward bending of the trunk

  • Thoracic spine osteokinematics
  • Thoracic spine arthrokinematics

Palpation of thoracic spinal osteokinematics and arthrokinematics

Costal osteokinematics

  • Costal arthrokinematics
  • Palpation of the thoracic costal osteokinematics and arthrokinematics

Side-bending of the trunk

  • Thoracic spine osteokinematics
  • Thoracic spine arthrokinematics
  • Palpation of thoracic spinal osteokinematics and arthrokinematics
  • Costal osteokinematics
  • Costal arthrokinematics
  • Palpation of the thoracic costal osteokinematics and arthrokinematics

Axial rotation of the trunk

  • Thoracic spine osteokinematics
  • Thoracic spine arthrokinematics
  • Palpation of thoracic spinal osteokinematics and arthrokinematics
  • Costal osteokinematics
  • Costal arthrokinematics
  • Palpation of the thoracic costal osteokinematics and arthrokinematics
  • Manubrium and clavicle osteokinematics

Elevation of the arm

Breathing

  • Osteokinematics of inhalation
  • Arthrokinematics of inhalation
  • Palpation of the thoracic costal osteokinematics and arthrokinematics
  • Osteokinematics of exhalation
  • Arthrokinematics of exhalation
  • Palpation of the thoracic costal osteokinematic and arthrokinematics

Conclusion

Chapter 3 – ASSESSMENT OF THE THORAX AND ITS RELATIONSHIP TO THE WHOLE BODY

Introduction

The Neuromatrix or Cortical Body Matrix Approach

Principles of the Integrated Systems Model Approach

Hearing the story and identifying the meaningful complaint

Determining the meaningful task

The screening tasks and finding driver(s)

Determining the system impairments related to the driver(s)

The Clinical Puzzle

Where to put findings in the Clinical Puzzle?

Treatment planning

Summary

Common Screening Tasks for Assessment of Function of the Thorax

Standing posture

Third thoracic ring to the hips

Pelvic ring correction

Hip correction

Thoracic ring correction

Second thoracic ring to cranium

Upper thoracic ring correction

Cervical segmental correction

Cranial correction

Clavicle and scapula correction

Lower extremity

Hind foot correction

Squat

Pelvic control test in a squat

Impact of the thorax on pelvic control in a squat

Impact of pelvic control on alignment of the thorax

Seated head, neck and thoracic rotation

Summary

Tests to Determine the Underlying System Impairment of the Driver(s)

Further tests – vector analysis

Articular system – assessment principles

Active physiological mobility tests

Passive accessory mobility tests

Passive control tests

Articular system – specific tests

Active physiological mobility tests – costal joints

Active physiological mobility tests – thoracic zygapophyseal joints

Passive accessory mobility tests – costal joints

Vertebromanubrial region

Vertebrosternal region (including 2nd thoracic ring)

Vertebrochondral region

Passive accessory mobility tests – thoracic zygapophyseal joints

Mediolateral translation – Inter-thoracic ring mobility

Passive control tests

Anterior translation thoracic spinal segment (intra-thoracic ring)

Posterior translation thoracic spinal segment (intra-thoracic ring)

Anterior distraction costotransverse joint (intra-thoracic ring)

Posterior translation costochondral and sternocostal joints (intra-thoracic ring)

Lateral translation (intra-thoracic ring)

Neural system – assessment principles

Neural system – specific tests

Tests to determine which muscles to release

Tests to determine when to release the nervous system

Active control tests

Thorax – inter-thoracic ring control

Lumbar spine – intersegmental control and thoracic ring drivers

Pelvis – sacroiliac joint control and thoracic ring drivers

Hip – control and thoracic ring drivers

Cervical – intersegmental control and thoracic ring drivers

Visceral system

Pericardial vectors and posture

Myofascial system       

Thorax Driver(s) and Motor Control Strategies

Thoracic deep and superficial back muscle recruitment strategies

                        Abdominal muscle recruitment strategies

Response to verbal cue – transversus abdominis and the pelvic floor

                                    Short head and neck curl-up task

Pelvic floor muscle recruitment strategies

Dural/Perineural Mobility

Conclusion

Chapter 4 PRINCIPLES OF THE INTEGRATED SYSTEMS MODEL FOR TREATMENT OF THE INDIVIDUAL PATIENT

Introduction

Release – Cognitive and Emotional barriers

Release – Physical Barriers

Teach – Optimal Strategies for Function

Reinforce, Strengthen and Condition – Better Strategies for Function

Conclusion – Getting to Wow!

