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Certificate of Excellence (COE) Program • Program delivered by the RMTAO Certificate of Excellence In Assessment Rib Mobilizations • Certificate of Excellence in Assessment • CMTO and RMTAO member • Complete 10 RMTAO run assessment courses over a 5 year period • Pass each course’s examination with a minimum 70% (multiple choice quiz) Presented by Aaron Rutter PT, BScPT, FCAMPT, CAFCI www.leadtheway.ca/continuingeducation/ Introduction Course Objectives • What conditions can you help by improving rib mobility? • Registered Physiotherapist • Certified Manual and Manipulative Physiotherapist • Certified in Acupuncture • Queen’s University • RMTAO courses • What is normal lateral costal expansion? • How do you assess and treat joint stiffness or fixations of the ribs? • How do you distract a rib? • What home exercises can you give to improve pain, ROM and function in the thoracic spine and ribs? 1 Rib Cage Anterior Ribs • Do you treat the rib cage with your shoulder impingement patients or patients with decreased arm elevation? Jugular (suprasternal) notch Rib Manubrium Sternomanubrial joint (sternal angle) Sternum Costocartilage Sternocostal joint Xiphisternal joint Xiphoid process Costochondrium Costochondrial joint • Do you treat the rib cage with your mid to lower c-spine OA patients? • Do you treat the rib cage with your WAD I/II patients or patients with acute neck pain? Rib Cage Posterior Thoracic Vertebrae Scapula Transverse processes Spinous processes Ribs Ribs 1-6 ant to TP Ribs 7-10 ant/sup to TP Ribs 11-12 don’t touch TP Vertebral body Superior articular process Transverse process Costovertebral joint Costotransverse joint Intervertebral foramina Costovertebral joint of rib below Inferior articular process Spinous process 2 Ribs Rib Ligaments Anterior longitudinal ligament Superior costotransverse ligament (rib to TP above) Radiate ligament Intra-articular ligament 1st rib Head of rib Neck of rib Tubercle of rib Angle of rib Typical rib Posterior Thorax (deep) Rib Ligaments Radiate ligament (head of rib to vertebral body & disc) Intra-articular ligament (head of rib to vertebral body) Costotransverse ligament (neck of rib to TP at same level) 1. 2. 3. 4. 5. 6. Semispinalis Rotatores Levatores costarum longus & brevis External intercostals Multifidus Quadradus lumborum Lateral costotransverse ligament (tubercle of rib to TP at same level) 3 Sympathetic Chain • Sympathetic Nervous System T4 Syndrome • Facilitation of the nervous system at the T4 level caused by a mechanical dysfunction • Costotransverse joint, facet joint, disc • Diffuse arm pain • Diffuse arm and hand numbness and tingling • Glove like, no dermatomal pattern • Upper back stiffness • DeFrance GG, Levine LJ. The T4 syndrome. J Manipulative Physiol Ther 1995; 18(1):34-7. Thorax Palpation Thorax Palpation • Facilitated Segment • T1-12 spinous processes • T1-12 z-joints • Pilomotor reflex • Feel for local (1-2 levels) vs global (4-5 levels) muscle tension • Facilitated segment • Skin temperature is cool • Sudomotor reflex • Increased skin drag or resistance • Peau d’orange • Skin rolling/squeezing, change in texture/colour of skin • Trophedema • Non pitting edema that persists (skin denting) • Wheel response • Scratch test: lack of vascular response • Indicates an area of sympathetic nervous system facilitation • T1-12 transverse processes • Ribs 1-12 posteriorly • Costotransverse joint • • • • • • Jugular (suprasternal) notch Manubrium Sternal angle Sternum Xiphoid Ribs 1-6 anteriorly • Manubrocostal, sternocostal and costochondral joints • Ribs 7-10 anteriorly • Costochondrium 4 Ribs • Typical rib articulates with its own vertebrae and TP as well as the vertebrae above and disc between • Ribs 1, 11 and 12 articulate only