Manual Therapy For The Thorax - A Biomechanical Approach - D. Lee (DOPC, 1994) WW PDF

THERAPY
THE THORAX
MANUALTHERAPYFORTHETHORAX
A biomechanical approach
DIANE LEE BSR MC PA COMP

Instructor/Chief Examiner for the Or t hop a e d i c Division of the
Canadian Physiotherapy Association
Dope
De lta British Columbia, Canada,
, 1 994
PREFACE
In the literature pertaining to back pain, the muscul oskeletal com

ponents of the thorax have received Ittl e attention. T h e reference
l ist at the end of this text reflects the paucity of research availabl e
for review. And yet, clinicians are presented d a i l y with t h e chal
lenge of treating both acute and chronic thoracic pai n . It was this
chall enge which initiated cl inical work presented this texL
A biomechanical approach to treatment of the thorax requires an

understanding of its normal behaviour. Without a working mode l ,
the clinician l imited using unrel i able symptoms direction
and treatment planning. If we understand how the muscul oskel e
tal system behaves normally, we can then apply this knowledge to
the examination of the thorax. A systematic examinati on
of ity of associated bones j o i nts then
done . Since function is related to structure, an understanding of
the anatomy i s required.
The clinical investigation began 1990 when Jan Lowcock prc

sented a paper on stab i l i ty testing of the thorax to the Canadi an
Orthopaedic Manipu l ative Physiotherapists. I am indebted to her,
and any others, for the suhsequent academic and clin ical discus
sions w h i ch to the evolution the biomechan i cal mo del pre
sen ted here. Much of this material remains empirical and requires
validation through research.
The chapter reviews anatorny of the thorax as pertains

the biomechanical model. The emphasis h as been p laced on
osseous and articul a r anatomy a l though the muscu lar and neural
contribution function acknowledged. Chapter two descrihes
the b iomechanieal model and chapters three to five c l i nical
appli cation of this model to examination and treatment of the tho
rax . The purpose of this text is to provi d e the clinician with the
abi l t o assess and treat articular dysfunction of the thorax. The
reader is referred to other texts for review postural analysi s ,
myofascial syndromes and neural dysfunction .
I would l ike extend gratitude and recognition Mr. Fra n k

Crymbl e who responsible for cover desi gn all of
art work and photographs i n this text. To my col leagues at DOPC
their ongoing and constructive reviews ' yet another
presentation on the thorax ' , speci al thanks. And final ly, to
Thomas, Michael and Chelsea, thank you.
British Col umbi a, D.L

CONTENTS
1. ANATOMY 10
VERTEBROMANUBRJAL REGION 11
VERTEBROSTERNAL REGION 13
VERTEBROCHONDRAL REGION 20
THORACOLUMBAR JUNCTION 21
2. BIOMECHANICS 23
LITERATURE REVIEW 23
DEFINITION OF TERMINOLOGY 24
HABITUAL MOVEMENTS 25
Forward bending 25
Backward bending 31
Lateral bending 36
Rotation 42
Respiration
Unilateral elevation of the arm 47
3. CONDITIONS 51
MEDICAL MODEL OF C LASSIFICATION 51

Visceral 51
Metabolic 51
Infection 51
Neoplastic 52
Spondylogenic 52
MANUAl TIIERAPY MODEL

OF ClASSIFICATION 55
HEALING PROCESS 56
Substrate phase 56
Fibroblastic phase 56
Maturation phase 56
Clinical application to treatment 57
4. ASSESSMENT 59
surUECTIVE EXAMINATION 60
OBJECTIVE EXAMINATION 62
Postura l Analys i s 63
Habitual movement 63
Forward and backward bending 63
Lateral bending 64
Axia l rotation 65
Resp iration 66
Combined movement testing 67
Unilateral elevation of the a rm 68
Articular function 68
Active mobility,
osteokinematic 70
Forward 70
Backward 75
Lateral bending 76
Rotation 77
Respiration 78
Passive physiological mobility

tests 79
Passive
a rthrokinem a tic 80
Zygapophysea l 81
Costotransverse 82
Mediola teral translation 87
Passive stability tests of

a rthrokinetic function 88
Vertical (traction/compression) 88
Anterior translation - spinal 91
Posterior 92
92
93
Inferior
- posterior costal 96
Anterior/Posterior translation
- anterior costa l 97
Superior/Inferior transla tion
anterior costa l
Mediolatera l translation 97
Muscle function
Nerve function
Adj unctive tests 103
CLINICAL SYNJ)ROMES
HYPOMOBILITY WITH OR WITHOUT PAIN 105
Vertebromanubrial region
Bila tera l restriction offlexion
Un ilateral restriction offlexion 109
Bila tera l restriction of extension 111
Un ila tera l restriction of extension
Un ilatera l restriction of anterior
rotation - first rib 115
Unilatera l restriction of posterior
rotation rib
Vertebros ternal and vertebrochondral
regions 118
Bilatera l restriction offlexion 118
Un ila teral restriction of flexion
Un ila teral restriction of extension 125
Unilateral restriction of rota tion
(posterior or anterior) - rihs 3 to 10 127
Thoracolumbar j u nction
Unilatera l restriction offlexion 130
Unilateral restriction of extension 132
HYPERMOBILITY WITH OR WITHOUT PAIN
Subluxation of the costotransverse and

costovertebral
Vertebrosternal and
vertebrochondra l region s 138
Thoraculwnbar junction
Subluxation of 'Ring'
STABILIZATION THERAPY 143
NORM AL MOBILITY WITH PAI N

10 - Manual Therapy For The Thorax
1
ANATOMY
The thorax can be divided into four regions according to anatomi

cal and biomechanical differences. The vertebromanubrial region
(upper thorax) includes the first two thoracic vertebrae, ribs one
and two and the manubrium. The vertebrosternal region (middle
thorax) includes T3 to T7, the third to seventh ribs and the sternum.
T8, T9 and TI0 together with the eighth, n inth and tenth ribs form
the vertebrochondral region (middle/lower thorax). The lowest
region is the thoracolumbar junction which includes the Tll and
T1 2 vertebrae and the eleventh and twelfth ribs. The regional
anatomy pertinent to the biomechanical model will be described in
this chapter.
Figure 1.
The superior a spect of the
first thora c i c v ertebra. The
zygapophyse a l joints lie in
the coronal pla ne.
Manua l Therapy For The Thorax - 11
VERTEBROMANUBRIAL REGION
The first tho racic vertebra is atypical. It has a large , nonbifid s pin
ous process, club like at its end. The superior aspect of the spinous
process tends to lie i n the same transverse plane as the TI-2
zygapophys eal jo ints . The facets on the superior articular process
es lie in the coronal body plane (Fig. 1) w hile those o n the i nferi
o r articul ar process (Fi g . 2) present a gentle curve i n both the trans
verse a n d sagittal planes. The zygapophyseal joints are s y n ovial.
The transverse processes are long and thick. The y are located
between the s u perior and i n ferior articu l ar processes (Fig. 3) at the
dorsal aspect of the pedicle and are ideal ly s i tuated for palpation o f
i ntervertebral motio n . O n the ventral aspect o f the transverse
process there i s a deep, concave facet which articu l ates w i t h a con
v ex facet on the first rib to form the costotransverse j o i n t. In the
normal upright posture, the orientation of this joint is an teroinferior
Figure 2.
The i nferio r aspect of the first
thorac i c vertebra. The
zygapophyseal jo ints are gen
tly convex in both the trans
verse and sag i t tal plan es. The
ventral aspect of the trans
verse process contains a con
cave face t fo r a r t i culat i o n
with t h e firs t rib.
Figure 3.
Anterolateral v i ew of the first
t horacic vertebra. The unci
nate process at each postero
lateral corner creates a con
cav i t y on the superior aspect
of the vertebral body. There
is a full facet at the supe rolat
eral aspect of the vertebral
body for the head of the firs t
rib. A demi-facet on the
infero lateral aspect art i culates
with the head o f the second
rib in the second decade of
life . Note the concave facet
on the transverse process for
art iculati o n w i th the first rib.
12 - Manual Therapy For The Thorax.
(Fig. 4). Like the zygapophy

seal joint, the costotransverse
joint is synovial.
The superior aspect of the ver

.......;:;a
. tebral body of T1 is concave in
A"'''---- ' - the coronal plane. This con
......... cavity is formed by the unci-
1111.
....._"""
1 ....... nate process at each postero-
lateral corner. These processes
.... articulate with the inferior
Figure 4. jill...... aspect of the body of C7 to
Postero l ate r a l v i ew of the
form the non-synovial,
artic u l a ted t horax. Note the
cha nge in the orientat ion of
uncovertebral joint1. There are
the costotra nsverse joint from two ovoid facets on either side
the v ertebromanubrial region of the vertebral body for artic
to the v erte brochondral ulation with the head of the
region.
first rib. The inferior aspect of
the vertebral body of T1 is fiat and contains a small facet at each
posterolateral corner for articulation with the head of the second
rib. This articulation is incomplete until early adolescence when a
secondary ossification centre appears to complete the formation of
the head of the rib2,3. In children, the head of the second rib only
articulates with T2.
The first rib (Fig. 5) is the shortest of the twelve and the broadest
at its anterior end. The first sternochondral joint is unique in that it
is fibrous rather than synovial. The first costocartilage is the short
est and this, together with the fibrous sternochondral joint, con
tributes to the stability of the first ring. The convex head of the first
rib articulates with the body of T1 at the costovertebral joint. The
neck of the rib is located between the head and the tubercle. The
articular portion of the tubercle is convex and directed posterosu
periorly when the head and neck are in the normal upright posture.
The second rib is about twice as long as the first and its features are
similar to the vertebrosternal region described below. Anteriorly,
the cartilage of the second ring articulates with both the manubri
um and the sternum at the manubriosternal symphysis.
The manubrium (Fig. 6) is a broad triangular shaped bone which

articulates with the clavicle and the costocartilage of the first and
second ribs. The manubriosternal symphysis usually remains sep
arate throughout life although ossification can occur (Fig. 7).
Figure 5.
Superior aspect of the fi rst
rib.
Figure 6.
The manubrium.
VERTEBROSTERNAL REGION
The vertebrae in th is region (T3 to T7) have long, thin, overlapping

spinous processes (Fig. 8). The tip of the spinous process can be
three finger widths inferior to the transverse process of the same
vertebra and frequently deviates from the midline. Consequently, it
is an unre liable point for palpating intervertebral motion.
The facets on both the superior and inferior articular processes pre
sent a gentle curve in both the transverse and sagittal planes 4 (Fig.
9). This orientation permits multidirectional movement. If two
mixing bowls are placed one inside the other, a model of the
zygapophyseal joints can be made (Fig. 10). The top bowl can
rotate forward, backward, s ideways and around the bottom bow l .
Transl ation o f the top bowl meets immediate resistance. The coro-
Figure 7.
The m anubriostern a l symph
ysis is u s u ally main t a i n e d
thro ugh l i fe, however ossifi
cation can occur.
Figure 8.
Poster ior view of the articu
l ated thor a x .
nal orientation of the superior articular processes resists pos

teroanterior translation of the superior vertebra.
The transverse processes, located at the dorsal aspect of the pedi

cle between the superior and inferior articular processes, are ideal
ly situated for palpation of intervertebral joint motion. The ventral
aspect of the transverse process (Fig. 1 1 ) contains a deep, concave
facet for articulation with the rib of the same number. This curva-
Manual Therapy For The Thorax - 15
Figure 9.
The superior aspect of the
fourth thoracic vertebra. The
zygapophyseal j oint is ge ntly
convex in both the transverse
and sagittal planes. The ven
tral aspect of the transve rse
process contains a concave
facet for articulation w i t h the
fourth rib.
Figure 10.
Two mixing bowls model the
potential biomechanics of the
zygapophyseal j oints in the
thorax.
Figure 11.
Ante rola tera l v ie w of the
fourth t h o racic vertebra.
Note the concave facet on the
transverse process for articu
lation with the fourth rib as
we ll as the two demi-facets
on the lateral aspect of the
vertebral body for articula
tion with the heads of the
fo urth and fifth ribs.
ture (Fig. 12) influences the conjunct rotation which ocCurs when
the rib glides in a superoinferior direction. When the tubercle of
the rib glides superiorly, the curvature forces the rib to rotate ante
riorly. Conversely, posterior rotation of the rib occurs when the
Figure 1 2 .
Posterola t eral view o f the
articu lated th orax, verte
brosternal region. Note the
curvature of the fifth costo
transverse joint (arrow).
Figure 13.
Anterola teral view of the
articulated thorax. Note the
costovertebral joint, v erte
brosternal region (arrow).

tubercle glides inferiorly relative to the transverse process. In the

normal upright posture, the orientation of the facet on the trans
verse process is anterolateral.
The posterolateral corners of both the superior and inferior aspects

of the vertebral body contain an ovoid demifacet for articulation
with the head of the rib (Fig. 11). Development of the superior cos
tovertebral joint is delayed 'until early adolescence2,3 accounting
for the flexibility of the young thorax.
Figure 14.
The fourth rib.
Figure 15.
The sternum.
In the skeletally mature, the joint between the head of the rib and
the adj acent vertebral bodies i s div ided into two synovial cav ities,
separated by the intra-articular ligament (Fig. 13). The capsule i s
supported by t h e radiate l i gament which sends fibres from the head
of the rib both anteriorl y and posteriorly to b l end with the vertebral
bod y of the l evel above, the intervertebral disc and the vertebral
body of the level below. The costovertebral joint i s a compound,
synovial joint.
The n eck of the rib l i es parallel to the transverse process, joined by

the costotransverse or interosseous l igament. The non-articular
portion of the tubercle receives the lateral attachment of the short,
l ateral costotransverse l igament. Thi s l igament lies in the trans
verse plane between the transverse process and the rib . The s upe
rior costotransverse l i gament has a variable number of bands
which run in a superoinferio r direction from the inferior aspect of
the transverse process to the neck of the rib below. The neurovas
cular elements of the thoracic segment emerge between the bands
of this ligament. The shaft of the rib i s long and thin and twists to
a variable degree at the posterior angle (Fig. 14).
Very little is known about the anatomy and age related changes of
the intervertebral disc in the thorax. They are thinner than the cer
vical and lum bar intervertebral d iscs even i n youth. They are sup
ported anteriorly and posteriorly by w ide longitud inal ligaments.
Figure 1 6.
An terior view of t h e articu lat
ed t ho rax.
Figure 17.
An terola teral view of the
eighth thora cic vertebra .
Note the p l a n ar facet on the
transverse process fo r artic u
l a tion with the e ighth rib as
well as the l a rge sup e rior
dem i-fa c e t fo r articu l a t i o n
w i t h t h e h e a d of t h e eighth rib
and the small demi-facet for
a r t i culation with the head o f
the n in th rib .
The sternum (Figs. 7, 15) has eight full concave facets which artic
ulate with the costocartilages of ribs three to six. Superiorly, the
second rib articulates with the sternum at a demi-facet; inferiorly,
the seventh rib articulates with both the xiphoid and the sternum.
These joints are synovial unlike the lateral costochondral joints
which are fibrous, the periosteum and perichondrium continuous.
The costocartilage increases in length from the first to the seventh
ribs and then decreases to the tenth (Fig. 16). Thus the lower part
of the vertebrosternal region (ribs 6, 7) has greater flexibility ante
riorly than the upper part (ribs 3 , 4).
Figure 18.
Postero l a ter a l view of the
art i cul a ted thorax, vertebro
chondral region . Note the
planar n a ture of the nin th
costotransverse joint (arrow).
Figure 19.
Pos terior view o f the articu
l a ted t h orax, thoracolu m b a r
regi o n . Occa s i o n a lly the
spinous processes a re bifid .
Figure 20.
Lateral view of the twelfth
thoracic vertebra. Note the
change in directio n of the
facets on the superior and
inferior articular p rocesses.
There is one facet on the lat
eral aspect of the vertebral
body for articu lation with the
head of the twelfth rib. There
is no facet on the small trans
verse p rocess, there is no cos
totransverse join t .
Figure 21.
The eleventh and twelfth tho
racic and the first lumbar ver
tebrae. Note the orientation
of the zygapophyseal joints.
VERTEBROCHONDRAL REGION
The vertebrae in this region (T8, 9, 1 0) differ from the verte

