Download Manual Therapy Assessment and Treatment of the Thoracic Spine

Manual Therapy Assessment &
Treatment of the Thoracic Spine &
Ribs
Manual Therapy Assessment
& Treatment of the Spine,
Ribs, and Pelvis
Welcome!
Jamie Rodman PT, DPT, SCS, MTC
Manual Therapy Experts
Philip Greenman DO
Muscle energy techniques
Brian Mulligan PT
Mobilization with movement
Stanley Paris PT
Spinal manipulation
Manual Therapy Examination &
Intervention
Two keys to become proficient with
assessing and treating dysfunction
utilizing manual therapy:
*Palpation
*Practice
Treatment Philosophy
Joint Mobility
before
Muscle Length
before
Muscle Strength
Muscle Energy Technique
Introduced by Fred Mitchell Sr.
Civil Engineer who studied medicine
after his son was severely burned
Formulated system of manual
medicine that could be applied to
various parts of the body
Mentored Philip Greenman DO
Principles of Manual Medicine
Muscle Energy Technique
Muscle energy technique (MET)
A manual medicine treatment procedure
Involves the voluntary contraction of a
muscle in a precisely controlled direction
Operator utilizes varying levels of intensity,
against a distinctly executed counterforce
Muscle Energy Technique
Muscle energy technique (MET)
Based on the concept of post-isometric
relaxation & principle of reciprocal inhibition
Contraction of a given muscle will result in
the relaxation of the antagonist muscle
If hypertonicity of a muscle is limiting joint
motion, a contraction of a muscle will inhibit
tone in the muscle
Muscle Energy Technique
Example: Extension is limited
Flexors have become hypertonic and short
Extensors have become stretched and
weakened
Treatment: Engage extension barrier and
recruit flexors through isometric
contraction. Post isometric contraction the
flexors can be stretched as the joint is
moved further into the motion restriction.
Muscle Energy Technique
Muscle Energy Technique
Goals of muscle energy technique
1.
2.
3.
4.
Improving joint position
Promoting increased joint mobility
Decreasing pain
Increasing function
Introduction to Spinal
Manipulation
Key elements for successful MET
Manipulation
1.
2.
3.
4.
5.
Active muscle contraction
Controlled joint position
Mm contraction in a specific direction
Operator-applied counterforce
Controlled contraction intensity
Chiropractors
Osteopathic
physicians
Physical therapists
Introduction to Spinal
Manipulation
Who should perform
spinal manipulation?
Introduction to Spinal
Manipulation
Precautions
Hypermobility
Fusion
Acute inflammation
Anti-coagulants
Recent trauma
Scoliosis
Osteoporosis
Introduction to Spinal
Manipulation
Manipulation- “the skilled passive
movement to a joint with therapeutic
intent.”
Stanley Paris
Introduction to Spinal
Manipulation
When should the spine
be manipulated?
Introduction to Spinal
Manipulation
Contraindications
Instability
RA
Connective tissue
disease
Marfan’s/Down’s
Fracture
Introduction to Spinal
Manipulation
Manipulation
vs.
Mobilization
Introduction to Spinal
Manipulation
Effects of Spinal Manipulation
Psychological
Neurophysiological
Biomechanical
Chemical
Introduction to Spinal
Manipulation
Neurophysiological Effects
Gate control
Centralization of pain
Muscle inhibition- Type III
Joint mobility increasing nutrition
Firing of type III
mechanoreceptors
Introduction to Spinal
Manipulation
Chemical Effects
Probable release of endorphins
Introduction to Spinal
Manipulation
Psychological Effects
Touch
Induced movements
“Pop” or “snap”
Introduction to Spinal
Manipulation
Biomechanical Effects
Stretch capsular restrictions
Stretch adhesions between
the capsule and the bones
Introduction to Spinal
Manipulation
Assessment
Passive intervertebral
motion PIVM
Graded 0-6
ankylosis to instability
Thorax Skeletal Anatomy
Clavicle
Scapula
Sternum
Thoracic spine
Ribs
Thoracic Case Study
Thorax Muscular Anatomy
Rotator cuff
Rhomboids
Traps
Serratus Anterior
Biceps
Lats
Pecs
Scalenes
Thoracic Case Study
Examination Findings
Pt was a 32 y/o female with chronic
thoracic pain for > 10 years. Pt works
as a nurse with prolonged sitting for
documentation and patient lifting
responsibilities. Pt had been treated by
chiropractor and massage therapy for
> 1 year.