with their own vertebrae • Ribs 11 and 12 do not articulate anteriorly with the costochondrium or their TP. They are floating ribs • The ribs make the thoracic spine the mechanically stiffest and least mobile region of the spine Rib Function • Support/protect the viscera • Muscle attachment • Motion • Breathing, ROM • Ribs 1-6 ant to TP • Ribs 7-10 ant/sup to TP • Ribs 11-12 don’t touch TP Thorax Pain 1. Nociceptive • • • Pain from any structure that has nerve supply (articular, myofascial, ligamentous, disc, dura etc) Costotransverse joint pain stays localized Mechanical pain from somatic structures is by far the most common type of thorax pain Costotransverse Joint Pain Nociceptive Pain • Young BA et al. Thoracic costotransverse joint pain patterns: a study in normal volunteers. BMC Musculoskeletal Disorders 2008, 9:140. • Innervated by the lateral branch of the primary dorsal ramus and also has connections to the sympathetic nervous system at the corresponding level and the level above 2. Neurogenic • • Neural tissue inflammation, compression etc Pain, weakness and paraesthesia in intercostal space of level affected 3. Visceral • Pain referral from internal organs 4. Central • • • • • Ipsilateral Localized, no referral to chest 3.3/10 Deep dull ache, pressure sensation • Rarely does it refer above or below, but if it does it goes a maximum of 2 levels Chronic pain due to sensitization of the nervous system, lowered pain threshold 5 Left 3rd Costotransverse Joint Nociceptive Pain Right T7 Peripheral Neurogenic Pain Radiates around towards sternum in intercostal space T7 Visceral Pain Key Thorax Subjective Questions • Cord signs and symptoms • Disc signs and symptoms • Pain on cough/sneeze/valsalva • Cancer history • Bony metastasis to spine • Breast, bronchus, bowel, prostrate, thyroid, kidney, lymphoma • Pancoast tumour • Visceral symptoms • • • • Pain with breathing, shortness of breath Chest pain with exertion Bladder/Bowel GI problems 6 Flattened Thoracic Spine Observations Scoliosis Dowager’s Hump • Lateral curvature of spine • Structural vs nonstructural • Always named for the convex side • Example • Right thoracic • Left lumbar • Results from postmenopausal osteoporosis • Multiple compression fractures causing excessive kyphosis and an associated scoliosis 7 Scheurmann’s Disease • Disturbance in normal development of endplates due to Schmorl’s nodes Pigeon Chest (pectus carinatum) • Sternum projects forward and downward • Increased thoracic kyphosis, onset usually in 2nd decade in males Funnel Chest (pectus excavatum) Sternum is pushed posteriorly by an overgrowth of the ribs Barrel Chest • Sternum projects forward and upward increasing the anterior/posterior diameter • Common in chronic lung diseases 8 Thorax Observations • Spinal curves/posture • kyphosis (apex about T7-8), scoliosis • increased, normal, decreased • Muscle bulk/tension • Posterior • UFT, MFT, LFT, LS, Rhomboids, ES, LD, QL, multifidi • Anterior • RA, EO, IO • Scars (bypass surgery etc) • Bump/lump at manubrocostal, sternocostal or costochondral joints AROM Thorax ROM Movement Flexion Extension Side bend Rotation Chest Expansion (xiphoid process) ROM 20-45 degrees 25-45 degrees 20-40 degrees each way 35-50 degrees each way 3-7.5 cm Big variation in the amount of motion between individuals Is movement symmetrical? Do they meet the minimum amount of motion? Thorax ROM Flexion Thoracic Spine • Flexion: elbows towards belly button • Extension: lift arms and chest • Side bend: shoulder towards hip • Rotation: twist to the right and left • Clear joints above and below • Cervical and lumbar spine, shoulder Clinical Tidbits • Do in sitting to stabilize pelvis • Cross arms, one underneath each other or hands behind neck • May need to stabilize the lumbar spine • Add overpressure