brosternal r egi o n in the follo w ing aspects . The spi nous process is
shorter (Figs. 8, 17), altho ugh still directed inferiorly such that the
tip lies close to the transverse plane of the transverse process of the
inferior vertebra .
The facet on the ventral aspect of the transverse process is flat and faces
anterolateral and superior (Fig. 18). Therefore, when the tubercle of the
rib glides superiorly, it also glides posteromedially with minimal con
junct rotation. When the tubercle of the rib glide s inferiorly, it also
glides anterolaterally following the plane of the costotransverse joint.
Figure 22.
The transverse processes of
the twelfth thoraci c vertebrae
are small tubercles (arrow)
and cannot be used for pal
pating i ntervertebral mot ion.
T8 and T9 have four demifacets for articulation with the head of
the eighth and ninth ribs. T10 is variable. Often, there is only a
small articulation between the superior aspect of the head of the
tenth rib and the inferior aspect of the vertebral body of T9.
Occasionally, the tenth rib will articulate only with T10 at the base
of the pedicle via an unmodified ovoid joint.
Anteriorly the eighth, ninth and tenth ribs articulate indirectly with
the sternum via a series of cartilaginous bars which blend with the
seventh costocartilage (Fig. 16). There is a variable number of syn
ovial joints between the costocartilages (interchondral joints). This
arrangement permits greater flexibility.
THORACOLUMBAR JUNCTION
The spinous processes of Tll and T12 are short, stout and con
tained entirely within the lamina of their own vertebra (Figs. 8, 19,
20). The facets on the articular processes of Tll (Fig. 21) resem
ble those of both the vertebrosternal and vertebrochondral regions.
The facets on the inferior articular process of T12 resemble the
lumbar region. They have a coronal and sagittal component and
when articulated with Ll restrict axial rotation. The orientation of
Tll-12 does not restrict axial rotation.
Laterally, the transverse processes are small tubercles (Fig. 22), the
mamillary processes are larger and more superficial. The spinous
process is a more reliable point for palpating intervertebral motion
in this region.
Figure 23.
Lateral view of the thoracic
spine. Note the unmodified
ovo id facet (arrow) for the
head of the twelfth rib.
The heads of the eleventh and twelfth ribs articulate o nly with the
vertebral body at the base of the pedicle via an unmodified ovoid
joint (Fig. 23). There is no costotransverse j oint in this region. The
ribs do not have a neck and do not twist significantly. They remain
detached from the rest of t he tho r ax a n terio rly (Fig. 16) and pro
vide attachment for the diaphragm and trunk musculature. The
shape of the costovertebral joint facil i tate s multi-directio nal move
ment of the vertebral b ody even when the large muscles contract
and fix the eleventh and twelfth ribs. The eleventh segment (Tll,
T12, eleventh rib) is the most flexible in the thorax.
Man u a l For The Thorax 23
BIOMECHANICS
The m ateri a l been previousl y published,

the of Manual Manipulative Therapy5 and in
Therapy of the Cervical and Thoracic Spine6 and is reproduced
here with perm ission from the author and the publishers.
A biomcchanical to the assessment and treatment of

musculoskeletal dysfunction of the thorax requires an understand
ing normal behav iour. Without a ng model, ml
cian is l i m i ted to using often unreliable symptoms for direction and
treatment planni ng. If we understand how the osteoarticular system
behaves norm a l l y, we can then apply this knowledge when exam-
dev iant movement patterns thorax . A
of mob i l o f the associ ated bones
can done. The of this to present
of in vivo biomechanics of the thorax which has been used cli ni
cally as the basis for assessing and treating mechanical dysfunc
tions of hath the spi n a l a n d costal joi nts. Some parts of this m odel
have substantiated through scientific research 7 while others
rema i n empirica l .
LITERATURE REVIEW
Reference to the l i terature reveals very that is known ab out

the biomechanics the thoracic Four studies the
human thorax8,9,1O,1l based on three imensional
ical models and are difficu lt to apply clinically. Andriacchi 10 noted
that the rib cage increased the bending sti ffness of the spine by a
factor of two in extension. He fo und that when the rib cage w as l eft
intact, spine could three times load in com
before i nstability occurred . The impl ication
is that loss of the segmental thoracic would
impair the ab i lity of the entire cage to sustai n a vertical load.
Saumarez8 noted that there can be considerable independent move

ment of the sternum and the spine, "thus allowing mobility of the
spine without forcing concomitant movements of (the) rib cage".
Neither study8,10 proposed a kinematic model of the in vivo bio
mechanics of the thorax.
y
Panjabi, Brand and
White 7 investigated
the mechanical prop
erties of the thoracic
spine through an in
vitro study. Three
Figure 24. hundred and ninety
In an in v i tr o s t u dy by six load displacement
Panjabi, B r a n d and Wh ite 7, curves were obtained
396 load d isplacement curves
for six degrees of
were obta i ned for six degrees
of motion at each thoracic
motion, comprising
z
segm e n t. The a m p l i tude of three translations and
the i n d u ced m otion as well as three rotations along
the ampl itude and direct i o n of and about the X, Y
any consequ ential coupled
and Z axes for each of
motion was recorded. From
Lee 5,6 w ith perm ission.
the eleven motion
segments of the tho
racic spine (Fig. 24). The specimens tested ranged in age from 19
to 59 years. The motion segment included the anterior interbody
joint, the posterior zygapophyseal joints, the costovertebral and
costotransverse joints. The ribs were cut 3 cm lateral to the costo
transverse joints and the front of the chest was removed. The func
tional spinal unit was left intact, however, the functional costal unit
was not. The results of this study will be discussed later.
DEFINITION OF TERMINOLOGY
To facilitate the subsequent discussion, the terminology used

requires definition. Osteokinematics12 refers to the study of motion
of bones regardless of the motion of the joints. Angular motions
are osteokinematic motions and are named according to the axis
about which the bone rotates. Flexion/extension occurs about a
coronal axis, anterior/posterior rotation about a paracoronal axis,
sideflexion (lateral bending) about a sagittal axis and axial rotation
about a vertical axis. Coupled motion refers to the combination of
movements which occur as a consequence of an induced motion.
Linear motions are named according to the axis along which the
bone translates. Mediolateral translation occurs along a coronal
axis, anteromedial!posterolateral translation along a paracoronal
Flexion Anterior Translation
Figure 25.
Forward sagittal rotation
around the X axis induced
anterior translation along the
Z axis and slight distraction
along the Y axis. Anterior
translation along the Z axis
induced forward sagittal rota
tion around the X axis and
slight compression along the
Y axis. Redrawn from
Panjabi, Brand and White 7.
From: Panjabi et al 1976
From Lee5,6 with permission.
axis, traction/compression along a vertical axis, and anteroposteri

or translation along a sagittal axis.
Arthrokinematics 12 refers to the study of motion of joints regard

less of the motion of the bones. These movements are named
according to the direction the jo int surfaces glide.
HABITUAL MOVEMENTS
The thorax i s capable of six degrees of motion along and about the
three cardinal axes of the body; however, no movement occurs in
isolation 7. In other words, all angular motion is coupled with a lin
ear motion and vice versa. The habitual movements of the thorax
include forward and backward bending, lateral bending and axial
rotation of the head and trunk. Elevation of the arm also requires
movement of the upper thorax . Simultaneously, the chest moves
during i nspiration and expi ration. The biomechanics of the thorax
varies according to the region cons idered. The common features
and the regional differences will be described.
Forward bending
Flexion of the thoracic vertebrae occurs during forward bending of

the head and trunk. Panj abi, Brand and White 7 found that forward
sagittal rotation (flexion) around the X axis was coupled w i th ante
rior translation along the Z axis (.5 mm) and very slight distractio n
(Fig. 25). W h e n anterior translation along t h e Z axis (1 mm) was
induced i n the experimental model, forward sagittal ro tatio n
around t h e X a x i s w a s coupled with slight compression .
Th e osteokinematic
motion o f the ribs
during forward
sagittal rotat i o n of
the thoracic verte
brae was not noted
in the study by
Panja b i et a17 .
C l i n i ca l l y, three
m ovement patterns
can o ccur and are
dependant upon the
rel ative flex ibil ity
between the verte
bral column and the
rib cage . In the very
Figure 26. yo ung (less than 1 2
Flexion of the thoracolu mbar y e a rs of age), the
spine in a 6 year o l d .
head of the rib does
not a rticulate with
the inferior aspect of
the superior ve rte
bra . The secondary
ossification centre
for the superi or
aspect of the head of
the rib does not
develop until puber
ty, therefore the
young chest is very
Figure 27.
mobile (Fig. 26) . In
Flexion of the thoracolumbar
spine in a 71 year old.
the ske letally
m ature, the superior
costovertebral j oi nts limit the quantity of vertebral rotation i n all
three planes. With increasing age, the costocartilages stiffen and
decrease the flex ibility of the rib cage (Fig. 27). This change in rel
ative flexibility between the vertebral column and the rib cage is
apparent when examining the specific costal osteokinematics dur
i ng forward and backward bending of the trunk.
Mobile thorax
During forward bending of the mobile thorax, forward sagittal

rotation of the superior vertebra couples with anterior translation.
This anterior translation 'pulls' the superior aspect of the head of
the rib forward at the costovertebral j oint inducing an anterior rota-
Flexion
Figure 28.
The osteokinematic and
arthrokinematic motion pro
posed to occur in the mobile
thorax during forward bend
ing - vertebrosternal region.
From Lee5,6 with permission.
tion of the rib. The rib rotates about a paracoronal axis along the
l ine of the neck of the rib such that the anterior aspect travels infe
riorly while the posterior aspect travels superiorl y (Fig. 28). At
those l evels where the superior costovertebral j oint does not exist
(1, 11, 12) or i s very small (10), the anterior translation of the supe
rior vertebra cannot facilitate anterior rotation of the rib below.
Arthrokinematically, the inferior facets of the superior thoracic

vertebrae glide superoanteriorly at the zygapophyseal joints during
flexion. The superior articu lar processes of the inferior thoracic
vertebrae present a gentle curve convex posterior in both the sagit
tal and transverse plane. The superior motion of the inferior artic
ular processes follows the curve of this convexity and the result i s
a superoanterior glide. Thus, the arthroki nematic motion o f the
joint surfaces supports the osteokinem atic motion of the vertebrae,
anteri or translation being coupled with forward s agittal rotation.
In the vertebrosternal region of the thorax, the anterior rotation of

the neck of the rib results in a superior glide of the tubercle at the
costotransverse joi nt. Since the costotransverse j o i nts of T3 to T7
are concavoconvex (the facet on the transverse process is concave)
in both the sagittal and transverse plane, the superior glide of the
Facet
Plane -i--+---:,r
Figure 29.
ing - vertebroc hondral region.
Figure 30.
The oste okinemat ic and
posed to occu r in the mobile
i n g - thoracolumbar region.
Figure 31.
posed to occur in the stiffer
ing - vertebrostern al r egion
.
tubercle results in anterior rotation of the neck of the rib. Once

again, the arthrokinematic motion at the costotransverse joint sup
ports the osteokinematic motion of the rib during forward bending
of the trunk.
In the vertebrochondral region of the thorax (T8 - T10) the costo

transverse joints are planar and oriented in an anterolateral and
superior direction (Fig. 18). The posteromediosuperior (PMS)
glide of the tubercle (Fig. 29) does not induce an anterior rotation
of the neck of the rib to the same degree as the middle and upper
ribs.
The first rib is always less mobile than T1 and the movement pat
tern in the vertebromanubrial region is described b elow (stiffer
thorax). In the thoracolumbar region (Fig. 30), the eleventh and
twelfth costovertebral joints are unmodified ovoid in shape and
flexion of the thoracic vertebra can be a pure spin.
Stiffer thorax
The ribs are less mobile than the vertebral column when the stiffer
thorax is flexed. During forward bending of the head and trunk, the
anterior aspect of the rib travels inferiorly while the posterior
aspect travels superiorly. Once the mobility of the rib cage is
Figure 32.
The o s t e okinematic and
art hrokin e m a tic motio n pro
posed to occur in the verte
broma nubrial regio n during
forward ben d i n g.
Facet
Plane -+--i='7FII
Figure 33.
The o s t e ok i n e m a tic and
arthrokin e m a tic m o tion pro
posed to occur in the stiffer
thorax d u r i n g forward bend
ing - vertebrochondral region.
exhausted, the thoracic vertebrae continue to flex o n the stationary

ribs (Figs. 31, 3 2). The arthrokinematics of the zygapophyseal
joints rem ain the sam e as in the mobile thorax, however the degree
of anterior translation is less . At the costotransverse j o ints , the
arthrokinematics are different. As the thoracic vertebrae continue to
flex, the concave facets on thetransverse processes of Tl to T7 glide
superiorly relative to the tubercle of the ribs. The result is a rela tive
inferior glide of the tubercle of the rib at the costotransverse j o int.
Manual Therapy For The Thorax-
the vertebrochondral region 33), the facets of costo-

transverse joints are planar and the relative glide of the rib is.
anterolateroinferior.
Rigid thorax
When the relative flexibil between the vertebral column and the
rib cage is the same, there is no palpable movement between the
thoracic vertebrae and the ribs. Some superior gliding occurs at the
zygapophyseal but very if any posteroanterior transla
tion occurs.
Limiting factors
of the ligaments posterior to including the posterior half

the intervertebral disc limit flexion of the thoracic spinal unit. In a
study by Panjabi, Hausfeld and White13, the thoracic spinal unit
loaded to failure in both flexion and extension. Failure was
defined as complete separation of the two vertebrae or more than
10 mm of translation or 45 degrees of rotation. The ligaments were
Iransected sequentially the contribution of various liga
ments to stability was noted. In flexion, they found that the unit
remained stable until the costovertebral joint was transcctcd. The
integrity the posterior one-third of the disc and the costoverte
bral joints is critical to anterior translation stability in the thorax.
Backward bending
Extension of the thoracic vertebrae occurs during backward bend

ing of the trunk and during bilateral elevation of the arms. Flexion
of the upper thorax occurs when the head is bent backward.
Panjabi, Brand White7 found that backward sagittal rotation
(extension) around the X axis was coupled with posterior transla
tion along the Z axis (1 mm) and very slight distraction (Fig. 34).
When backward translation along the Z (2.5 was induced
in the experimental model, posterior sagittal rotation around the X
and very compression also occurred.
The osteokinematic motion of the ribs that occurs during backward

sagittal rotation the thoracic vertebrae was not noted in study
Panjabi et . Clinically, the movement patterns observed
depend on relative flexibility between the vertebral column and the
cage. ]'hree patterns have been noted.
Extension Posterior Translation
vJ
I I
Figure 34.
Backw a r d sa gittal rotation
vi
around the X axis ind uced
posterior translation al ong the
Z axis and slight dis tract i o n
along the Y ax i s . Posterior
t ra n s l a t i o n a l o n g the Z axis ----
3------
in duced b a ckward sagittal
rotat i o n around the X axis
and slight compression along
the Y axis . Red rawn fro m
Panjabi, Bra nd a nd Wh ite 7.
From: Panjabi et al 1976
From Lee56 with permiss i o n .
Extension
Figure 35.
The o s t e o k i n ema tic and
arthro k i n e m a tic motion pro
posed to occur in the mob i l e
thorax duri n g b a ckw ard
bending -
v e r t e brostern al
regi o n . From Lee 5.6 with per
m i ss i o n.
Mobile thorax
During extension of the mobile thorax, backward sagittal rotation

of the superior vertebra couples with posterior translation and
'pushes' the superior aspect of the head of the rib backward at the
costovertebral joint i nducing a posterior rotation of the rib (Fig.
35). The rib rotates about a paracoronal axis along the line of the
neck of the rib such that the anterior aspect travel s superiorly while
the posterior aspect travels inferiorly. At those levels where the
superior costovertebral joint does not exist (1, 11, 12) or is very
sm all (10), the posterior trans lation of the superior vertebra does
not force the rib to posteriorly rotate relative to its transverse
process .
Arthrokinem atically, the i nferior facets of the superior thoracic

vertebrae glide inferoposteriorly at the zygapophyseal j oints dur
ing extensi on. The superior articular processes present a gentle
curve that i s convex posteri orly i n both the sagittal and transverse
Figure 36.
thorax during backward
bending - vertebrochondral
region.
Figure 37.
thorax during backward
bending thoracol umbar
region.
plane. The inferior motion of the inferior articular processes fol

lows the curve of this convexity, and the result is an inferoposteri
or glide. Thus the arthrokinematic motion of the joint surfaces sup
ports the osteokinematic motion of the vertebrae; posterior transla
tion being coupled with backward sagittal rotation.
In the vertebrosternal region of the thorax, the posterior rotation of

the neck of the rib results in an inferior glide of the tubercle at the
costotransverse joint. The costotransverse joints of T3 to T7 are
concavoconvex in both the sagittal and transverse plane, thus the
inferior glide of the tubercle results in posterior rotation of the neck
of the rib. Once again, the arthrokinematic motion supports the
osteokinematic motion of the rib during backward sagittal rotation.
In the vertebrochondral region of the thorax (T8 - Tl0) the costo

transverse joints are planar and oriented in an anterolateral and
superior direction (Fig. 18). The anterolateroinferior glide of the
tubercle does not induce a posterior rotation of the neck of the rib
to the same degree as the middle and upper ribs (Fig. 36).
The first rib is always less mobile than Tl and the movement pat
tern is described below. In the thoracolumbar region, the eleventh
and twelfth costovertebral joints are unmodified ovoid in shape
and extension of the thoracic vertebra can be a pure spin (Fig. 37).
Stiffer thorax
The ribs are less mobile than the vertebral column when the stiffer
thorax is extended. Initially, the anterior aspect of the rib travels
superiorly and the posterior aspect travels inferiorly. Once the
mobility of the rib cage is exhausted, the thoracic vertebrae con-
Figure 38.
The o s t e ok i n e m a t i c and
arthro kine m a t i c motion pro
posed to occur in the s tiffer
thorax duri n g backward
bending - vertebrostern a l
region .
tinue to extend on the stationary ribs (Figs. 38 , 39). The arthrokine

matics of the zygapophyseal j o ints remain the same as in the first
movement pattern described, however, the degree of posterior
translation is less . At the costotransverse j oints, the arthrokinemat
ics are different. As the thoracic vertebrae continue to extend, the
concave facets on the transverse processes of Tl to T7 travel infe
riorly relative to the tubercle of the ribs . The result is a relative
superior glide of the tubercle of the rib at the costotransverse j oint.
In the vertebrochondral region, the facets of the costotransverse
j oints are planar and the relative glide of the rib is posteromedio
superior (Fig. 40) .
Rigid thorax
When the relative flexib i l ity between the vertebral column and the
rib cage is the same, there is no palpable movement between the
thoracic vertebrae and the ribs. Some inferior gliding occurs at the
zygapophyseal j oints, but very l ittle anteroposterior translation
occurs.
L imiting factors
All of the l igaments anterior to and including the posterior longi

tudinal ligament limit extension of the thoracic spinal unit. Panj abi
et al 1 3 sequentially transected the anterior longitudinal ligament,
the anterior half of the intetvertebral disc, the costovertebral j o ints
Figure 39.
arthrokinematic m o t i o n pro
posed to occur i n the verte
brom a nubrial reg i o n d uring
bi l a te r a l e l ev a t i o n of the
arm s .
Figure 40.
The o s te o k i n e m a t i c and
arthroki n e m a t i c m o t i o n pro
posed to occur i n the s t i ffer
t h o ra x d u r i ng b a c k w a rd
be n d i n g - v ertebro c h o n d ral
reg i o n .
and the pos teri o r half of the i nterv ertebral disc and noted the c on
tribution of each to st a b i l i ty in extension . In ex t en sion they found

,
that the unit remained stable until the p o sterio r l o ngitu d i n al liga
ment was transected.
36 - Manual Th erapy For Th e Thorax
Right Sideflexion Right Tra n s l ation
Figure 41 .
Right sideftexion around the
Z ax is ind uced left rotation
around the Y axis and right
translation along the X axis.
Right lateral translation along
the X axis induced right side
flexion around the Z ax is and
left rotat ion aro und the Y
axis. Redrawn from Panjabi,
B rand and W h i t e 7 From From : Panjabi et a l 1 976
Lee 5 , 6 with perm ission.

