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.
Diane Lee is an orthopaedic musculoskeletal physiotherapist (FCAMT) and designated as a Clinical Specialist in Women's Health by the Canadian Physiotherapy Association. She has long been interested in the biomechanics of the thorax and the impact of sub-optimal thoracic alignment, mobility and control in multiple conditions throughout the whole body. She has written several chapters on both the pelvis and the thorax as well as published two peer-reviewed articles (1993, 2015 JMMT) on her biomechanical model of the thorax. She self-published two books on the thorax (Manual Therapy for the Thorax 1994 and The Thorax - An Integrated Approach 2003), which are both no longer available and is excited to collaborate with Handspring Publishing on this new text. The intent is to describe a biopsychosocial approach that incorporates the novel, updated biomechanical model of the thorax to facilitate wise decisions for clinicians working with musculoskeletal, urogynecological and respiratory conditions. Diane lectures internationally on the thorax and other topics and provides online education through her company Learn with Diane Lee at www.learnwithdianelee.com.
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