if client has full and pain free AROM 9 Thorax ROM Extension Thorax ROM Rotation Thorax ROM Side Bend Thorax ROM Alternative Position: Rotation 10 Thorax ROM Alternative Position: Rotation AROM flexion L rotation R rotation L side bend R side bend extension Thorax ROM Chest Expansion Thorax ROM Breathing • pump handle (ribs 1-6) • bucket handle/lateral costal expansion (ribs 7-10) 11 Thorax ROM Breathing • Usually want to minimize pump handle breathing and improve bucket handle (lateral costal) and diaphragmatic breathing Costotransverse Joint Costovertebral Joint Costotransverse (CT) Joint Synovial Modified ovoid (rib convex, transverse process concave) Joint between articular facet of posterior aspect of rib tubercle and the articular facet on the anterior aspect of the transverse process Costovertebral (CV) Joint Synovial Modified ovoid (rib convex, vertebrae concave) Joint between head of rib and vertebral body Clinically unable to test costovertebral joint, as is too deep Biomechanics • Osteokinematics • How the bone moves in space • Range of motion • Arthrokinematics • How the bone moves relative to the one it is attached to • Joint glide Costotransverse Joint Osteokinematics • The rib can only perform two motions • Anterior rotation • Posterior rotation • Palpate rib using web space of hand (thumb and index finger) on each side • Feel for rib movement as perform physiological movements 12 Costotransverse Joint Osteokinematics Movement Right Costotransverse Joint Osteokinematics Ribs • Anterior Rotation Thoracic flexion Thoracic extension Thoracic SB Thoracic Rot • Posterior Rotation Inspiration Expiration Combined Motions • Thoracic flexion/right rotation Combined Motions • Thoracic left rotation/right side bend • Thoracic flexion/left rotation • Thoracic right rotation/left side bend • Thoracic extension/right rotation • Thoracic extension/left rotation These combined motions match z-joint motion as well These combined motions can help differentiate rib restriction from z-joint restriction 13 Combined Motions Flexion Quadrants Combined Motions Extension Quadrants Combined Motions Side Bend and Opposite Rotation Costotransverse Joint Arthrokinematics (Joint Glide) • The rib can only perform two motions • Ribs 1-6 (pump handle) • Superior glide • Inferior glide • Ribs 7-10 (bucket handle) • Post/med/sup glide (PMS) • Ant/lat/inf glide (ALI) • Palpate transverse process and rib at same level • Feel for rib movement relative to transverse process as perform physiological movements through midrange 14 Costotransverse Joint Arthrokinematics (Joint Glide) Movement Thoracic flex Thoracic ext Thoracic SB Ribs 1-6 Ribs 7-10 Right Costotransverse Joint Arthrokinematics (Joint Glide) • Superior Glide/PMS • Inferior glide/ALI Thoracic Rot Inspiration Expiration Clinical Tidbit • Anterior rotation produces a superior glide (ribs 1-6) or PMS glide (ribs 7-10) • Posterior rotation produces an inferior glide (ribs 1-6) or ALI glide (ribs 7-10) Passive Motion of the Costotransverse Joint • Use less movement than you think, lumbar spine must stay stable • Palpate rib relative to transverse process at same level • Watch and feel • IT EITHER MOVES OR IT DOESN’T 15 Passive Motion of the Costotransverse Joint Arm Placement Passive Motion of the Costotransverse Joint When to right of patient perform • R rot while palpating on R (post rot on R) • R rot while palpating on L (ant rot on L) When to left of patient perform • L rot while palpating on L (post rot on L) • L rot while palpating on R (ant rot on R) May also feel passive motion of upper ribs with cervical motions and arm elevation May also feel passive motion of ribs through other single plane motions or combined movements Joint Glides • Use thumbs to assess • Use hypothenar eminence (pisiform) to