Lateral bending
Sideflexion of the thoracic vertebrae occurs during lateral bending

of the head and trunk. Panj abi et a1 7 found that sideflexion, o r rota
tion around the Z axis, was coupled with contralateral rotation
around the Y axis and ipsilateral translation along the X axis (Fig.
4 1 ) . Translation along the X axis was coupled with ipsilateral side
flexion around the Z axis and contralateral rotation around the Y
axis .
It is i n teresting t o postulate on what produces this coupling o f

motion i n t he thorax. In t h e m i dcervical spine, i t is thought2 , 14 that
the oblique orientation of the zygapophyseal j oints together with
the uncinate p rocesses directs the ipsilateral rotation which occurs
with lateral bending of the head . In the lumbar spine, the
zygapophyseal j o ints also are thought 15 to influence motion cou
pling. However, the facets of the zygapophyseal j o ints in the tho
racic spine lie in a somewhat coronal plane and would not l i m it
pure sideflexion during lateral bending of the trunk. It is difficult to
see how they could be responsible for the contralateral rotation
found to occur during sideflexion 7 . A clinical hypothesis of the
factors wh ich produce motion coupl ing during l ateral bending of
the thorax is proposed .
Clinical hypoth esis
As the head and trunk bends laterally to the right, a left convex
curve is produced . The thoracic vertebrae sideflex to the right, the
ribs on the right approximate and the ribs on the left separate at
their l ateral m argins (Fig. 42). In both the mobile thorax and the
t Figure 42 .
As t he thorax s i d e fl exes to the
right, the ribs on the righ t
approximate and the ribs on
the l eft separate a t their later
al ma rgin s The costal motion
.
stops fi r s t , the thoracic verte

brae then con t i n u e to s i d eflex
s lightly to the right. From
Lee5, 6 with permi ss io n .
Figure 43 .
In the vertebrostern al region,
the superior glide of the right
rib at the costotran sverse j o i n t
i nduces anterior rotation of
the same rib d ue to the c u rv a
ture of the j o int surfaces. The
inferior glide of the left rib at
t he co s t o t r a n sverse j oint
induces posterior rotat ion of
the same r i b . From Lee5.6
with permiss ion.
stiffer thorax, the ribs appear to stop moving before the thoracic
vertebrae. The thoracic vertebrae then continue to sideflex to the
right. This motion can be palpated at the costotransverse j oint.
In the vertebrosternal region (T3 to T7), this slight increase i n r ight

sideflex ion of the thoracic vertebrae against the fixed ribs causes a
relative superior glide of the tubercl e of the right rib and a relative
inferior glide of the tubercle of the left rib at the costotransverse
j oi nt (Fig. 43). Since the costotransverse j oint is concavoconvex in
38 - Manual Th erapy For Th e Thorax
Figure 44.
In the vertebrosternal region,
anterior rota t ion of the right
rib and posterior rotation of
the left rib facil itates a con
tra l ateral rotation of the supe
---
rior vertebra due to the

attachment of the rib to the
inferior aspect of the superior
vertebral bod y . -/..?--
a sagittal plane, the superior glide of the right rib produces a rela
tive anterior rotation of the neck of the rib with respect to the trans
verse process. The inferior gl ide of the left rib produces a posteri
or rotation of the neck of the rib relative to the transverse process.
It is important to note that the moving bone is the thoracic verte
bra, not the rib ; however, the relative motion is described as though
the rib was moving. Bilaterally, the effect of this rotation is to
rotate the superior vertebral body to the left (contralateral to the
sideflexion) (Fig. 44).
Panj abi, Brand and White 7 found that right lateral translation along
the X axis (.5 1 mm) occurred during right sideflexion (Fig. 41) .
-
The effect of this right lateral translation is negated by the left lat
eral translation which occurs as the superior vertebra rotates to the
left. The net effect is minimal, if any, mediolateral translation of
the ribs along the l ine of the neck of the rib at the costotransverse
j o i nts. The clinical impress ion is that no anteromedial or postero
lateral sl ide of the ribs (relative to the transverse process to which
they attach) occurs during l ateral bend ing of the trunk.
At the zygapophyseal j oints, the l eft inferior articular process of

the superior thoracic vertebra glides superomedially and the right
process glides inferolaterally to facilitate right sideflexion and left
rotation of the superior vertebra. The arthrokinematic motion of
the j oint surfaces supports the osteokinematic motion of the verte
brae and ribs .
In the vertebromanubrial region, the head of the first rib does not
articulate with C7 and the superoi nferior glide of the ribs and the
conj unct rotation which occurs cannot influence the di rection of
Figure 45.
The o s t e okin e m a tic and
arthrokin ematic motion pro
broma nubria l region during
l atera l bend ing of the head to
the righ t .
Figure 46.
R ight l a tera l bending of the
trunk w i t h the apex a t the left
grea ter troch a n ter.
movem e n t cou pling between C7 a n d T l . C7-T l a n d TI -T2 fol l ow

t h e s a m e pattern of moti o n cou p l i n g as t h e m i dc e rv i ca l s p i n e w h e n
t h e head i s b e n t l aterall y ( F i g . 45) . S idefle x i o n i s c o u p l e d w i t h i ps i *
l a t e r a l r o t a t i o n o f t h e superio r vertebra. T h e u n c i n ate p r o c e s s e s a t
C7-T l i n fl u e nce the d i r e ct i o n o f m o t i o n coupl i ng h e r e .
D u r i n g right l a t e r a l b e n d i n g o f the h ead/neck the transverse
process gl i des rel ative to the rib o n the right a n d s u p e r i
o r l y r e l a t i v e t o the rib o n t h e l eft .
The b i om e ch a n i cs of t h e vertebrochondral regi o n d u r i ng lateral

b e n d i n g o f the trunk i s dependant upon the apex o f t h e c u r v e p r o
d u c e d i n s i d eflexion . I f t h e apex of t h e l ateral b e n d i n g c u r v e i s at
the l ev e l o f t h e greater trochanter o n t h e l e ft (Fig . 46), t h en a l l o f
t h e thoracic vertebrae s i d e fl e x to t h e r i g h t a n d the r i b s appro x i m ate
on t h e right and separate o n the l eft . A s t h e rib cage is com pressed
on right a n d stops furth er r i g h t s i de fl e x i o n o f t h e l ow e r
t h o r a c i c vertebrae resu l ts i n a superior g l i de o f t h e t u b ercle o f the
r i g h t r i b and a n i n ferior g l i d e o f t h e tubercle o f t h e l e ft . G iv e n t h e
o rientat ion o f the articular s urfaces, t h e d i rection o f t h e g l ide
w h i c h occurs i s posterom e d i osuperior o n t h e right a n d a n t e r o
l atero i n fe r i o r o n t h e l eft w i t h m i n i m a l rotation of the n e c k o f the
r i b (Fig . 47) . The ribs do n o t appear to d i rect the s u p e r i o r vertebra
i nt o contral ateral rotation as they in the vertebro s t e r n a l regi o n ,
Th e vertebrae a r e t h e n free to fo l low t h e rotati o n w h i c h is congru-
e n t with levels above a n d b e l ow,
If ape x of the l ateral b en d i ng curve w i t h i n t h e t h o r a x , (Fig.

48), then t h e o s teok i n e m atics o f the lower thoracic v e rtebrae
appear to h e d i fferent T h e r i b rem a i n s co m prcssed o n the
right and separated o n t h e left, b u t the thoracic vertebrae s id c fl e x
to t h e l eft b e l ow t h e apex of t h e r i g h t l ateral b e n d i ng c u r v e ( L e . T9,
Tl T 1 1 , T 1 2) . G i v e n the o r i e n tat i o n o f t h e articular su rfaces of
t h e costotransverse j o i n t s , the direction o f t h e glide which occurs
is anterol ateroi n fe r i o r o n t h e right and postero m e d i osuperi o r on
t h e l eft w i th m i n i m a l rotati o n o f the neck o f the r i b . O n ce aga i n ,
the ribs not appear t o d irect the superior v e rtebra rotate i n
s e n s e i ncongrue n t to t h e l e v e l s above a n d b e low.
At t h e thoracolumbar j un ct i o n , pure s idcftexi o n c a n o cc u r (Fi g .

4 9 ) . The h e ads o f t h e e l ev e n t h a n d tw e l ft h r i b s do n o t art i c u l ate
w i t h the v ertebr a above a n d there i s n o costotransverse to
consider. The costoverteb ral j o i n t shape is an u n m od i fi e d o v o i d
a n d therefore s idefl e x i o n o f the thoracic v e rtebrae between
two fixed r i b s can occur.
Figure 47.
L The osteoki nematic

a rthro kinematic motion pro
posed to occur during right
and
lateral bend ing of the verte

brochondral regio n . The
direction of the art hro k i ne
matic glide at the costotrans
verse joi nts i s posteromedio
superior on the right and
a n t e rolatero i n fe r i o r o n the
left . Minimal rotation of the
head of the rib occurs si nce
the costotra nsverse j o i n t is
planar. The rib, therefore, has
little infl uence o n the direc
tion of motion coupling of the
superior vertebra. The superi
or vertebra is free to fol low
t h e d i rect ion of rot a t i o n
which is congruent w i t h t h e
levels above a n d below .
Figure 48.
Right lateral bend ing of the
trunk w i t h the apex within the
thorax.
Figure 49.
The o s t e o k i ne m a t i c and
posed to occur duri n g right
l ateral b e n d i n g of the thora
columbar regio n .
Rotation
Figure 50.
Panj ab i , Brand and W h ite7
fo u n d that right rotation
aro u n d the Y axis i n d uced left
s i deflexion around the Z axis
and left translation along the
X a x i s . From Le e5,6 with per
m is s i o n . Fro m : Panj abi et al 1 976
Rotation
Panj abi, Brand and White 7 found that rotation around the Y axis
was coupled with contralateral rotation around the Z axis and con
tralateral translation along the X axis (Fig. 50) . This is not consis
tent with clinical observation (Fig. 5 1) . In both the vertebro
manubrial and vertebrosternal regions, rotation around the Y axis
Manual Th erapy For Th e Thorax - 43
Figure 51 .
Cl i n i cally, t h e m i d thorax
appears to sideflex and rotate
to the same side during rota
tion of the trunk.
has been found to be coupled with ipsilateral rotation around the Z

axis and contralateral transl ation along the X axis. In other words ,
when axial rotation is the first motion i nduced, rotation and side
flexion occur to the same side. It may be that the thorax must be
intact and stable both a nteriorly and posteriorly for this i n vivo
co upling of motion to occur. The anterior elements of the thorax
were removed 3 em l ateral to the costotransverse j o i nts in the study
by Panj abi et aI 7 .
When the anterior elements of the thorax are removed surgically,

ipsilateral sideflexion and rotati on cannot occur i n the midthorax .
The costocarti lage of the left sixth rib was removed for cosmetic
reasons in the 1 7 year old youth illustrated i n Figures 52 and 5 3 .
H e presented four years later with pers istent pain in the m idthorax,
and on examination of axial rotation he could not produce ipsilat
eral rotation/sideftexion of the midthoracic region .
Clinical hypothesis
During right rotation of the trunk the following b iomechanics are

proposed. The superior vertebra rotates to the right and transl ates
to the left (Fig. 5 4) . Right rotation of the superior vertebral body
' pulls ' the superior aspect of the head of the left rib forward at the
costovertebral joint i nducing anterior rotat ion of the neck of the
left rib (superior glide at the left costotransverse j oint), and ' push
es ' the superior aspect of the head of the righ t rib backward, i nduc
ing posterior rotation of the neck of the right rib (inferior glide at
the right costotransverse joint) . In the vertebrochondral region, the
rel ative glide at the costotransverse j oint is posteromediosuperior
Figure 52.
The costocarti lage of the left
s i x t h rib was removed ( arrow
poin t s to the inc i s ion) i n t h is
seventeen year old.
Man u a l Therapy For The Thorax - - 45
Figure 53 .
Note the i n ab i l i t y of the

mid thorax to rotate a n d s i de
flex to the r i g ht dur i ng right
rotation of the tru n k (a rrow) .
Instab i l ity prevents the n or
mal b i omechan ics of i ps i l at
eral sideflex i o n/ro t a t i o n dur
i n g rotation of the tru n k.
o n the l e ft and anterolatero infe r i o r on the r i gh t (Fi g . 55). The l e ft

lateral t ra n s l a t i o n of t he superior vertebral body ' pushes ' the l eft
rib posterolateral l y along the l i n e of the neck of the r i b and causes
a postero l ateral tra n s latio n of the rib at the l eft costotransverse
j o i n t . S i m ul taneo u s ly, the left lateral translation ' pu l l s ' the right rib
antero m e d i a l l y along the l i n e of the neck of the rib and causes a n
antero m e d i a l transl ation of t h e rib at the right costotransverse j o i n t .
An antero medi al!po sterolateral s l i d e of the ribs rela tive to the
transverse processes to wh ich they a ttach is thought to o ccur dur
ing a x i a l rotation .
When the l i m i t of t h i s ho rizontal trans l at i on is reached, b o t h the

costoverte b r a l and t h e costo transverse l igam e n t s are ten s e d .
Stab i l i t y o f t h e r i b s both anteriorly and poster i o r l y is required fo r
the fol l ow i n g m o t i o n to occur. Further right rotation of t h e s u p e r i
or v ertebra o c c u r s a s the superior vertebral body t i l t s to the r i gh t
(gl ides s u p e r i o r l y a l o n g th e left s u p e r i o r costovertebral j o i n t a n d
inferiorly along the r i g h t s u p e r i o r costoverteb ral j o in t) . This t i l t
Figure 54.
arthrokinematic m o t i o n p r o
p o s e d to occur i n the verte
brosternal region during right
ro tation of the trunk. From
Lee5 . 6 with perm i s s i o n .
Figure 55.
broch o n d r a l reg i o n d u r i ng
right ro t a t i o n of the tru n k .
causes right sideftexion of the superior vertebra during right rota

tion of the midthoracic segment (Fig. 5 6).
At the zygapophyseal j oints, the left i nferior arti cular process of

the superior vertebra glides superolaterally and the right inferior
articular process glides inferomedial ly to facilitate right rotation
and right sideflexi o n of the thoracic vertebra. The arthrokinematic
motion of the joint surfaces supports the osteokinematic motion of
the vertebrae and ribs.
I n the vertebromanubrial region, C7 Tl and Tl -T2 follow the