Thoracic Case Study
Treatment
Spinal manipulation
Rib manipulation
Exercise
L Rot restriction T1-4 PIVM 2-3
Grade 2 PIVM L @ T6-7
Posterior subluxation of R rib 7
Inhalation restriction R ribs 4-5
Grade 2-3 PIVM on L @ T8-9
Grade 1-2 PIVM on R @ T9-10
Thoracic Case Study
Outcome
Pt treated 5 times over 8 ½ weeks
Reported 75-80% overall improvement
Thoracic & rib dysfunction significantly
improved
Thoracic Vertebrae
Structure
– Body
– Costal demifacets
Except T1, T10T12
– Articular facets
– Transverse
processes:
project lateral and
slightly posterior
Thoracic Biomechanics
Upper Thoracic Spine (C7-T4)
Transition from cervical lordosis
to thoracic kyphosis
Facet joints more vertical in frontal plane
Functional cervical mobility to T4
Area of inherent hypomobility
– Spinous processes
Thoracic Biomechanics
Thoracic Biomechanics
Mid Thoracic Spine (T4-T10)
Rotation and SB coupled in opposite
direction
Elongated spinous processes nearly
vertical
Vertical alignment of facets
Presence of Ribs
Lower Thoracic Spine (T11-12)
Transition from kyphosis to lordosis
Ribs atypical
Drastic change in facet planes from
frontal to sagittal
T12-L1 area of inherent instability
“Rule of Threes”
T1 – T3
Spinous processes project
directly posteriorly
T4 – T6
Spinous processes project
downward ½ level below the
transverse processes
T7 – T9
Spinous processes project
one whole level below their
own transverse processes
“Rule of Threes”
T10
Mimics (T7 – T9); projects one
level below the transverse
processes
T11
Mimics (T4 – T9); projects ½ level
below the transverse processes
T12
Mimics (T1 – T3); projects directly
behind the transverse processes
Spinal Kinematics
1st Law of Physiologic Spinal Motion: When
the spine is in a neutral position, SB and Rot are
coupled in the opposite directions.
2nd Law of Physiologic Spinal Motion: When
the spine is flexed or extended, SB and Rot are
coupled in the same direction.
3rd Law of Physiologic Spinal Motion: If
motion is introduced in one plane, then motion in
all other planes will be restricted.
Spinal Kinematics
Exceptions are in the thoracic spine
Coupling occurs to the same side if rotation is
introduced 1st
Coupling occurs to the opposite side if
sidebending is introduced 1st
Thoracic Motion Dysfunction
Thoracic Motion Dysfunction
Type I (Neutral dysfunctions)
1. Three or more vertebral segments
involved
2. Dysfunction found in all positions
3. Rot and SB occur in opposite directions
NRRSL or NRLSR
Type II (Non-neutral dysfunctions)
1. Single vertebral motion unit involved
2. Either flexion or extension restriction
component
3. Motion restriction of SB and Rot to the
same side
FRS or ERS
Thoracic Motion Dysfunction
Thoracic Motion Dysfunction
Type I (Neutral dysfunctions)
Type II (Non-neutral dysfunctions)
Position: NRRSL- neutral, rotated R, sidebent L
Motion Restriction: Rot L & SB R
Position: FRS- flexed, rotated, sidebent
Motion Restriction: extended, rotated & SB to
the opposite side
Position: NRLSR- neutral, rotated L, sidebent R
Motion Restriction: Rot R & SB L
Position: ERS- extended, rotated, sidebent
Motion Restriction: flexed, rotated & SB to the
opposite side
Thoracic Motion Dysfunction
Type II (Non-neutral dysfunctions)
Position: FRS Left
Motion Restriction: extended, rotated & SB to
the right
Rib Articulations
Costotransverse Joints
– Ribs 1-10 join with transverse processes of
parent vertebrae
Costovertebral joint: all ribs
Position: ERS Right
Motion Restriction: flexed, rotated & SB to the
left
– Ribs 1, 11, 12: articulate with only the body of
the parent vertebrae
– All other ribs articulate with inferior demifacet
and the superior demifacet of the related
vertebral bodies
– All articulations are synovial
Costal Facet Joints
Costotransverse Joints
Costal Facets
– Present on
posterolateral corners
of the superior and
inferior plateaus of the
bodies from T1 – T9
– Costal facets are
present on the anterior
surface of each
transverse process
from T1 – T10