Chapter 5 CASE REPORTS THAT HIGHLIGHT THE RELATIONSHIP OF THE THORAX TO THE WHOLE BODY

Thorax Driven Pelvis and Hip – Diane Lee

Jennifer’s story

Jennifer’s current meaningful complaints… Jennifer’s cognitive beliefs… Jennifer’s emotional status… Meaningful task and screening tests chosen for strategy analysis

Screening task analysis – standing postural screen

Impact of corrections on standing posture – finding drivers

Screening task analysis – squat

Impact of corrections on squat task – finding drivers

Vector analysis of the drivers

Primary driver – thorax (2nd, 3rd, and 4th thoracic rings)

Secondary driver – left hip

Impact of the thoracic driver on abdominal wall recruitment strategy

ISM treatment for Jennifer’s thorax driven pelvis and hip

Release and align… Connect and control… Move

Conclusion

 Pelvis then Thorax Driven Recurrent Hamstring Injury – Diane Lee

Steve’s story

Steve’s current meaningful complaints… Steve’s cognitive beliefs… Steve’s emotional status… Meaningful task and screening tasks chosen for strategy analysis

Screening task analysis – prone hip extension with resistance

Vector analysis of the driver – pelvis

Hypothesis to explain Steve’s pain and impairments

Initial ISM treatment for Steve’s pelvis driven hamstring

Follow up – second session one month later

Screening task analysis – prone hip extension

Screening task analysis – squat task

Screening task analysis – seated thoracic rotation

Vector analysis of the driver – thorax

ISM treatment – second session

Follow up – third session two weeks later

On field visit two weeks later

Conclusion

Thorax Driven Abdominal Wall and Pelvis – Diane Lee

Amanda’s story and current meaningful complaints

Amanda’s cognitive beliefs and emotional status… Meaningful task and screening tasks chosen for strategy analysis

Screening task analysis – standing postural screen

Screening task analysis – standing weight shift

Vector analysis of the driver – thorax

Abdominal wall assessment

Abdominal profile and behavior in standing

Abdominal wall and thoracolumbar control

Supine single leg load – active bent leg raise test

Behaviour of the abdominal wall and linea alba in a curl-up task

ISM treatment for Amanda’s thorax driven abdominal wall and intra-pelvic ring control

Release and align

Connect and control

Conclusion

Thorax Driven Persistent Diastasis Rectus Abdominis and Poor Lumbosacral Control – Diane Lee

Christine’s story and current meaningful complaints

Screening task analysis – standing postural screen

Screening task analysis – standing weight shift

Screening task analysis – lumbar segmental control under load

Screening task analysis – short head and neck curl-up

Vector analysis of the driver and relationship of the driver to motor control strategies – thorax

ISM treatment for Christine’s thorax driven DRA and poor lumbosacral control

Follow up – 4 months later 

Thoracic and Cranial Driven Pelvis

Brad’s story

Brad’s meaningful complaints… Brad’s cognitive beliefs and emotional status

Screening task analysis

Screening task analysis – standing postural screen

Impact of corrections on standing posture – finding drivers

Screening task analysis – squat

Impact of corrections on squat task- finding drivers

Screening task analysis – right and left one leg standing (OLS)

Impact of corrections on OLS tasks – finding drivers

Vector analysis of the drivers

Driver – thorax (2nd and 7th thoracic rings)

Driver – cranial region

Driver – pelvis

Impact of drivers on pelvic floor recruitment strategies, strength and endurance

A biologically plausible mechanism for thoracic and cranial contributions to incontinence

ISM treatment for Brad’s thoracic and cranial driven pelvis

Release and align

Connect and move

Conclusion

Thorax and Cranial Driven Pelvic Floor – Tamarah Nerreter

Lisa’s story and current meaningful complaint

Lisa’s cognitive beliefs… Lisa’s emotional status… Meaningful task and screening tests chosen for strategy analysis

Screening task analysis – standing

Impact of corrections on standing posture – finding drivers

Screening task analysis – squat to sit

Impact of corrections on the squat task- finding drivers

Vector analysis of the drivers

Primary driver – thorax (2nd, 3rd, 4th and 5th thoracic rings)

Secondary driver – cranial region

Impact of thorax driver on abdominal wall and pelvic floor recruitment strategy

ISM treatment for Lisa’s thorax and cranial driven pelvic floor

Release and align

Connect and control

Move

Conclusion

 Short Case Reports

Thorax Driven Head/Neck for Rotation – Diane Lee

Miyuki’s story and current meaningful complaint and task

Meaningful task analysis – left head and neck rotation in sitting

Vector analysis of the driver – thorax (3rd thoracic ring)