-
same pattern of motion coupling as the m idcervical spine when the

Figure 56.
the limit of left l a teral
t ra n s l a t ion, s u perior
tebra sideflexes to the right
1111!!
111/ii!I!!!I!!!!!I!I!!i!!!,!I!!!I!lil !li!liii!!!iillll,;
a long the plane of the pseudo
' U ' j o i n t (analogous to the
unco v erteb r a l joint of
m i dee rv i c a l fo rmed
the i n tervertebral d isc and the
superior costoverteb ral j oi n t s .
. .
Lee56 permission .
head rotated. Rotation i s coupled with ipsilateral sideflexion the

superior vertebra. The two uncinate processes at C7-Tl m ay influ
ence the d i rection of motion coupling here. During right rotation of
the h ead/neck transverse process g lides i nferiorly relative to
the o n the and superiorly relative to the o n the (Fig.
45) .
Con siderable flexib il ity motion coupling apparent the

lo\\'er thora x . Anatomical the lower thoracic levels (T T11)
are designed t o rotate with m i n i mal restrictio n from the ribs.
Passively, the T l 1 - 1 2 segment can be purely rotated about a verti -
cal with restriction from the zygapophyscal j o ints the
ribs 57). Actively, coupled movement for rotat ion
i n th is region can he ipsi l ateral s ideflexion or contralateral s i de
flexion. The coronally oriented facets of t h e zygapophyseal j o i nts
do dictate specific coupl i n g sidefiexi o n when
induced. The absence of costotransverse j oint and the
direct anterior attachment of the associated ribs facili tates this flex
i b i l it y i n motion patterning at the e l eventh and twe l fth segments.
Rlspiration
The diaphragm is the most efficient respiratory m uscle. However,

con traction of d iaphragm can two different of
motion within thorax .
Figure 5 7.
The osteokinem a tic and
posed to occur i n the thora
columbar regio n d u r i n g right
rotation of the trunk.
During i nspiration, the diaphragm descends and pulls the central
tendon inferiorly through the fixed twelfth ribs and Ll to L3. When
the extensibility of the abdominal wall is reached, the central ten
don becomes stationary and further contraction of the diaphragm
results in posterior rotation of the lower six ribs . This posterior
rotation causes torsion of the cos tocartilage anteriorly. If the cos
tochondral and chondrosternal joints are stable, the torsional forces
are transmitted anteriorly to the sternum .
As the ribs posteriorly rotate, the sternum is thrust in an anterosu

perior direction thus increasing both the anteropos terior and verti
cal dimensi ons of the intrathoracic cavity. During fu ll inspiration,
this anterior thrust is also transferred to the manubri um. S i nce ribs
one and two are s horter than ribs six and seve n , the anterior
manubrial displacement is less than the anterior sternal displace
ment. The manubriosternal symphysis accommodates this differ
ence by bending in the sagittal plane (sternal flexion).
Alternatively, the diaphragm may contract through a stationary

central tendon. The central tendon is the fixed point and produces
the same osteoki nematics as described above. There is no abdom
inal distension with this breath ing pattern but rather lateral costal
expansio n .
Expiration occurs passively du r in g relaxation of the diaphragm .

Forced expiration requi res recruitment from the anterior and pos
terior trunk musculature.
Regardless of the pattern of respiration, the arthroldnematics of the costo

transverse joints remain the same. During inspiration, the tubercles of ribs
one to seven glide inferiorly, ribs eight to ten glide anterolateroinferiorly and
ribs eleven and twelve remain stationary. During expiration, the tubercles of
ribs one to seven glide superiorly, ribs eight to ten glide {X>Steromediosupe
riorly and ribs eleven and twelve remain stationary. The arthrokinematics of
the zygapophyseal joints is variable depending on the osteoldnematic
motion which occurs . During quiet respiration, very little motion is required
from the zygapophyseal joints.
Figure 58.
D u r i n g elevation of the left
arm the v e r te b r o m a n ub r i a l
region should p r o d u ce a
localized concavi t y on the
side of the e lev a t i n g a r m .
Unilateral elevation of the arm
During u n i l ateral elevation the arm has been noted that

vertebromanubrial region rotates, l atera l l y bends and s l i gh t l y
extends to the side of the elevating arm (Fig. 5 8 ) . The first t w o ribs
posteriorly rotate the same side and anteriorly rotate on
opposite. The arthroki n ematics at the costotransverse
j oi n ts depend upon relative flexibil i ty between the thoracic verte
b rae and the ribs. In a recent study by Stewart and Ju11 1 6 , the
Fastrak 3-D Movement System was used measure movement of
the thoracic spine u n i l ateral e levatio n o f the The
confirmed that u n i lateral elevation of the arm did induce move
ment i n the thoracic spine h owever, i t was noted that the pattern of
sideflexion and rotatio n was variab l e . some asy m ptomatic
viduals sideflexion occurred the side the elevating
arm . Although asymptomatic at the time of testing, it i s fel t that
this pattern indicates an articular restrictio n or m u scle i mbalance
w hich when corrected results i n a return to the i ps i l ateral
tion/sioeilexion
Manual Therapy For The Thorax - 5 1
3
CONDITIONS
Accor d i n g to the medical m o deJ , con d i t i o n s the t horax m a y

classified as visceral , m e t ab o l ic, i n fe ct i v e , n e o p l astic, a n d spond y
l ogenic i n o r i g i n .
MEDI CAL MODEL OF CLA S S IFICATION
Visceral
As a p r i m ary cont act cl i n i c i a n , i t i s i mportant to recognize t h a t p r i

m ar y i n trathoracic a n d i n traabom i n a l d i sorders can refer p a i n to
the thorax . The p a i n ten ds to b e dull and deep a n d not i n fl u e n ce d
h y p h y s i ca l activ i t i e s . R e s t m a y n o t afford rel i e f fro m the p a i n .
Metabolic
Some m e t a bo l i c con d i t i o n s w h ich can e ffect the thorax i n cl u de

a n ky l o s i n g spondy l i t i s , d i ffuse i d i op at h i c skeletal h yperosto s i s
(DISH Fig. 59), rheumatoid arthritis, osteoporosis (Fi g . 60) ,
fibro m y a l g i a , ochronosis, g o u t , t u bercu l o s i s and Page t ' s d i s e a s e .
Although m a n u a l t h e r a p y i s n o t con t r a i n dicated w h e n these con d i
tions a r e pre s e n t , t h e cl i n i ci a n m u s t m o d i fy t h e i n ten s i ty o f treat
m e n t and possibly reduce the expected outcome.
Jnfection
Bacter i a l a n d v i ral i n fe c t i o n s can occur w ith i n t h e skeletal compo

n e n ts o f t h e t h o r a x . The patient u s u a l l y feel s syste m ical l y u n w e l l
a n d t h e characte r i stics o f the p a i n behav i o u r s h o u l d a l e rt t h e cl i n i
cian t o suspect a nonmechanical s o u rce o f p a i n . Ess e n ti a l l y, s y s
temi c i n fl a m m atory and/or i nfective d i sorders affe ct i n g the t h o ra x
Figure 59.
Ossification of the l o ngitudi
nal l iga m e n t s of t h e spine
occurs w i t h d i ffuse i d iopathic
skeletal hy perosto sis .
can be differentiated from traumatic inflammation (i .e. sprain) by

the lack of trauma in the h istory, the inconsistent response of the
j o int to mechanical stress and rest as wel l as the lack of resolution
with appropriate therapy over a short period of time. The experi
enced clinician will quickly recognize the pattern o f response to
therapy which deviates from the norm and question the etiology at
this point. Subsequent investigation is then ind icated .
Neoplastic
Both benign and malignant tumours can occur in the skeletal components
of the thorax. Secondary metastases are common from the lung and breast
and a past history of carcinoma should alert the clinician to this possibility.
Spondylogenic
Spondylosis includes any dysfunct ion of the muscul oskeletal sys

tem secondary to maj or or m inor trauma. Degenerative changes are
i ncluded h ere .
Figure 60.
The typ i ca l p o s t u re of a
patient with advanced osteo
porosi s .
Scoliosis is a complex, multifactorial problem of both known and

unknown causes (Fig. 61). It may be congenital or acquired; from
disease or i nj ury. It has long been recognized 17 that idiopathic sco
liosis involves muscle imbalance. Henry Kendall (1930) noted that
"The muscl e weakness was almost always found in the

lateral abdom inals, anterior abdominals, pelvic, hip and
leg muscles. This weakness caused the body to deviate
from ei ther the l ateral median plane or the anterior-pos
terior median plane, causing the patient to compens ate
for the deviation by substituting other m uscles in order to
54 - Manua l Therapy For The Thorax
Figure 61 .
This patient has a ma rked
thoracolumbar scol iosis sec
ondary to p o l i o m y e l i tis .
maintain e q u i l i b r ium In doing the substituting, the

.
patient i nvariably develops muscles which cause lateral

rotatory movements and it is easy to see why we have
lateral curvature with rotation." 17
However, even the most compl iant patient a n d d i l igent therapist can
not prevent the progression of some scoliotic curves with exercise.
Current re search on the et iology o f idiopathic sco l iosis h a s revealed a
possible centra l process i ng or neural componen t 1 8, 1 9 . The reader is
referred to Kend a l l 1 7 for the ev aluation and treatment of muscle i mba l
ances of t h e trunk a n d l ower extre m ities a n d to t h e refe renced m ateri
ai fo r further information on the neural basis of idiopathic sco liosis.
Man u a l Therapy The Thorax
MANUAL THERAPY MODEL OF CLASSIFICATION
Although medical of classification usefu l for

standing etiology of classifications \vhich follow
mechan ical model based o n m ob i l ity and stab i l ity are more useful
for the manual therapist. In keeping with this mode l , disorders
w i th i n the thorax can be classified into three groups, each of which
describes the obj ective findings noted on m ob i l ity testing and
gests appropriate They include :
1 . Hypomob il ity w i th o r without pain
2. Hypermobi lity with o r without pain
3 . Normal mobil ity with
This classification does not provide a specific an atom ical nor phys
iological cause for the aberrant mob i lity noted, however, since
manual therapy techn iques are specific to restoring m ovement pat-
terns, cause is not for
The a i m evaluation procedures is
art i c u l ar, m y o fas c i a l , w h i ch e ffecting
Treatment can then be modified to e ither mob i l ize or stabilize the
appropriate system . If the biomechanics are restored and if the
underlying etiology i s biomechanical in nature, symptomatic and
obj ective im provement fol lows .
The principles upon wh ich treatment i s b ased fol l ow those of the

body 's natural healing process. One of the goals of therapy i s to
facilitate the natural process by preventing or reversing the factors
whi ch tend to retard recovery.
Long \vhen living were unicel death of cell

meant death of the organism . With the evolution of m u l ticel l u l ar
organ i s m s , c a m e the process of repair fol l o w i n g i nj ury.
Subsequently, this repair process was perfected such that complete
regeneration of a l i m b possible after am putation. Lizards and
newts retained this capab i l i ty today. Unfortunately,
lution complex forms ( i . e . mammal) has
at the expense of such total regenerative abi l ities. The cardiac mus
cle i n man does not regenerate fol l owing infarction, neural tissue
does not regenerate fol l owing cellular death, skin does not regen-
erate ful l i nj ury and amputated
not back. With few exceptions,
to i nj ury repair rather regeneration .
56 - Manual Thorax
Repair occurs by fibrous pro l i feration regardless of w hich tissue

h as been damaged, The process can be d i v i ded into three
substrate, fibrobl astic and m aturation. Treatment varies according
to the stage o f tissue repai r.
HEALING PROCESS
Substrate phase
The substrate phase extends the time of i nj ury the fourth t o

sixth and i s characterized the response,
inflammatory reaction prepares the wound for subsequent healing
by removi ng necrotic t i ssue and b acteria, At the same time, fibrob-
lasts to wound The wound is weak this
time it is the action fibrin, has very
low breaking strength, wh ich holds the wound edges together.
Fibrobla stic phase
The fibroblast i c phase l asts up to fou r to ten weeks post t rauma 20 ,

Manual t herapy has its greatest influence during this t i m e when the
p ro l i ferat i n g fib r o b lasts b e g i n s y n th e s i ze
m ucopo l y saccharides and glyeo proteins, Fibrobl asts repai r th e
wounded t issue b y replacing i t w i t h fibrous tissue. Tropocol lagen
i s secreted from the fibroblasts and quickly aggregates into col l a-
gen The orientation the fibres can be i nfluence d
mechan ical forces t h e wound s i te 2 0 , tensile strength the
wound at this time is proportional to the quantity of COl l agen pre
sent as opposed to crossl i nking between the co l l agen fibres,
Matm"ation phase
There is n o sharp demarcati o n between the end of the fibrobl astic

phase the begin n i ng of maturation phase, quan t i ty of
col lagen within wound remains between the t h i rd and
fourth weeks a lthough the wound conti nues to gain i n tensi l e
strength. T h i s strength gai n i s due t o crosslinking a n d remode l l ing
of the l agen to give stronger \veave, The q uant ity
l agen equi librium, however, the organ izati o n u n dergoing
change . This process of remo de l l i n g may requ ue s i x to twelve
m o n th s for completion20 .
Man u al Therapy For The Thorax - 57
C l i n i c a l application to tre a tment
Scar t i s s u e can create p a i n an d d i s ab i l i t y w i t h i n the m u s c u l o s k e l e

t a l s y stem depen d i n g o n how t h e repai r e d t i s s u e d i ffers fro m t h a t
i t replace s . Essent i al ly, t h e repa i r process restores the structure
with l i t t l e regard to fu ncti o n . For exa m p l e , col l agen is n o n - c o n
tract i l e a n d w h e n i t rep a i rs a torn m us c l e , b o th the contract i l i ty a n d
extensib i l i t y of t h e m u s c l e w i l l be effected . The a i m o f treatme n t ,
therefo r e , m u s t b e t o c o n t r o l a n d to g u i d e t h e r e p a i r process such
that optim a l structure and functi o n are restore d .
In t h e substrate and the e a r l y fibrob l a s t i c stage, v igorous e x e r c i s e

program s o r aggres s i v e passive m o b i l izations are contra- i n d i cated
s ince t h e r e i s m i n im a l cross l i n k i n g o f co l l agen fibres . Gentle p a s
s i v e m ob i l i za t i o n s and exercises w i t h i n the p a i n free r a n g e of
m o t i o n w i l l fac i l i tate the proper orientation of co l l agen depo s i t i o n
at the w o u n d s i t e . T h e p a t i e n t w i l l find t h a t t h e b e s t rest i n g posi
t i o n for acute thoracic p a i n i s s e m i -s i t t i n g . S up i n e l y i ng o n a h ard
surface forces t h e t h o r a x i nto an extended posture w h i l e s i d e l y i n g
often i nduces s i de ft ex i o n and r ot at ion .
O rga n i ze d , restrictive a d h e s i o n s can develop d u r i n g t h e m at u r a t i o n

p h a s e o f t i s s u e repai r if t h e r a n g e of m o t i o n i s n o t r e s t o r e d w i t h i n
t h e fibrob l a s t i c p h a s e . W h i l e t h e structure m ay b e restored, fu n c
tion m a y be adverse l y effected b y the adhes i o n . More v i go r o u s
mob i l i za t i o n t e c h n i q u e s and frequent e x e r c i s e s at h o m e w i l l b e
requ ired to faci l i tate a r e t u r n of the range of m o t i o n .
Left a l o n e , w o u n d e d t i s s u e w i l l repa i r. T h e e fficacy of t h e rep a i r

process depen d s o n h o w w e l l t h e repl acement t i s s u e restores t h e
t i s s u e ' s o r i g i n a l fu n c t i o n . T h e r o l e of therapy i s to g u i d e t h e depo
s i t i o n and r e m o de l l i n g of the scar at e ach stage of rep a i r s u c h t h at
the res u l ta n t structure w i l l subserve the t i s s u e 's fun ct i o n . To s u c
cessfu l l y ach ieve t h i s go a l , i t i s param o u n t that the p a t i e n t b e c o m e
i nv o l v e d i n t h e i r o w n r e h ab i l i t a t i o n through home e x e r c i s e pro
grams w h i c h fo l l o w the p r i n c i p l es of tissue h e a l i n g .
Manual Therapy The Thorax
AS SES SMENT
When cons istent approach assessment

of mechanical dysfunction the thorax
this section is to outline the basic subj ective and obj ective exami
nation .
60 - Thorax
--- --........ --
Ta ble I. Subj ective examination
Name : Age : Dr:
Curre n t H istory (mode of onset) :
Past History : Past Treatment:
PAIN/DYSAESTHESIA
Location : Rel iev ing/Aggravat i n g Activities:
Special Questions: Distal paraesthesia, Bowel/b l adder

Effect of sustain ed SLUMP
n eck flexion
S LE E P
Su rfacelPos i t io n : Status i n a . m . :
Night wakeni n g :
GENERAL INFORMATION
Occupation/sport/hobbies:
General Health : Medicatio n :
Resul ts of adj u n ctive tests :

SUBJECTIVE EXAM I NAT I O N
T h e a n s w e r s to the s u bj ective e x a m i n a t i o n i n d icate t h e n a t u r e , i r r i

tab i l i t y and seve r i t y o f t h e prese n t i n g probl e m .
Mode o f onset
Was t h e onset o f s y m p to m s s u d d e n o r i n s i d i ou s ? Was there a n e l e

m e n t o f traum a ? I f s o , w a s there a m aj o r traum a t i c e v e n t o v e r a
short p e r i o d of t i m e , such as a m o t o r v e h i c l e accident, o r was there
a s e r i e s o f m i n o r traumatic events over a l o n g p e r i o d of t im e . I s the
p at i e n t p r e s e n t i n g d u r i n g t h e substrate, fibrob l a s t i c or m at u r a t i o n
phase o f h e a l i n g ? I s t h i s t h e first e p i sode req u i r i ng treatme n t o r i s
t h i s a r e c u r r i n g proble m ?
Pain/ dysaesthesia
Where i s t h e p a i n a nd/or d y s aesthes i a ? I s it l o c a l ized or d i ffu s e ?