Upper levels are
concave/convex
– Rib: convex
– Transverse Process:
concave
Lower costotransverse
articulations are more
planar
Therefore, there is more
rotation available in the
upper and middle ribs
and more gliding of the
lower ribs
Rib Mobility
Rib Motion
Inhalation
Exhalation
Coupled with
motion of the
thoracic spine
Rib Mobility
Pump Handle Mobility
Ribs 1-10
Bucket Handle Mobility
Ribs 1-10
Anterior rib movement
Moves superiorly
during inhalation
Moves inferiorly during
exhalation
Rib Mobility
Thoracic Flexion
Lateral rib movement
Moves superiorly
during inhalation
Moves inferiorly
during exhalation
Rib Mobility
Thoracic Extension
Anterior rib moves inferiorly
Anterior translation
Internal rotation
Superior glide at costotransverse joint
Rib Mobility
Thoracic Sidebending
Ipsilateral ribs
Approximate
Superior glide at the
costotransverse joint
Internal rotation
Rib Mobility
Anterior rib moves superiorly
Posterior translation
External rotation
Inferior glide at costotransverse joint
Rib Mobility
Thoracic Rotation
Contralateral ribs
Separate
Inferior glide at the
costotransverse joint
External rotation
Ipsilateral ribs
Anterior rib moves
superiorly
Posterior translation
External rotation
Contralateral ribs
Anterior rib moves
inferiorly
Anterior translation
Internal rotation
Thoracic Outlet Syndrome
Thoracic Outlet Syndrome
Most common areas of
entrapment between:
Neurovascular compression
of the subclavian artery
and brachial plexus
Thoracic Outlet Case Study
Anterior & middle
scalene
Clavicle & 1st rib
Pec minor & ribs
Thoracic Outlet Case Study
Examination Findings
Pt was a 58 y/o female with a > 20 year
Hx of progressive bilateral UE
numbness. At the time of the exam
she was unable to elevate her R arm >
120° without immediately
experiencing symptoms. She could not
drive for more than 20 min due to
symptoms.
Sig decreased ant upper quarter
flexibility deficits
+Allen’s test, + neural tension testing
Sig R>L 1st rib elevation
T1-4 sig hypombility
Sig R 2nd rib hypomobility
Thoracic Outlet Case Study
Thoracic Outlet Case Study
Treatment
Outcome
Pec minor release
Ant upper quarter stretching
Sternal release
1st rib depression mob
Upper T spine and 2nd rib manipulation
Posture and ergonomic education
Pt was seen 5x over 14 weeks. Pt was
symptom free with all ADLs at week
14.
Intercostal Space
Muscles
– External
Intercostals
– Internal
Intercostals
– Innermost
Intercostals
Blood Vessels
Nerves
Shoulder Complex
Why assess the thoracic spine &
ribs for patients with shoulder
pain?
Review of Literature
Masaracchio, Micheael et al. Short-Term Combined Effects
of Thoracic Spine Thrust Manipulation and Cervical
Spine Non-thrust manipulation in Individuals with
Mechanical Neck pain: A Randomized Clinical Trial
JOSPT March 2013
64 subjects with mechanical neck pain
2 groups: Both groups received cervical no-thurst
manipulation and a home ex program. Experimental
group received thoracic thrust.
Findings: Experimental group demonstrated statistically
greater improvements in pain scale and the Neck
Disability Index immediately and at one week f/u.
Shoulder Complex
Scapula dyskinesia
is a prime
contributor to
shoulder
impingement.
Shoulder Case Study
Shoulder Case Study
Pt was a 15 y/o male football player with
L shoulder pain and a diagnosis of pec
minor contracture and scapular
dyskinesia. He had sustained a burner
over a year prior making a tackle
during a football game.
Presentation and examination findings
L shoulder sig forward and IR-sig
anterior
upper quarter flexibility-Pecs, lats, subscap
Increased thoracic kyphosis
Very stiff mid T spine
L shoulder GH strength 5/5. Scap stabilizers
P/N
L shoulder AROM- sig scap substitution
PROM flex 155°, ER 35°
Min post>inf GH capsular mobility deficits
+Impingement testing
Shoulder Case Study
Primary treatment intervention
T4-5 trust manipulation
Resulted in a in immediate 35°
increase in passive GH ER
Review of Literature
Boyles RE et al.
