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