Where d o e s i t r a d iate t o and c a n i t 's q u a l ity b e described? I f t h e r e
i s symptom refe rral , does i t tend to refe r around t h e chest o r
through t h e chest? W h a t activ i t i e s , i f a n y, aggravate t h e s y m p
t o m s ? H o w l o n g does i t t a k e for t h i s act i v i t y to produce s y m p
t o m s ? W h i ch act i v i ti e s ( i ncl u d i n g how m u ch) provide rel i ef?
Sleep
Are t h e symptoms i nterfe r i n g w i t h sleep? W h a t kind o f b e d i s

b e i n g s l ep t i n and w h a t pos i t i o n i s m o s t frequently adopted? D o e s
rest p r o v i d e r e l ief?
Occupation/leisure activities/sports
What l e v e l o f ph y s i c a l a c t i v i t y does the patient c o n s i d e r t h e i r n o r

m a l a n d e s se n t i a l for return to fu l l funct i o n ? W h a t a r e t h e p at i e n t ' s
goals fro m therap y ?
General i n fo rmati on
How i s the patient's general h e a l t h ? I s any m e d i ca t i o n being t aken

for t h i s o r a n y other con d i t i o n ? W h at are t h e results of any a dj unc
t i v e d i ag n o s t i c tests ( i . e . X-rays, CT scan , M R I , l aboratory tests)?
62 - Ma n u a l For The Thorax
Table II. Obj e ctive examination
Postural
Habitual movement tests
Forward and ba ckward b ending

L a tera l
Axial rotation
Respiration
Com bined movement testing
Un ilatera l eleva tion of the arm
Articular
ctive/passive mobility tests osteokinematic
Forward
Backward bending
L a tera l bending
Rota tion
R espira tion
Passive mobility tests of arthrokinematic function

Zygapophysea l joints
Costotrans verse joints
Mediolatera l translation
Pass ive tests of arthrokinetic function

Vertica l (traction/compression)
A nterior translation - spinal
Posterior transla tion - spina l
Transverse rotation - spina l
A n terior translation - posterior costa l
Inferior - posterior costa l
A n terior/Posterior translation - anterior cos ta l
Superior/Inferior translation - anterior costa l
Mediola tera l translation
Muscle function
Nerve function
Adj unctive
Man u a l Therapy The Thorax
Postural Analysis
Deviation the thorax three cardinal hody planes

mon necessari associated with syrnptoms.
mechanical dysfunction presents with postural deviation and
therefore, postural analysis i n relation to the s agittal , coronal and
transverse body p l anes is essential.
plane, a l ine should through the

nal m e atus, the of the cervical vertebrae, the
humeral j o i nt, s lightly anterior to the bodies of the thoracic verte
brae transecting the vertebrae at the thoraco l umbar j unction, the
bodies of the lumbar vertebrae, the sacral promontory, slightly pos-
terior hip j oint and anterior talocrural
naviculo-ca Icaneo-cubo i d
I n the coronal plane, the clavicles should be horizontal, the

manubrium and sternum vertical and the scapulae should rest such
that the medial border is para l l e l to the thoracic spine with the infe -
rior appro x i m ated chest wall . Deviations of
ous processes are com m o n often The restin g
o f the of the back should be noted .
Habitua l moveme n t tests
These examine the habitual movement patterns of

and trunk. quantity quality of avai m otion as
the presence/location of evoked symptoms are noted. The results
of these tests alone are not sufficient to diagnose a local dysfunc
tion. They are used as screening tests to localize further mobility
testing.
Forward ba ckward
With the patient standing o r sitting h e/she is i nstructed to forward

bend the head/trunk and the q uantity and symmetry of m o t io n i s
observed 62, 63). Neither rotation sideftexion
forward and if req uires further
cific testing. Backward bending vertebromanubrial
region i s achieved b y asking the patient to elevate their arms b i l at
eral l y (Fig. 64). When exam i ning b ackward bending of the verte
brosternal and vertebrochondral regions of the thorax (Fig . 65), it
is critical n ote that the being i s actually
ward Some m ovement m odificat i o n m a y b e
ensure m otion performed
Figure 62.
H a b i t u a l movem e n t testing -
forward bending of the h e a d .
Figure 63 .
H a b i t u a l movement tes ting -
forward b e n d i n g of the trunk.
Figure 64.
H a b i tual movemen t tes t i n g -
backward bending of the ver
tebro m anubrial region occurs
d u ring bila teral elevation of
the a r m s .
Figure 65.
Habitual movement testing -
b a c k w a rd bending of the
tru n k .
Lateral bending (Figs. 66, 67, 68)
With the patient standing or s i tting he/she i s instruct

ed to l ateral l y bend the head/tr u n k to e i ther s i d e . The
ab i l i t y of the t h o r ax to p r o d u c e a s m o o th r e g i o n a l
c u r v e i s n o t e d . A fl at r e g i o n o r a k i n k i n t h e
Manual Th erapy For The Thorax - 65
Figure 66.
Habitu a l move ment testing -
l ateral ben d i n g of the h e a d .
Figure 67.
H a b i t u a l movement testing -
lateral bending of the t ru n k .

Note the fl e x i b i l ity of t h e 6
y ear o l d chi l d .
Figure 68.
H a b i t u a l movement test i n g -
l a t e ra l bend ing of the tru n k .
No te the rigid i ty o f the 7 1
y ear old adu l t .
Figure 69.
H a b i t u a l movem e n t tes t i n g -
rotat i o n of the tru n k should
produce a smoo t h S cu rve.
c u r v e r e q u i re s fu r t h e r s p e c i fi c m o b i l i t y t e s t i n g
to determine the cause.
Axial rota tion (Figs. 69, 70, 71)
With the patient standing or sitting he/she is instructed to rotate the

Figure 70.
H a b i t u a l movement t e s t i n g -
rotation of t h e tru n k . Note the
flexib i l i t y of the 6 year old
child.
Figure 71 .
H a b i t u a l movement testing -
rotation of the tru n k . Note the
rigid i t y of the 71 y e a r old
adult.
Figure 72.
Hab i t u a l movement testing -
respi ra t i o n .
Figure 73.
H a b i t u a l movement tes t i ng -
respi r a t i o n .
head/trunk to either side. The ability of the thorax to produce a

smooth regional S curve is noted. A lack of movement or a kink in
the curve requi res further specific mobility testing to determine the
cause .
Respiration (Figs. 72, 73)
With the patient standing or sitting he/she is i nstructed to take a

deep breath in and a long breath out. Any asymmetry of chest

expansion and release i s noted and when present requires further
specific m o b i l ity the cause.
Combined movement
Hypomobile j o i nts clinical picture w h e n

bined movements are tested. t h e patient standing or
he/sh e is instructed t o :
1 . forward bend the h ead/trun k and then right l ateral bend the
head/trun k .
2. forward b e n d the and then left l ateral b e n d the

head/trunk .
3 . backward bend and then right l ateral bend

head/tru n k .
4. backward bend the head/trun k and then left l ateral bend the
head/trunk.
A n y restr i c t i o n to m o v e m e n t or k i n ks in the curve are n o t e d .

The r e s p o n s e to t h e s e c o m b i n e d m ov e m e nt s c a n be charted o n
t h e l e tter 1 . The fo rward/b ackward b e n d i ng com po n e n t o f t h e
m o t i o n i s d e n o ted b a n d o f t h e I and the
bending com p o n e n t b a n d . W h e n a n a b n or m
m o v e m e n t p attern is p l ac e d on t h e '
t h e I w h i c h m arl! abn orm a l pattern . For
when a z y g a po p h y s e a l restricted i n s u perior g l i d i n g
t h e l e ft, a n a b n orm a l m o v e m e n t p a ttern w i l l b e detected o n for
w ard b e n d i n g co m b ined w i t h r i g h t l ateral bendi n g . Th i s i s
c harted b y p l ac i n g an X o v e r t h e r i g h t t o p h orizo n t a l b a n d o f
t h e l etter I .
The patient i s then i nstructed to :
4 . right l ateral a n d t h e n forward b e n d

h e ad/tru n k .
5 . l e ft l a tera l b e n d a n d t h e n forw ard b e n d

h e a d/tru n k .
6 . right l ateral b e n d the h e a d/tr u n k a n d t h e n backw ard b e n d t h e

h e a d/tr u n k .
7 . left lateral bend the head/tru nk and then b ackward bend the
he ad/trunk.
Any restriction to movement or kinks i n the curve are noted . The

response to these combined movements can be charted on the let
ter H. The forwardlbackward bending component of the motion is
denoted by the vertical band of the H and the lateral bending com
ponent by the horizontal band. When an abnormal movement pat
tern is detected, an X is placed o n the ' arm ' of the H which mani
fested the abnormal pattern . For example, when a zygapophyseal
j oint is restricted in superior gl iding on the left, an abnorm a l move
ment pattern will be detected on right lateral bending combined
with forward bending. This is charted by placing an X over the
right top vertical band of the letter H.
A hypomobile j o i nt is consistent in that an abnormal movement

pattern i s detected i n the same ' arm ' of the H and I tests . It does
not matter which movement is induced first, lateral bending or for
ward bending, the abnormal motion shows u p i n both .
Hypermobile j oints are inconsistent in the pattern they present. An
abnormal movement pattern may occur when forward bending
occurs first but not when lateral bending is the initial motion .
Unila tera l elevation of the arm
Unilateral elevation of the arm is useful i n evaluating the com

bined movements of the vertebromanubrial region . The upper tho
rax should rotate and sideflex to the side of the elevat ing arm and
thus produce a very local ized C curve concave towards the elevat
ing arm . The first two ribs should posteriorly rotate on the same
side and anteriorly rotate on the opposite.
Articular functi on
When a mobility abnormality is detected during the habitual move

ment tests, further examination is required to determine the etiolo
gy. The specific segmental tests of osteokinematic and arthrokine
matic function are used to differentiate an intra-articular from a
myofasci al cause for the abnormal motion noted . They include
active physiological mobil ity tests, passive physiological mobility
tests and passive accessory mobil ity tests. The active physio logical
mobility tests exam ine the osteokinematics of a functional spinal
and costal unit which includes two adj acent thoracic vertebrae, the
two ribs which attach to these vertebrae and the manubrium/ster
num. The passive physiological mobil ity tests prov ide further
information on the end feel of motion. The passive accessory
Figure 74.
Active m ob i l i t y t e s ts of
o s t e o ki n e m a t i c fu n c t i o n -
points of p a l p a t ion for T l -2.
Figure 75.
Ac t i v e mob i l i t y tests of
o steoki n em a t i c fu nct i o n - pal
p a t i o n for flexion of T l - 2 .
Figure 76.
Act i v e mobility t e s ts of
o s t e o k i nem a t i c fun c t i o n -
po ints of p a l p a t i o n for TS -6.
mobility tests examine the arthrokinematic fu nction of the

zygapophyseal joints, the costotransverse and costovertebral j o ints
and help to differentiate the cause of the abnormal motion noted on
the habitual movement tests. By correlating the findings from these
tests, the therapist can determine if the abnorm al movement pattern
is due to a hypomobile j oint or an outside influence (myofascial,
neural). Further tests are required to detect a hypermobile or unsta
ble joint.
A ctive mobility tests of osteokinematic function
Forward bending (Figs. 74, 75, 76, 77, 78, 79) . The fol lowing test
is used to determ ine the osteoki nem atic function of two adj acent
thoracic vertebrae during forward bending of the head/trunk. The
transverse processes of two adj acent vertebrae are palpated with
the index finger and thumb of both hands . The patient is i nstructed
to forward bend the head/trunk and the quantity of motion as well
as the sym metry of motion i s noted during flexion of the thoracic
segment. Both index fingers should travel superiorly an equal dis
tance . When interpreting the mobility findings , the position of the
joint at the beginning of the test should be correlated w ith the sub
sequent mobility noted, since alterations in j oint mob ility m ay
merely be a reflection of an a ltered starting pos ition. To determ ine
the position of the superior vertebra, the dorsoventral relationship
of the transverse processes to the coronal body plane is noted and
compared with the level above and below. If the left transverse
process of the superior vertebra is more dorsal than the left trans
verse process of the inferior vertebra then the segment is left rotat-
Manual Therapy For Th e Thorax - 7 1
Figure 77.
Active mob i l i ty tests of
osteokinematic function - pal
pation for flexion o f TS - 6 .
ed. If the left transverse process of the superior vertebra is less dor
sal than the left transverse process of the inferior vertebra but more
dorsal than the right transverse process of the superior vertebra,
then the superior vertebra is relatively right rotated compared to
the level below but left rotated when compared to the coronal body
plane . Thi s is a typical compensatory pattern seen when a superior
segment is derotating or unwinding a primary rotation at a lower
level.
The fol lowing test is used to determine the osteokinematic func

tion of a rib rel at ive to the vertebra of the same n umber during for-
Figure 78.
Act i v e mobi lity tests of
o s t eo k i n e m a t i c fu n c t i o n -
points of pal pation for T9 - 1 0 .
Figure 79.
Active m o b i l i ty tests of
osteoki n e m a t i c fu nction - pal
pation for flexion of T9- 1 0 .
Figure 80.
Active m o b i l i ty tests of
osteoki n e m a t i c fu n c t i o n
points of palpation for T l -
first rib .
Figure 81 .
Active m o b i l i t y tests of
osteokinematic fu nction - pal
pation for flexion of the first
costotransverse j o i n t .
ward bending of the head/trunk (Figs . 80, 8 1 , 82, 83). The trans
verse process is palpated with the thumb of one hand. The rib is
palpated j ust lateral to the tubercle and m ed ial to the angle with the
thumb of the other hand. The index finger of this hand rests along
the shaft o f the rib . The patient i s instructed to forward bend the
head/trunk and the relative motion between the transverse process
and the rib is noted.
In the mobile thorax, the rib should anteriorly rotate and the tuber-
Figure 82 .
Active m ob i l i ty tests of
oste o k i n e m a t i c fu n c t i o n -
points of palpatio n fo r T9 -
ninth rib.
Figure 83 .
Active mobility tests of
osteo k i n e m a t i c fu nction - p a l
pation for fl e x ion of t h e n i n t h
costotransverse j oi n t .
cle of the rib travel fu rther su p eriorly than the transverse process.
In the stiffer thorax, the rib should anteriorly rotate and the tuber
cle of the rib stop before ful l thoracic flexion is achieved such that
the transverse process travels further superiorly than the rib When
the relative mobility between the thoracic vertebra and the rib is
the same, no motion is p al pated between the vertebra and the r ib
during forward bending. To determine the patient's normal move
ment pattern it is cr i tical to evaluate levels above, below and con
tralateral to t h e tested segment.
Manu a l Therapy For The Thorax - 75
Figure 84.
Active m ob i l i t y tests of
osteokinem a t i c function - pal
pation for exte n s i o n o f T9- 1 O .
Figure 85.
osteo k i n e m a t i c fu nction - p a l
p a t i o n fo r extension o f T l -2 .
Backward bending. The fo l lowing test is used to determ i n e the

osteo k i n e m a t i c function of two adj acent thoracic v ertebrae during
b ackw ard bending of the h e ad/trunk. The transverse processes of
two adj acent vertebrae are palpated with t h e index finger and
thumb of both h ands (Figs . 74, 76, 78). The patient i s i nstructed to
b ackw ard bend the trunk and the quan t i ty of m o t i o n as w e l l as the
s y m m etry of motion i s noted d u r i ng extens i o n of the thoracic seg
ment (Fi g . 8 4) . B ackward bending of the upper thorax i s achi eved
b y aski n g the patient to elev ate both arms (Fi g . 85). Both index fin
gers should travel inferiorly an equal d i stance . When i nterpret i n g
t h e m o b i l i ty findings, the position of the j oi nt at the beg i n n ing of
the test should be correlated with the subsequent mobility noted,
since a l terations i n j oi n t m o b i l ity may merely be a reflect i o n of a n
altered starting pos i t i o n .
The fo l l ow i ng test i s used to determ ine the osteo ki nem at i c fu nc

