The Thorax

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