treat • Be as close to costotransverse joint as possible • Let patient’s arms hang over side of bed to protract scapula, gives you more room to work with • IT EITHER MOVES OR IT DOESN’T Joint Glides Ribs 1-6 • Superior Glide (end feel?) 16 Joint Glides Ribs 1-6 Joint Glides Rib 1 • Inferior Glide (end feel?) • Inferior Glide (end feel?) Joint Glides Ribs 7-10 Joint Glides Ribs 7-10 • PMS (end feel?) • ALI (end feel?) Indirect Technique 17 Joint Glides Ribs 1-12 Distraction in Sitting • Anterior glide/distraction (end feel?) Towel position • Tests all of the costotransverse and costovertebral ligaments Stiffness versus Fixations • With stiffness will have positive passive mobility and passive accessory testing only for the direction that is stiff • With a fixation all of your passive mobility and passive accessory testing should be positive Right 6th Rib Posterior Rotation Stiffness • ROM Findings • Joint Glide Findings • Combined Movement Findings • Fixated joints respond well to distraction mobilizations 18 Left 8th Rib Anterior Rotation Stiffness Left 2nd Rib Fixation • ROM Findings • ROM Findings • Joint Glide Findings • Joint Glide Findings • Combined Movement Findings • Combined Movement Findings Anterior Costal Joints Anterior Costal Joints • Rib 1: synarthrosis • Costochondral Joints • manubrocostal • Ribs 2-6: synovial • sternocostal • Where rib attaches to costocartilage • Located approximately 1 inch lateral to the sternum • Feel for where the bone changes to cartilage • Ribs 7-10: fibrous • attach indirectly to sternum through costochondrium • Ribs 11-12: do not attach to sternum • floating 19 Common Pathologies • Fractures/stress fractures • Manubrium, sternum, ribs, costocartilage Joint Glides Anterior Costal Joints • Inferior glide (end feel?) • Slipping rib syndrome • Joint fixations • Subluxations (palpable bump) • Joint stiffness • Costochondritis • No swelling visible • Tietze syndrome • Swelling visible • Gregory PL et al. Musculoskeletal problems of the chest wall in athletes. Sports Med 2002; 32(4): 235-250. Joint Glides Anterior Costal Joints • Superior glide (end feel?) Joint Glides Anterior Costal Joints • Posterior glide (end feel?) 20 Thorax Stretching 1. Combined motions Right side bend/left rotation Left side bend/right rotation Thorax Stretching 3. Tennis ball • Lean up against tennis ball on wall (chin retraction) • Causes distraction of the costotransverse joint Thorax Stretching 2. Mobilizations with movement (belt) • Place belt at level of dysfunction • Apply an anterior force (distraction) with belt • Perform appropriate combined or physiological motion Thorax Stretching 4. Extension over a foam roller • • • • • Place foam roller at level of dysfunction PPT Chin retraction Arm elevation Causes distraction and posterior rotation of ribs 21 Thorax Stretching 5. Thorax extension on wall • • • • • PPT Chin retraction Arm abduction and ER up wall Causes posterior rotation of ribs Concentrate on inspiration Thorax Stretching 6. Chin retraction over towel • Sitting with back against wall • Place firmly rolled towel/tennis ball at level of dysfunction to stabilize rib • Chin retraction • Gentle push through feet so buttock slightly deweights off chair which applies an inferior glide to rib Thorax Stretching Thorax Stretching 7. 1st rib (inferior glide) 7. 1st rib (inferior glide) 22 Review Thank you • Ant rot and sup/PMS glide are the same motion • Post rot and inf/ALI glide are the same motion • Use combined motions to test and treat • Improve rib mobility into extension • For future courses visit www.leadtheway.ca/continuingeducation/ or email me at [email protected] • Posterior rotation/lateral costal expansion • Inferior glide/ALI • Stabilization exercises for patients with reoccurrences of stiffness/fixations 23