tion of a rib and the vertebra of the same n umber during b ackward
bending of the h ead/tru n k . The transverse process i s palp ated w i t h
t h e t h u m b o f one h a n d . T h e r ib is palpated j ust l ateral to the tuber
cl e and medial to the angle w i t h the thumb of the other hand (Figs .
80, 82). The index finger of t h i s hand rests along t h e s haft of t h e
r i b . T h e p a t i e n t i s i n stru cted to backward b e n d the trunk and the
relative m o t i o n between the transverse process and the rib i s noted
(Fi g . 8 6) . Backward bending of the upper thorax i s ach ieved b y
ask i n g t h e p a t i e n t to elevate b o t h a r m s (Fi g . 87).
Figure 86.
Active mob i l i t y tests of
osteo k i nematic function - p a l
p a t i o n for extension of t h e
n i n t h costotransverse j o i n t .
Figure 8 7.
Active mob i l ity tests of
osteo k i nematic fu nction - pal
pation for e x t e n s i o n of the
first costotra nsverse j o i n t .
In the mobile th orax , the rib should posteri orly rotate and the
tubercle of the rib travel fu rther i nferiorly than the transverse
proces s . I n the stiffer thorax, the rib should posteriorly rotate and
the tubercle of the rib stop before fu ll thoracic exte n s i o n is
achieved such that the transverse process travels further inferi orly
than the rib . When the relative mobil ity between the thoracic ver
tebra and the rib i s the same, no motion is palpated between the
vertebra and the rib during backward bending. To dete r m i n e the
patient 's normal movement pattern i t i s critical to evaluate lev e l s
a b o v e , b e l o w a n d contralateral to t h e tested segm ent. I n the upper
thorax, the stiff pattern is normal both i n the m o b i l e and stiff tho
rax.
Latera l bending. T h e fo llowing t e s t i s u s e d to determ i n e t h e

osteokinematic function o f t w o adj acent thoracic vertebrae d u r i n g
lateral b e n d i n g o f t h e head/trunk. T h e transverse processes of two
adj acent ve rtebrae are palpated with the index finger and thumb of
both hands (Figs. 74, 76, 78) . The patient is i n structed to lateral
bend the head/trunk and the quantity and d i rection of motion is
noted. I n the upper thorax , the superior thoracic vertebra shou l d
l ateral bend a n d rotate t o the same s i d e such t h a t t h e superior trans
verse process on the side of the concav ity moves dorsa l l y and i nfe
riorly (Fig. 88) . Below T3 , the superior thoracic vertebra sho uld
l ateral bend i n the pu re coronal plane until the l ast few degrees of
movement. At this p o i n t , t h e superi o r vertebra shou l d rotate c o n
tral ateral to the di rection of the l ateral bend . T h e s u peri o r trans-
Figure 88.
A c t ive m ob i l i t y tests of
osteo k i n e m a t i c function - p a l
p a t i o n fo r r i g h t l a teral be nd
i n g of Tl-2.
Figure 89.
osteo k i n e m a t i c function - p a l
pation for r i g h t l a teral b e n d
ing of t h e fi f t h costotrans
verse j o i n t .
verse process o n the side of the concavity should move inferiorly

and ventrally.
Below T7 , the direction of motion coupling depends o n the apex of

the curve (Chapter 2). The direction of rotation should be congru
ent with the levels above and bel ow.
The following test is used to determine the osteoki nematic func

tion of a rib and the vertebra of the same number during lateral
bending of the head/trunk. The transverse process is palpated with
the thumb of one hand. The rib is palpated j ust lateral to the tuber
cle and medial to the angle with the thumb of the other hand (Figs .
80, 82) . The mdex finger of this hand rests along the shaft of the
rib. The patient is instructed to lateral bend the head/trunk and the
relative m otion between the transverse process and the rib is noted
(Fig. 89) .
Rota tion. The following test is used to determine the osteokine

matic function of two adj acent thoraci c vertebrae during rotation
of the head/trunk. The transverse processes of two adj acent verte
brae are palpated with the index finger and thumb of both hands
(Figs . 74, 76, 78) . The patient is instructed to rotate the head/trunk
and the quantity and directi on of motion is noted. In the upper tho
rax (vertebrom anubrial) and the vertebrosternal regions, the supe
rior thoracic vertebra should l ateral bend and rotate to the same
side such that the superior transverse process on the side of the
Figure 90.
Active mob i l i ty tests of
osteokinema tic fu nction - pal
pation for right rotation of
T5 -6.
Figure 91 .
Active mobility tests of
osteokinematic fu nction - pal
pation for right rotation of the
fift h costotransverse j oint.
concavity moves dorsally and inferiorly (Fig. 9 0) Below T7, the
.
direction of the conj unct lateral bend is variable. It may be either

to the same side as the rotation or to the opposite side.
The fol lowing test is used to determi ne the osteokinematic func

tion of a rib and the vertebra of the same number during rotation of
the head/trunk. The transverse process is palpated with the thumb
of one hand. The rib is palpated j ust lateral to the tubercle and
medial to the angle w ith the thumb of the other hand (Figs . 80, 82) .
The index fi nger of this hand rests along the s haft of the rib. The
patient is instructed to rotate the head/trunk and the relative motion
between the transverse process and the rib is noted (Fig. 91).
Respiration . The fol lowing test is used to determine the osteokine

matic function of a rib relative to the vertebra of the same number
during respiration. The transverse process is palpated with the
thumb of one hand. The rib is palpated j ust lateral to the tubercle
and medial to the angle with the thumb of the other hand (Figs. 80,
82) . The index fi nger of this hand rests along the shaft of the rib .
The p atient is i nstructed t o breathe i n fully a n d the rel ative motion
between the transverse process and the rib is noted. The patient is
then instructed to breathe out fully and the relative motion between
the transverse process and the rib is noted (Fig . 92).
Ma nual Therapy For The Thorax - 79
Figure 92.
osteoki nematic fu nct i o n - p a l
pat i o n for respira tion o f the
n in th costotransverse j o i n t .
Passive physiologica l mobility tests
Passive p h y s i o l o g i ca l m o b i l i t y tests are used to confirm the level

of the abnorm a l movement pa t t e rn noted on active m ob i l i t y test
i n g . In add i t i o n , the q u a l i t y o f the end fee l of motio n is determined
during these tests .
Wi th the patient s i t t i n g and the arms crossed to the opposite s h o u l

ders for t h e verteb ro manubrial and vertebrosternal reg i o n s , t h e
transverse processes o f the superior vertebra a r e palpated . In t h e
thoraco l umbar reg i o n , the i n terspinous space i s palpate d . The
head/trunk is pass i v e l y flexed, extended, l aterall y flexed and rotat
ed. The q u a n t i t y of motion and the qual ity o f the end fee l i s noted
and co m p ared to the levels above and below.
Figure 93 .
Passive m ob i l i t y tests of
arthroki n e m a t i c function -
points of palpation for superi
or glide of the right T4-5
zygapophyseal j o i n t .
Figure 94.
Passive m ob i l i t y tests o f
arthro k i n e m a t i c fu nction -
superior glide of the right T4-
5 zygapophyseaJ j oint .
Passive mobility tests of arthrokinematic function
Zygapophyseal joints - Eg. T4 -5 to test the superior glide of the

righ t zygapophysea l joint (Figs. 93, 94). This test is used to deter
m ine the ab i lity of the right inferior articular process of T4 to glide
superiorly relative to the superior articular process of T5 . With the
patient prone and the thoracic spine i n neutral, the i nferior aspect
of the left transverse process of T5 is palpated with the left thumb.
The right thumb palpates the inferior aspect of the right transverse
Figure 95.
Passive mobility tests of
arthrokinematic fu n c t i o n -
p o i n t s of palpation fo r infe r i
or glide of the right T4-5
zygapophysea\ j o i n t .
Figure 96.
Pass i v e m ob i l i t y t es ts of
a r t h ro k i n e m a t i c funct i o n -
i nferior g l i d e of t h e r i g h t T4-
5 zygapophyseal j o i n t .
process o f T4 . The left thumb fixes T5 and a superoanterior gl ide

is applied to T4 with the right thumb. The quantity and end feel of
motion is noted and compared to the l e v els above and below. This
technique can be used for all thoracic segments.
Zygapophyseal joints - Eg. T4-5 to test the inferior glide of the

righ t zygapophysea l joint (Figs. 95, 96) . This test is used to deter
mine the ability of the right inferior articular process of T4 to gl ide

inferiorly relative to the superior articular process of T5 . With the
Figure 97.
Passive m ob i l i ty tests of
a r t h r ok i ne m a t i c fu n c t i o n -
poin t s of palpation for i n feri
or glide of the right fifth cos
totra nsverse j o i n t .
Figure 98.
Passive m o b i l i ty tests of
arthro k i n e m a t i c fu n c t i o n -
i nferior gl ide of the right fifth
patient prone and the thoracic spine in neutral , the inferior aspect
of the transverse process of T5 is palpated with the left thumb . The
right thumb palpates the superior aspect of the right transverse
process of T4. The left thumb fixes T5 and an inferior glide is
appl ied to T4 with the right thumb . The quantity and end feel of
motion i s noted and compared to the levels above and bel ow. This
technique can be used for all thoracic segments.
Costotransverse joints Eg. To test the inferior glide of the right

-
fifth rib at the costotransverse joint (Figs. 97, 98). This test is used
Figure 99.
arthrok inematic fu n c t i o n -
The d i rection of the cos to
t r a n s verse joint glide is
a n t er o l a t e r o i nfe r i o r at the
l evel o f t he n i n t h rib ( a rrow ) .
Figure 1 00 .
Passive mobility t e s ts of
a r t h r o k i ne m a t i c fu n c t i o n -
i n fe r i o r glide of the right
n i n t h costo t r a n sverse j o i n t .
to determ ine the ab i l ity of the right fifth rib to glide inferiorly rel
ative to the transverse process of T5 . With the patient prone and the
thoracic spine in neutral, the inferior aspect of the right transverse
process of T5 is palpated with the left thumb. The right thumb pal
pates the superior aspect of the right fifth rib j ust lateral to the
tubercle . The left thumb fi xes T5 and an i nferior glide (allowing
the conj unct posterior roll to occur) is appl ied to the fifth rib with
the right thum b . The quantity and end feel of motion is noted and
compared to the levels above and below.
Figure 1 01 .
Passive mobil ity tests of
a r t h ro k i n e m a t i c function -
p o i nts of p a J p a t i o n (b lack box
and wh i t e arrow ) for i n ferior
glIde of the right first costo
transverse j o i n t .
Figure 1 02.
Passive m o b i l i ty tests of
a r t h ro k i n e m a t i c fu n c t i o n -
inferior glide of the right first
costo t r a n sverse j o i n t .
Figure 103 .
Passive mob i l ity tests of
art hrok i n e m a t i c function -
points of palpation for superi
or gl ide of the right fifth cos
totransverse joint.
Figure 104.
Passive mob i l i t y te sts of
a r t h r o k i ne m a t i c fu n c tion -
superior g l ide of the right
fi fth cos totransverse joint.
Between T7 and TiD the orientation of the costotransverse j oint

changes such that the direction of the g lide is anterolatero inferior.
The position of the right hand is modified to facilitate this change
in j o i nt direction such that the index finger of the right hand l ies
along the shaft of the rib and assists i n gliding th e rib in an antero
latero inferi or direction (Figs . 99 , 1 00) .
Cos totrans verse join ts - Eg. To test the inferior glide of the right
first rib a t the costotransverse join t (Figs. 1 01, 1 02). This test i s
Figure 1 05 .
Passive mo b i l i ty tests of
a r t h ro ki n e m a t i c fu n c t i o n -
The d i rection of the costo
transverse j o i n t g l i d e is pos
teromed iosuperior at the level
of the n int h rib and is
ach ieved b y gli d i n g the trans
verse process of T9 a ntero
l atero i n ferior (a rrow) .
used to determine the ability of the right first rib to g l ide inferior
ly relative to the transverse process of T l . The patient lies supine
with the head and neck comfortably supported on a pillow. Wi th
the lateral aspect of the MCP of the index finger of the left hand,
the superior aspect of the left transverse process of T l is palpated
and fixed. With the lateral aspect of the MCP of the index finger of
the right hand, the superior aspect of the right first rib is palpated
j ust lateral to the costotransverse j o i nt. The left hand fixes Tl and
an inferoanterior glide (allowing the conj unct posterior rotation to
occur) is applied. The quantity and end feel of motion is noted and
compared to the opposite side.
Cos totrans verse joints - Eg. To test the superior glide of the right
fifth rib a t the costotransverse join t (Figs. 1 03, 1 04) . This test is
used to determ ine the ab il ity of the right fifth rib to glide superior
ly relative to the transverse process of T5 . With the patient prone
and the thoracic spine i n neutral , the superior aspect of the trans
verse process of T5 is palpated with the right thumb . The left
thumb palpates the inferior aspect of the right fifth rib j ust lateral
to the tubercle. The right thumb fixes T5 and a superior glide
(allowing the conj unct anterior rol l to occur) is applied to the fifth
rib with the left thumb . The quantity and end feel of motion is
noted and compared to the levels above and below.
Between T7 and T 1 D the orientat ion of the costotransverse j o i nt

changes such that the glide is posterom ediosuperior. The position
of the right hand is modified to facil itate this change in joint direc
tion such that the index finger of the right hand l ies along the shaft
Manual Therapy For The Tho rax - 87
Figure 1 06.
Passive mob i l i t y tests of
a r t h ro k i n e m a t i c fu nc t i o n -
posteromed iosuperior glide

o f t h e r i g h t n i n t h costotrans
verse j o i n t .
of the rib. The right hand fixes the rib and the transverse process is
glided anterolateroi nferior thus producing a relative posteromedio
superior gl ide of the rib at the costotransverse joint (Figs. 1 0 5 ,
1 06) .
Costotransverse joints - Eg. To test the superior glide of the righ t

first rib a t th e costotransverse joint (Figs. 1 0 7, 1 08) . Thi s test i s
used to determine t h e ab il ity of t h e right fi r s t r i b to glide superior
iy relative to the transverse process of Tl . The patient lies supine
with the head and neck comfortably supported on a pillow. The
superior aspect of the right transverse process of T1 is palpated
with the right thumb . The index and middle fingers of the right
hand palpate the inferior aspect of the right first rib . The right
index and m i ddle fingers fix the first rib and a postero inferior glide
(allowing the conj unct anterior rotation to occur) is applied to the
transverse process of T 1 thus producing a relative superior glide of
the first rib at the costotransverse joint. The quantity and end feel
of motion is noted and compared to the opposite side.
Mediolatera l transla tion - Eg. To test th e ability of TS and the right

and left sixth ribs to glide transversely to the right on the T6 ver
tebra (Figs. 1 09, 11 0) . This motion is necessary for full left rota
tion/l eft si deftexion to occur. I t requires the left sixth rib to glide
anteromedially relative to the left transverse process of T6 and the
right sixth rib to glide posterolaterall y relative to the right trans
verse process of T6. The patient is sitting with the arms crossed to
opposite shoulders . With the right hand/arm, palpate the thorax
such that the fifth finger of the right hand l ies along the sixth rib .
Wi th the left hand, fix the transverse processes of T6. With the
Figure 1 0 7.
Passive m o b i l i t y tests of
arthrok i n e m a t i c function -
points of palpation (two white
arrows) for superior glide of
the right first costotransverse
j oi n t .
Figure 1 08.
arthrok i n e m a t i c fu n c t i o n -
superior glide of the right first
right hand/arm translate the T5 vertebra and the ribs PURELY to
the right in the transverse plane. The quantity and i n particular the
endfeel of motion is noted and compared to the levels above and
below.
Passive stability tests of arthrokinetic function 21
Vertical (traction/compression) . Th is test stresses the anatom ical

structures which resist vertical forces . A positive response is the
Figure 1 09.
P a s s i ve mobility tests of
arthrokinematic fu n c t i o n -
p oint s of p a l pation for righ t

mediolateral tran s l a t i on g l i d e
of T 5 a n d the s ix t h r i b s .
Figure 1 1 0 .
Passive mo b i l i t y t e s t s of
arth roki n e m a t i c fu n c t i o n -
right m e d i o l a teral tra n s l a t ion

test of T5 a n d the sixth r i b s .
reproduction of the patient's pain as opposed to a sense of

increased osteoarticu lar motion. The patient is sitting with the arms
crossed to opposite shoulders such that the arm closest to the chest
grasps the scapula. The other arm rests on top of the contralateral
shoulder. The thoracic spine is i n neutral. Traction i s applied to the
middle and lower thorax by applying a vertical force through the
patient's crossed arms (Fig. 1 1 1) . Traction is applied to the upper
thorax b y app l y i n g a vertical force through the cran ium .
Figure 1 1 1 .
Passive s t a b i l i ty tests of
a rt h rokinetic function - trac
tion of the m iddle and lower
thorax.
Figure 112.
Passive stab i l i t y tests of
art hrokinetic fu nction - com
pres s i o n of the m iddle and
lower thorax.
Manu a l Therapy For The Thorax - 91
Figure 1 1 3 .
arthro k inetic fu nction - po i n ts
of p a l p a t i on fo r anterior
translation (spinal).
Figure 1 1 4.
Passive s t ab i l i t y te s t s of
arthrokinetic fu nction - a n te
rior t ransl a t i o n (spinal).
Compression i s applied t o the m iddle and l ower thorax b y app l y
ing a vertical fo rce throu gh t h e top of t h e patient 's shou lders (Fig.
I n) . Com pres s i o n is applied to the upper tho rax b y appl y i n g a
vertical force through the cran i u m .
A n terior transla tion - spina l. Th is test stresses the anato m i ca l