Active listening during correction of the 3rd thoracic ring

Passive listening on release of the correction of the 3rd thoracic ring

ISM treatment

Thorax Driven Thorax for Rotation – Articular System Impairment – Diane Lee

Ayami’s story and current meaningful complaint and task

Meaningful task analysis – right rotation of the thorax in sitting

Vector analysis of the driver – thorax (3rd thoracic ring)

ISM treatment

Pelvis Driven Thorax for Sitting – Diane Lee

Leah’s story and current meaningful complaint and task

Meaningful task analysis – sitting using a weight bearing arm strategy

Thorax Driven Neck Control for Arm Elevation – Diane Lee

Elayne’s story and current meaningful complaint and task

Meaningful task analysis – left arm elevation

Hypothesis

Summary

Chapter 6 RELEASE TECHNIQUES FOR THE SYSTEM IMPAIRMENTS

Introduction

Release and Align

Cognitive barriers

Emotional barriers

Sensorial/physical barriers

Articular System Impairments

Thoracic zygapophyseal joints

                        Vertebromanubrial region 

                                    Bilateral restriction of flexion – bilateral superior glide T1-2

Bilateral restriction of extension – bilateral inferior glide T1-2

Unilateral restriction of flexion – unilateral superior glide right T1-2

Unilateral restriction of extension – unilateral inferior glide right T1-2

                        Vertebrosternal/vertebrochondral region 

                                    Bilateral restriction of flexion – supine roll down technique

Bilateral restriction of flexion – seated distraction technique

Unilateral restriction of flexion – supine roll down technique (e.g. left T5-6)

Unilateral restriction of flexion – prone arthrokinematic technique (e.g. right T3-4)

Unilateral restriction of extension – supine roll down technique (e.g. left T5-6)

Unilateral restriction of extension – prone arthrokinematic technique (e.g. right T6-7)

Thoracic costotransverse joints

                        Vertebromanubrial region     

Unilateral restriction of anterior rotation right 1st rib

Unilateral restriction of posterior rotation right 1st rib

                        Vertebrosternal region          

Unilateral restriction of anterior or posterior rotation – supine roll down technique

Unilateral restriction of anterior rotation – prone arthrokinematic technique right 4th rib

Unilateral restriction of posterior rotation – prone arthrokinematic technique right 4th rib

 

                        Vertebrochondral region       

Unilateral restriction of anterior rotation – prone arthrokinematic technique right 9th rib

Unilateral restriction of posterior rotation – prone arthrokinematic technique right 9th rib

                        Vertebrosternal/vertebrochondral region

                                    Fixation of the left 5th costotransverse joint

Thoracic ring lateral translation/rotation fixation

Left lateral translation/rotation fixation of the 6th thoracic ring

Neural System Impairments

Release with awareness – principles

Dry needling – principles

Muscle recoil or muscle manipulation – principles

Specific techniques for individual muscles

Transversus thoracis

Diaphragm

Multifidus and rotatores

Intercostals

Serratus anterior

Pectoralis major

Pectoralis minor

Subclavius

External oblique

Internal oblique

Rectus abdominis

Back/neck extensors/rotators

General, non-structure specific technique for multiple system impairments

Dural/perineural system release techniques

Cranium to sacrum

Cranium to lower extremity

Cranium to upper extremity

Progression for the dural/perineural system to the lower extremity

Dural and posterior perineural system to the lower extremity

Dural and anterior perineural system to the lower extremity

Myofascial System Impairments

 Visceral System Impairments

Summary

CHAPTER 7 MOTOR LEARNING AND MOVEMENT TRAINING

Introduction and Principles for Motor Learning and Movement Training

Intra-thoracic Ring Motor Control Training

Stage 1 – release and connect cues for intra-thoracic ring impairments

Sternocostal or costochondral joint impairment

Thoracic ring lateral translation/rotation impairment

Posterior translation impairment – thoracic spinal segment

Costotransverse joint fixation

Inter-thoracic Ring Motor Control Training

Stage 1 – release and connect cues for inter-thoracic ring impairments

Stage 1 – motor control training for the upper fibres of transversus abdominis and diaphragm

Stage 1 – motor control training prescription dosage

Taping for inter-thoracic ring control

Single thoracic ring translation/rotation – vertebrochondral region

Single thoracic ring translation/rotation – vertebrosternal region

Multiple adjacent thoracic ring translations/rotations

Taping the scapula

Stage 2 – strategy capacity training for inter-thoracic ring control

Stage 2 – training examples using body weight, free weights and light equipment

Stage 2 – training examples using Pilates equipment

Intra-pelvic Ring Motor Control Training

Lumbar and/or Cervical Segmental Control

Inter-regional Movement and Control – Moving into Function

Stage 3 – movement training

Hypopressive Exercise and Low Pressure FitnessTM

Summary

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