Man Therapy 2008.
56 Patients
Shoulder exam: Neer impingement sign, Hawkins
impingement sign, resisted empty can, resisted external
rotation, resisted internal rotation, and active abduction
Intervention: Thrust manipulation of the
thoracic spine
48 hour follow-up to rate patient’s perceived
change
Shoulder & Scapular
Mechanics
Shoulder Abd & ER
Ipsilateral rotation
of the thoracic
spine and external
rotation of the ribs
Shoulder IR
Ipsilateral rotation
of the thoracic
spine and internal
rotation of the ribs
Review of Literature
Boyles RE et al.
Man Therapy 2008.
Conclusion:
Thoracic spine thrust manipulation
provided a statistically significant
decrease in self reported pain measures
in all 6 tests at 48 hour follow-up.
Review of Literature
Review of Literature
Van Der Heijden et al.
Ann Rheum Disease 1999
RCT 180 patients
Exercise, exercise+IFC+US, exercise+plecebo
IFC +placebo US
12 sessions over 6 weeks
95% sample 12 month f/u
Conclusion:
Neither ET nor US prove to be effective as
adjutants to exercise therapy for soft tissue
shoulder disorders.
Robertson et al.
Phys Ther 2001
Review of literature-35 RCT 1975-1999
10 judged to utilize acceptable methods
Conclusion:
There was little evidence that active therapeutic
ultrasound is more effective than placebo
ultrasound for treating people with pain or a
range of musculoskeletal injuries or for
promoting soft tissue healing.
Review of Literature
Kurtais et al.
Phys Ther 2004
RCT 40 patients with shoulder problems
Each group received MH, ES, and exercise
2O received US and 20 placebo US x 15 sessions
3 week f/u to assess pain, ROM, disability
Conclusion:
The results suggest that true US, compared with placebo
US, brings no further benefit when applied in addition
to other physical therapy interventions in the
management of soft tissue disorders of the shoulder.
Review of Literature
Dogru et al.
Joint Bone Spine 2008
RCT 49 patients with adhesive capsulitis
All patients given ROM and superficial heat
25 Rx with US and 24 with placebo US 10x
3 month f/u: Pain, ROM, disability index
Conclusion:
Results suggest that US compared with placebo
US gives no relevant benefit in the treatment of
adhesive capsulitis.
Review of Literature
Deutscher et al.
Archives of Physical Medicine & Rehabilitation
2009
Prospective, observational outcomes study of
22,091 patients
Data collected 2005-2008 in 54 out patient
clinics
Impairments studied were lumbar spine, knee,
cervical spine, and shoulder with functional
measurements at intake and discharge.
Outcomes measure: functional status at
discharge
Review of Literature
Ainsworth et al.
Rheumatology 2007
RCT 221 patients with shoulder pain
Patients given education and home exercises
113 Rx with US and 108 with placebo US
2 week, 6 week, & 3 month f/u for disability
Conclusion:
The addition of US was not superior to placebo
US when used as part of a package of
physiotherapy in the short-term management
of shoulder pain.
Review of Literature
Santamato et al.
Physical Therapy 2009
RCT 70 patients with SAIS
US vs cold laser
10 sessions over 2 weeks
Conclusion:
Participants diagnosed with SAIS showed
greater reduction in pain, increased ROM, and
muscle strength of the affected shoulder after
10 treatment sessions of laser than did
participants receiving US therapy.
Review of Literature
Deutscher et al.
Outcomes:
Best outcomes were associated with
patient compliance with self-exercise and
therapy attendance, application of
therapeutic exercise and manual therapy.
Worse outcomes were associated with
electrotherapy for pain, and therapeutic
ultrasound for shoulder impairments.
Conclusions
Review of Literature
Wilson E, Payton O, Donegan-Shoaf L, Dec K. Muscle energy technique
in patients with acute low back pain: a pilot clinical trial.
J Orthop Sports Phys Ther. 2003 Sep;33(9):502-12.
19 subjects with LBP matched by age, gender, function
Control group taught supervised ex; experimental
group received same ex and treated with MET
All subjects seen 2x/wk for 4 weeks
Statistical significance in group treated with MET for
decreasing disability and increasing function
Thank You
1.
2.
3.
4.
5.
Don’t expect to “get it” right away
Everyone starts somewhere
Your patients are depending on you
Know when & where to refer
Palpate and practice during every
exam