structures which resi st anter ior trans l ation of a segmental spinal
u n i t . A p o s i t i v e response i s the reproduct i o n of the patie n t ' s symp
toms together w i t h an i n crease i n the quantity of motion and a
For The Thorax
decrease i n the resistance at the end of the range of moti o n . With

the patient prone l y i ng, the transverse processes of the superior
vertebra arc palpated. With the other hand, the transverse process
of the i nferior vertebra are (Figs. 1 1 3 , A posteroan
terior force applied through superior while fixing
the i nferior vertebra. The quantity of motion, the reproduction of
any symptoms and the endfeel of motion i s noted and compared to
the levels above and below. The findings fro m th i s test should be
correl ated those of the translation to determine
the level of i nstab i l i ty. Excessive anterior translation of the
vertebra coul d due to either anterior instah i of T45 or
posterior instab i l i ty of T3 4.
Posterior tra nsla tion spina l. Th i s test stresses the anatom ical
structures resist posterior translation of segmental spinal
unit. A positive response i s t h e reproduction of patient 's syrnp-
toms together an i n crease the quanti motion and
decrease i n the resistance at the end of the range of motion . The
patient is s i tting with the arms crossed to opposite shoulders . The
thorax is stab i lized with one hand/arm u nder/over (depending on
the level) crossed and the contralateral s capul a
grasped. transverse o f the vertebra
fixed w i t h the dorsal hand. Static stab i l ity i s tested b y applying an
anteroposterior force to the superior vertebra through the thorax
w h i l e fixing the i nferior vertebra (Figs. 1 1 5 , 1 1 6) . The quantity of
motion, the reproduction of symptom s and the endfeel of
motion is and compared levels above and below.
t1ndings from test should correl ated with of the ante-
rior translation test to determine the level of the instab i l i ty.
Dynamic stabil ity can be tested by resisting elevation of the

crossed arms. If the segmental muscul ature to control
translation, posterior w i l l be
is dynam stable.
Transverse rota tion - spina l. Thi s test stresses the anato m i cal
structures w h i ch resist rotation of a segmental spinal unit. A posi-
tive response reproduction the patient's sym ptom s togeth-
with an i n the of motion decrease in
resistance end of the motion. Wi th patient
l y i ng , the transverse process of the superior vertebra i s palpated.
With the other hand, the contral ateral transverse process of the
inferior vertebra is fixed. A transverse plane rotation force is
appl i ed by apply i ng u n i l ateral
leroanterior while the inferior (Figs .
1 1 8) . The quantity of motion, reproduction
Man u a l Therapy For The Thorax - 93
Figure 1 15.
arthrokinetic fu nction - po ints
of palpation fo r posterior
transla t i o n (sp i n a l ) .
Figure 1 1 6.
Passive stab ility tests of
arthrokinetic function - poste
rior transla t i o n (spi n a l ) .
and the endfeel of m o t i o n i s noted and compared to the levels

above and b e l ow.
A n terior transla tion - posterior costa l. This test stresses the

anatomical structures w h i c h res ist an terior tran s l a t i o n o f the poste
rior aspect of t h e r i b relative to t h e thoracic vertebrae to w h i ch it
attach es . A positive response i s the reproduct i o n o f the p a ti e n t 's
Figure 11 7.
Passive stab ility tests of
arthrokinetic fu nction - p o i n t s
of p a l p a t i o n f o r l e f t ro tation
(sp i n a l ) .
Figure 1 1 8.
arthro kinetic fu nction - left
rota tion (spinal).
symptoms together with an increase in the quantity of motion and

a decrease in the resistance at the end of the range of motion. With
the patient prone lying, the contralateral transverse processes of the
thoracic vertebrae to which the rib is attached are palpated . For
example, when testing the r ight seventh rib the left transverse
processes of T6 and T7 are palpated . With the other hand, the rib
is palpated j ust lateral to the tubercle (Fig. 1 1 9) . A posteroanterior
force is applied to the rib while fixing the thoracic vertebrae (Fig .
1 20) . The quantity of motion, the reproduction of any symptoms
Figure 1 19.
Passive s t ab i l i t y tests of
arthrokine tic function - p o i n t s
of palpation fo r anterior
translation (posterior cost a l ) .
Figure 120.
Passive stab i l i t y tests of
arthroki n e t i c fu nction - ante
rior translation (posterior
costa l ) .
Figure 121 .
Passive s t a b i l i ty tests of
arthrok i n e t i c fu nction - points
of palpation for i n ferior trans
l a t i o n (pos terior cos t a l ) .
Figure 1 2 2 .
arthro k i n e t i c fu nct i o n - inferi
or tra n s l a t i o n (pos t e r i o r
costal).
and the endfeel of motion is noted and compared to the levels

above and below.
Inferior translation - posterior costa l. This test stresses the

anatomical structures which resist inferior translat ion of the rib rel
ative to the thoracic vertebrae to which it attaches . A positive
response is the reproduction of the patient's symptoms together
with an increase in the quantity of motion and a decrease in the
resistance at the end of the range of motion. With the patient prone
w[anual Therapy For Thorax - 97
t h e c o n t r a l a te r a l transverse process of the t h o r a c i c v e rte

bra a t t h e s a me l e v e l as the rib i s p a l p ated. With the s a m e h a n d ,
t h e i p s il a teral transverse process o f t h e thoracic vertebr a a t t h e
l e v e l a b o v e t h e r i h i s p a l p a ted . t h e other the super i
o r aspect of t h e r i b j us t l at e r a l to t h e tubercl e i s p al p a te d . An
i n fe r i o r force i s a p p l i e d through the r i b w h i l e fi x i n g t h e t h o r a c i c
vertebr a e (Figs . T h e q u a n t i t y of motion, t h e repro
duction o f a n y s ymptoms and t h e endfe e l of m o t i on i s n o t e d and
com p a r e d t o t h e l e v e l s ahove a n d h e l ow.
Anterior/Posterior translation - anterior costa l. This test stress

es the a n a t o m i c a l s t r uctures w h i c h r e s i s t transl a t i o n o f cos
toca r t i l age r e l a t iv e to the ster n u m ; a n d t h e r i b r e l a t i v e to t h e
costocartil a g e . When the sternocostal and/or costoch o n d r a l
have been a gap and a can b e p a l pated at
the j oi nt l i n e . The p o s i t i o n a l fi n d i ngs a rc noted prior to s tr e s s
i ng the j oi n t . A p o s i t i v e r e s p o n s e i s t h e repro d u ct i o n o f t h e
p a t i e n t 's s ymptoms toge t h e r w i t h a n i ncrease i n t h e qu a n t i t y o f
m o t i o n and a decrease i n t h e r e s i s t a n ce at t h e e n d o f t h e r ange
of m o ti o n . Wit h o n e thumb, the ante r i o r aspect o f the ster
n urn/costocarti l age is p a l p a t e d . Wit h t h e other thumb, ante
r i o r aspect of t h e costocarti l age/ri b i s palpated. A anteroposte r i
o r/poste r o a n t e r i o r fo rce is app l i e d to the costocart i l age/ri b
1 24). T h e q u an t i ty moti o n , t h e repro d u c t i o n o f
any s y m p t o m s a n d t h e endfe e l o f m o t i o n i s noted a n d c o m p a red
to t h e l ev e l s a b o v e and h e l ow.
Superior/Inferior transla tion - a n terior costa l. This test stresses

the a n a t o m i c a l structures w h i ch resist s u p e r i o r/infe r i o r t r a ns l a
t i o n o f t h e costo c a r t i l agc r e l a t i v e t o t h e stern u m ; a n d t h e r i b rel
a t i v e t o the costocarti l age . W h e n the sternocostal a nd/o r costo
chondral j o i n ts h a v e b e e n separated, a g a p and a s t e p c a n h e p a l
pated a t t h e j oi n t l i n e . The p o s i t i o n a l fi n d i ngs a r e noted p r i o r to
stress i ng t h e j o i n t . A p o s i t i v e response i s t h e reprod u c t i o n of t h e
patient's toget h e r w i t h a n i ncrease i n t h e q u a n t i t y o f
motion and a decrease i n t h e r e s i stance a t t h e e n d o f t h e r a ng e
o f m o t i o n . Wi t h one t h u m b , t h e a n teri o r aspect o f t h e s t e r
n u m/costocarti l age is p a l p a t e d . t h the o t h e r thumb, i nfe
r i o r/su p e r i o r aspect of the costocarti l age/ri b i s p a l p a t e d . A s u p e
r i o r/in fe r i o r force a pp l i e d to t h e costocart i l a ge/ri b (Fi gs . 1 25 ,
The qu a n t i ty o f mot i o n , repro d u c t i o n o f a n y s y m p -
to ms and t h e endfeel of m o t i o n is noted and compared to t h e
leve l s above a n d h e l ow.
Mediolatera l transla t ion . T h i s test stresses t h e a n at o m i ca l struc-

tures w h i c h resist horizontal t r a ns l a t i o n h e tween two ace n t
98 - Man u a l Therapy For The Thorax
Figure 123.
a r t h ro k i n e t i c fu n c t i o n
anteroposterior transl ation
(anterior sternocost a l ) .
Figure 124.
a r t h ro k i n e t i c fu n c t i o n
a nteroposterior translation
(anterior costochondral).
vertebrae when the ribs between them are fixed . This test is used
between the segments T3-4 and T I O- I 1 . The primary structu re
being tested is the intervertebral disc. When the ribs are fixed
b i laterally there should be very little, if any, mediolateral trans
lation between two thoracic vertebrae. A positive response is an
i ncrease in the quantity of motion and a decrease in the resis
tance at the end of the range . To test the TS - 6 segment, the
patient is sitting with the arms crossed to opposite shoulders .
With the right hand/arm, the thorax i s palpated such that the
Figure 125.
arthrok inetic fu nction - supe
rior translation (anterior ster
nocost a l ) .
Figure 126.
arthrokinetic function - i n fe r i
or transl a t i o n (anterior ster
nocostal ) .
fifth finger of the right hand l i es along the fifth rib . With the left
hand, T6 and the s i xth ribs are fixed b i l aterally by compressing
the ribs centra lly tow ards the i r costovertebral j oints (Fig. 1 27) .
The T5 vertebra is trans lated through the thorax PURELY i n the
transverse plane . The quantity of motion, the reproduction of
any symptoms and the endfeel of motion is noted and compared
to the levels above and below.
1 00 - Man u a l Therapy For The Thorax
Figure 1 2 7.
arthrokinetic function TS - 6
-
mediolateral translation sta

b i l i ty test.
Muscle function
If the specific tests of articular fu nction are norma l , then the m u s

c l e s w hi c h c a n influence t h e thorax a r e assessed . H y perto n i c i ty,
s e co n dary to s egmental facilitation, m a n i fests as a multiseg
mental d y sfu nction (rotoscoli o s i s) d u r i ng t h e h a b i t u a l mov e
m e n t s w h i c h requ i r e l e ngthe n i ng of t h e m u s cl e . M u s cl e i m b a l
a n c e s due to fau l t y recru i t m e n t p a tterns a l s o p r o d u c e a m u l t i
s e g m e n t a l dysfu nc t io n . In b o t h i n s t a n c e s t h e p a s s i v e mob i l i ty
tests of a r t h rokinematic function are n o r m a l . M u s c l es w h i c h
posture i n a s h o r t e n e d p o s i t i o n w i l l e v e n t u a l l y b e co m e struc
t u ra l l y s h o rter. Whe n the m u s c l e i s faci l i t a t e d , a n e u ro p h y s i o
l o g i c a l t e c h n i q u e a i me d a t restoring t h e r e s t i n g t o n e of t h e m u s
c l e w i l l y i e l d a n i m m e d i a t e c h a n g e i n m o b i l i ty . W h e n t h e m u s
c l e i s s tructu r a l l y s horte n e d , stronger s t retch i n g tech n i qu e s a n d
m o r e t i m e i s requ ired t o a c h i e v e n o r m a l mob i l i ty.
The d i a p h ragm is oft e n i nv o l v e d in p o s t u r a l d y s fu n c t i o n a n d

t e n d s to b e a fl e x o r of t h e thorax w h e n i t i s h y p e rto n i c . It h a s
b e e n observed22 to p roduce a lordosis a t t h e thoraco l u m b a r
j un c t io n . I n a d d i t i o n , i n s u ffi c i e n t re l a x a t i o n of t h e d i ap h ragm
c a n lead to overuse of the m i d thoracic s p i n a l e xt e n s o rs c a u s i n g
a m i dt h o r a c i c l o r d o s i s ( Fi g . 128). Thes e c u r v e rev e rs a l s do not
Figure 128.
When the d iaphragm is
h y p e rt o n i c , overa c l l v l l y of
the m i d t horacic spinal exten
sors can produce a loc a l ized
lordosis .
re s p o n d to segme ntal mob i l i z a t i o n tech n i qu e s . Corre c t i o n

re q u i re s re l a x a t i o n of the d i a p hragm and treatm e n t of the
b r e a th i ng d i s o r d e r.
The e mph a s i s of t h i s text is on the i dentification a n d treatment

of articu l a r d y s fu n cti o n a n d the r e a d e r i s referred to o t h e r texts
fo r e l a b o ra t i o n on postural and m u s c l e d i s o r d e rs 1 7 .
Nerve function
These tests e x a m i n e the conductivity o f t h e motor and s e n s o r y

1 02 - Manual Therapy For The Thorax
------
n e rves as w e l l as t h e mob i l i ty o f t h e d u r a a n d the intercostal

n e rves i n t h e spinal c a n a l a n d i n te rv e rtebral for a me n . The s e n -
fu n c t i o n o f t h e i ntercostal exami ned by testing
s e n s a t i o n i n the i n te rcostal sensation i s not
u n c o m m o n a l th o u g h r a re l y p r i m a ry comp l a i n t .
Hyperaesthesia c a n b e o n e o f n e u ro lo g i c a l
nte rference a n d tends t o occlIr s e n s a t i o n becomes
( h yp o a e s t he s i a ) .
T h e motor fu n c t i o n of t h e i n terco s t a l nerves i s e x a m i n e d by

observ i n g a n d p a l p a t i n g the i n te rc o s t a l m u s c le s . S e gm e n t a l
faci l i t a t i o n l e a d s to hy perto n i c i t y o f the i nterco s t a l muscle a n d
t h e i n creased t o n e can be p a lp a te d a l o ng t h e i n tercostal s p ace .
The t o n e is oft e n associ ated w i t h t e n d e r within the mus-
Reduced m o t o r fu nction nerves c a u s e s
o f t h e i n te rcosta l muscle s .
tests a r e u s e d to detect upper motor n e u -

l e s i o n s . T h e p l a nt a r response test fo r c l o n u s
s ho u l d b e d o n e o n every p a t i e n t presenting w i t h p a i n i n t h e t h o
rax .
The mob i l it y tests for t h e n e u r a l a n d d u ra l tissue i n c l u d e the

slump t e s t a n d v a r i a t i o n s t h e reof. The mob i l i ty o f t h e i n trasp i n a l
t i s s u e s c a n b e tested b y fu l l y l en g th e n i n g t h e d u ral/neu r a l s y s -
T h i s i s a c h i eved b y p a t i e n t fu l l y fl e x t h e
a n d n e c k , slump t h e and extend the
w it h the a n k l e dorsiflexed d u r a i s released
h a v i ng t h e p a t i e n t and neck. The
i n s y mp t o m response t h o ra c i c p a i n is
brou g h t o n by fu l l slump a n d r e l i e v e d with e x te n s i o n o f the
h e a d a n d neck, i n v o l v e m e n t o f t h e d u r a is suggeste d23 .
The i n te rco s t a l nerves c a n be fu rther tensed by h av i ng t h e

' sl u m p e d ' p a t i e n t twist t h e t h o r a x to t h e l e ft a n d r i g h t (Fig.
1 30) . Often , the p a t i e n t w i l l present w i th a n o r m a l m o v e m e n t
w h e n r o t a t i o n occurs o f re l a t iv e n e u r a l
rel axation and an abnormal (seg m e n t a l k i nk
t h o r a c i c c u rve) w h e n in a position of
n e u r a l ten s i o n . I t i s p o s t u l ate o n t h e e ti o l -
t h e ' ap p a re n t segme n t a l ' in this situation
a n d u n l e s s t h e n e rv o u s sy stem i s a ddress e d , the s y m pt o m s per
sist regardless of t h e articular and m y ofas c i a l t r e a tme n t s
e m p l o y e d . The e m p h a s i s o f t h i s t e x t is o n t h e a s sessme n t a n d
Figure 129.
The slump test.
Figure 130.
Modifica t i o n of the slump test
for the detect i o n of segme n t al
neura l dysfu n c t i o n with i n the
thorax.
treatment of articu l a r d y sfu nction and the reader i s referred t o

Butler 's23 w o r k o n t h i s s u bj e ct fo r fu rther rev i ew.
Adj unctive tests
While X-rays exclude serious bone d i s e a s e a n d s i g n i fi c a n t

mec h a n i c a l defe c t s , t h e y rare l y p rov ide g u i d a nce fo r m a n u a l
t h e r a p y . Asy m metry i s t h e rule i n the thorax a n d dev i a t i o n of
the s p in o u s processes is to b e expecte d . For the m a n u a l t h e r a
p i s t , the p r i m a r y reason fo r o b ta i n i n g the r e s u l t s of a n y adj u n c -
1 04 - Manual Therapy For The Tho rax
tive i maging tests is to r u l e o u t s e r i o u s pathology a n d to i d e n t i

fy a n a t o m i c al a n o m a l i e s w h i c h may i n fl u e nce t h e i n terpretation
o f m ob i l i ty analysis. The fi n d i ngs o n adj u nctive testing of
thorax m u s t be corre l ated n o te d o n c l i n i c a l
e x a m i n a t i o n i f t h e s i g n i fi c ance u nde rsto o d .
J\fanual Therapy For Thoren - 1 05
5
CLINICAL SYNDROMES
chapter will focus on the mechanical syndrom es of thorax

recognizing that referral of pain to the thorax from the viscera, res
piratory syndromes, metabolic, infective and neurological condi
tions may coexist. The m odel classification will follow the
manual therapy model based on the objective findings noted on
mobility testing .
HYPO M OBILlTY WITH O R WITHOUT PAIN
essential objective finding for classification here is decreased

osteokinematic motion of either the thoracic vertebrae or the ribs.
etiology may be articul ar, myofascial or both and is often the
result of excessive bending or rotational force. The arthrokinemat
ic tests differentiate the underlying cause of the osteokinematic
restriction .
The mode of onset may be either insidious or sudden depending

the degree trauma. The irritability of the wounded tissue
dictates the intensity of the pain, the amount of radiation, the
degree of physical activity which tends to aggravate it and the
amount rest required relieve it. aim the
examination is to determine the stage and nature of the pathology
that treatment be adjusted accordi ngly (Chapter
The location of the pain may be on the ipsilateral or contralateral

of the hypomobility and may radiate around through to the
anterior aspect of the chest. An acute zygapophyseal j oint sprain
tends to produce very localized pain over the involved joint. A
chronic restriction of either the vertebra rib tends to produce
symptoms removed from the source and some of these may be sec
ondary to compensation of the adj acent levels. Referral of pain
the articulations of thorax tends be around the chest
106 - Man u a l Therapy For Thorax
opposed to through it. Referral from the intervertebral disc tends to

be t h rough the chest.
Magnetic i m aging
frequency di agnosis of disc Thoraci c
discs are no l onger thought to be an uncomm o n cause of thoracic
pai n . I n a study by Brown et a1 24 the most common symptom i n
patients with confirmed thoracic disc herniations w a s anterior
chest pain Other included lower extrern ity
dysaesthesia (8%) and
gastric pain
"The degree of herniation was characterized as mild,

m oderate, or severe. A m i l d h e rn i ation consisted of only
m in i m a l indentation. Moderate herniation created
l i m i ted significant deformation.
Severe hern i ations resulted free fragments evi de n ce
of cord compression manifested by i ndentation or flat
tening of the cord. " 24
The h i ghest incidence t o level was the second

h ighest was and T9- 1 O .
The sympathetic chain can also refe r symptoms into the upper or
lower extre m i ty. These patients commonly report temperature
changes, heavy sensations associated with fatigue and nonspecific
n u mbness i nvolved The upper thorax can
refer p a i n cranium the sympathetic pathway.
Hypomobile j o i nts are very consistent in the pattern they present

on habitual movement testing. The fi ndings for each j oint restric-
tion w i l l be described below. If j oint i s h ypomobile,
arthrokinematic glide will also restricted. If myofascia i s
source of restriction, t h e glide will norm a l . Disorders
i n t h i s classi fication do not exhibit a l oss of arthrokinetic function.
The neural/dural m ob i l i ty tests may be positive i f the mobil ity of

the sympathetic cha i n is by a change position of
head of the Restrictions t h e zygapophyseal j o i nt
i nvolve the neural/dural tissue.
The thorax will be divided into the anatom ical regions for further
discussion. The obj ective mobil i ty/stabi lity findings, the relevant
treatment and a exercise w il l described.
Bilateral restriction offlexion
The upper thorax is rarely fixed in a lordotic position , however, a

bilateral restriction of flexion is not uncommon at T2-3. Forward
bending of the head will reveal a limitation of the superior excur
sion of the transverse processes bilaterall y confirmed o n passive
physiological mobil ity testing. The superior arthrokinematic glide
at the zygapophyseal joint will be restricted bilaterally if the dys
function is i ntra-articular. The presence or absence of pain depends
upon the stage of the pathology (substrate, fibroblastic, maturation)
and the irritability of the surrounding tissue. The grade of the
mob il ization techn ique is directed by these factors (Chapter 3).
Mob iliza tion techn iqu e . Lo n g i t u d i n a l t r a c t i o n of t h e

upper t h o r a x w i l l p r o d u ce a s u p e r i o r gl ide of t h e
z y g a p o p h y s e a l j o i n t b i l a t e ra l l y. T h i s t e c h n i q u e m a y b e
done with the patient e i ther supine l y ing, sitting o r stand
i n g . Wi t h t h e p a t i e n t s u p i n e ( F i g . 1 3 1 ) , g r a d e s 1 a n d 2 t e c h
n i q u e s c a n b e a p p l i e d fo r p a i n r e l i ef. W i t h t h e l at e r a l a s p e c t
o f t h e M C P o f t h e i nd e x fi n g e r , t h e i n t e rs p i n o u s s p a c e i s
p a l p a t e d a t t h e l e v e l t o b e t r a c t i o n e d . W i t h a n o p e n p i n ch
gr i p o f t h e o t h e r h a n d , t h e l o w e r cerv i c a l s p i n e is p a l p a t e d
as c l o s e to t h e s u p e r i o r v e r t e b r a of t h e l e v e l t o b e t r a ct i o n e d
as p o s s i b l e . Lo ca l i z a t i o n i s ach i e v e d b y fl e x i n g/e x t en d i n g
t h e d y s fu n c t i o n a l s e g m e n t u n t i l t h e n e u t r a l p o s i t i o n i s
Figure 131 .
Vertebrom a n ub r i a l region -
b i l a te r a l flex i o n res t r i c t i o n .
Longitu d i n a l tract i o n .
Figure 132.
Vertebro m a n u bri al region -
b i l atera l fl e x i o n restrictio n .
Long i t u d i n a l tractio n .
a s c e r t a i n e d . G r a d e s 1 to 4 l o n g i t u d i n a l t r a c t i o n i s a p p l i e d
b y fi x i n g t h e c a u d a l v e r t e b r a a n d p u l l i n g t h e c r a n i a l v e r t e
bra superiorly.
Stronger distraction techniques are done with the patient either sit
ting or standing with both hands behind the neck, fingers i nterl aced
(Fig. 1 32) . The therapist winds both of their arms beneath the
p atient's ax i l lae through the tri angu l a r space created by the flexed
elbows. The fi ngers are interl aced and p l aced over the p at i e n t ' s
hands. T h e thorax is gently gripped by adducting t h e arm s . The
patient i s i n structed to look forward and the therapist ensures that
the l i gamentum nuchae is not o n fu l l stretch . From this position, a
Grade 3 to 5 longitudinal traction techn ique is applied by rocking
the patient b ackwards and forwards until a pendul ar type m o t i o n is
produced . Gravity provides the distractive fo rce . A h igh v e l ocity,
low ampl itude thrust techn ique (Grade 5) is app l i ed at the apex of
the descent when the patient 's body weight is droppi n g .
Home exercise (Fig. 133) . To m a i n t a i n the m o b i l ity gained,

the patient i s i n structed to perform the fo l l o w i ng e xercise fre-
Figure 133.
Vertebro m a n ubrial region -
b i l a teral flexion res t r i c t i o n .
Home exercise.
quently (up to ten t i m e s , ten times per day). Wi th the fingers inter
l aced behind the neck and the i ndex fingers i n the appropriate i n ter
spi nous space, the patient is in structed to fl ex the he ad/neck. The
fin gers m a y assist the motion by app l y i n g a superior pressure to the
inferi or aspect of the spinous process of the superior verteb ra. The
ampli tude of the exercise should be i n the pai nfree range and
should not aggrav ate any sympto m s .
Unila tera l restriction of flexion
This i s a com m o n restriction to find in the vertebromanubrial

regi o n . A u n i l ateral restriction of fl e x ion w i l l produce a segmental
ro tosco l i osis as well as a compensatory m u l t isegmental curv e
above a n d b e l o w t h e restricted l ev e l . Act ive fo rward bending o f
the head w i l l reveal t h i s asy m m etry. A u n i l ateral restriction of fl e x
i o n on the r i g h t at T l - 2 w i l l produce a right rotat i o n/right sideflex
ion pos i t i o n of T1 at the l i m i t of forward bending. The left trans
verse process of T l w i ll trav el further superiorly than the righ t .
Figure 134.
Vertebromanubrial region -
unilateral flexion restriction
of the right zygapophysea l
joint at T l -2. Mobilization
technique.
The right transverse process of Tl w i ll be more dorsal than the left.
Left rotation and left lateral bending of the head/neck will be
restricted in a consistent pattern in both the H and I combined
movement tests . Unilateral elevation of the left arm w i l l produce
right sideflexion and left rotation of T l -2. The superior arthrokine
m atic glide of the right zygapophyseaJ j o int at T l -2 will be restrict
ed if the dysfunction is intra-articular.
The presence or absence of pain during these tests depends upon

the stage of the pathology (substrate, fibroblastic, maturation ) and
the irritability of the surrounding tissue . The grade of the mobi
lization technique is directed by these factors ( Chapter 3 ) .
Mobi liza tion techniqu e to restore unila teral flexion on th e

right at Tl -2 (Fig. 1 34) . The pat i ent is supine l y i ng with the head
Manu a l Therapy The Thora),
supported o n a p i l l ow. With the lateral aspect of the i ndex finger,

the left transverse process of Tl is palpated. With the other hand,
the spine is down The motion
er is by passively flexing T l -2 then gliding
transverse process of Tl inferomedially C7-Tl is
(locked) with the oppos ite hand by sideftexing the C7-Tl s egment
to the left and rotating i t to the right. From this position, the right
zygapophyseal j oint of T l -2 i s m ob i l i zed into flexion through an
inferomedial and s l i ghtly glide LEFT hand.
will superior slightly anterior of the
at Tl -2. This is an arthrokinematic mobi l ization. By restoring the
accessory glide the osteokinematic motion (flexion) w i l l b e
restored. The technique c a n b e graded from 1 t o 5 .
An active mobilization (muscle techn i que)

used a change muscle tone segmentally. When
motion barrier has been localized, the patient is instructed to resist
further motion while the therapist applies a gentle sideftexion force
to the head/neck . The isometric contraction is held for up to five
seconds fol l owed by a of complete relaxation . The
then taken to new motion the
repeated times and l owed by re-eval uation of
m atic function.
To
Home exercise for a restriction offlexion on the right a t Tl -2.
m ob i l i ty the patient i nstructed to left
frequently to ten
Unilateral elevation of arm may
lems with repetitive rotation through the craniovertebral and mid
cervical regions. The amplitude of the exercise should be in the
painfree range and should not aggravate any symptoms.
B ilatera l restriction of
This restriction is commonly seen when the patient has a forward

head posture . B i l ateral elevation of the arms w i l l reveal a l i m ita
tion of the inferior excursion of the transverse processes h i l ateral-
ly. Rotation and l ateral of the often stops
restriction the upper thereby
m id cerv ical spine. Unilateral elevation of the arm is markedly
restricted on both sides. This restriction places more stress on the
clavicular j o ints and the glenohumeral j oint. Passive m ob i lity test-
ing i n ferior dorsal arthrokinematic glide
zygapophyseal j o i nt i s restricted b i lateral the dysfunction is
The presence absence depends
stage of the pathology (substrate, fibroblastic, m aturation) and the
Figure 1 35.
Vertebro m a n ub r i a l region -
b i l a t e r a l extension res trict i o n .
Mobi l iz a t i o n tech n i q u e .
irritabil ity of the surrounding tissue. The grade of the mobil ization
technique is directed by these factors (Chapter 3).
Mobiliza tion technique (Fig. 135) . The patient i s supine

lying with the head supported on a pil low. With the l ateral aspect
of the index finger of one hand, the i nterspinous space is palpated
at the level to be treated. The opposite hand supports the l ower cer
vical spine as close to the segment as possible. The motion barrier
is localized and passively mobilized by dorsally gliding and slight
ly extending the superior vertebra. This is an arthroki nematic
m obilization. By restoring the accessory glide, the osteoki nematic
motion (extension) will be restored. The technique can be graded
from 1 to 4.
Manua l Therapy The ThorfL>(
An active m o b i lization assist (muscle energy tech n ique) m a y be

used to effect a change i n the m uscle tone segmenta l l y. When the
has been ized, the i nstru cted
therapist reduces the of the
neck. The isometric contraction of the deep neck fl exors is held for
up to five seconds fol l owed b y a period of complete relaxation.
The j oi n t is then passivel y taken to the new motion barrier, the
technique repeated three times and fol l owed b y re-eval u ation of
osteokinematic fun ction.
Home exercise . To m a intain the mobility gained, the patient

is instru cted to elevate the arms b i l aterally frequently (up to ten
times, ten times per day). The amplitude of the exercise should be
i n the range and shou l d not any symptoms.
Uni la tera l restriction t;.'(tens ion
This is another common restriction to find i n the vertebromanubr

ial region . B i l ateral elevation of the arms w i l l produce a segmental
rotosco l iosis and a curve and below level
of restriction . A u n i l ateral restriction of extension on the at
Tl -2 produce a left rotation/left positlOn at
the l i m i t of extension. The left transverse process of T 1 will travel
further inferiorly than the right. The left transverse process of T1
w i l l be more dorsal than the right. Right rotation/s ideflexion of th e
head/neck w i l l be restricted. Unilateral of the
will left s ideflexion and right rotation Tl -2 . The
or arthrokinematic glide of the right zygapophyseal j o in t at T 1 - 2
w i l l be restricted i f t h e dysfunction i s intra-articular.
The or absence pain during tests depends

the the pathology (substrate , m aturati on) and
the of the tissue. grade of the
l ization technique is directed by these factors (Chapter 3 ) .
Mobiliza tion techn ique t o restore unila tera l extension on

TJ -2 (Fig. The patient supine lying
on a pil With the lateral of the
ger, the transverse of T1 is The
spine i s supported down to C7 w ith the other hand. The motion
barrier i s loca l i zed by passively extending T l -2 and then gliding
the r ight transverse process of T 1 inferomedi a l l y o n T2. C7-T1 i s
stabi I ocked) w ith opposite h and sideflexing
T1 to the right rotating it left . From
tion, zygapophyseal j o i nt of T l -2 mobilized into exten-
sion through an i nferomedial and s lightl y posterior glide with the
Figure 136.
Vertebro m a n ubrial region -
u n i l a teral extension restric
tion of t h e right zygapoph y
seal joint at T l -2.
Mobi l i z a t i o n t e c h n i qu e .
RIGHT hand . This is an arthrokinematic mob i l ization. By restor

ing the accessory glide, the osteokinematic motion (extension) w i l l
be restored. The technique can be graded from 1 t o 5 .
An act i v e m o b i l i z at i o n a s s i s t ( m u s c l e e n e r g y t e c h n i q u e )
m a y b e u s e d to effe c t a ch ange i n t h e m u s c l e t o n e s e g m e n
t a l l y W h e n t h e m o t i o n b ar r i e r h a s b e e n l o ca l i z e d , t h e
.
p a t i e n t i s i n s t r u c t e d t o r e s i s t fu r t h e r m o t i o n w h i l e t h e t h e r
a p i s t app l i e s a g e n t l e s i d e fl e x i o n fo rce t o t h e h e a d/n e c k .
T h e i s o m e t r i c c o n tract i o n i s h e l d fo r u p to fi v e s e c o n d s fo l
l o w e d b y a p e r i o d o f c o m p l e t e re l ax a t i o n . T h e j o i n t i s t h e n
p a s s i v e l y t a k e n to th e n ew m o t i o n b a r r i e r, t h e t e c h n i q u e i s
r e p e a t e d t h r e e t i m e s a n d fo l l o w e d b y r e - e v a l u a t i o n o f
o s teo k i n e m a t i c fu n ct i o n .
The Thorax
Home exerc ise for a restriction of extension on the right a t

Tl -2. To maintain the m obil ity gained, the patient is instructed to
right head/neck (up times, ten times
day) . U n i l elevation right a r m used i f
problems w it h repetitive rotation through craniovertebral and
m idcervical regions. The amplitude of the exercise should be i n the
painfree range and should not aggravate any symptoms .
Uni la tera l restriction of rota tion rib
Thi s dysfunction is seen when the scalene m uscles are hypertonic

or tight and hold the anterior aspect of the first rib superiorly o r
w h e n t h e superior g l i d e of the first r i b is restricted at t h e costo-
This will restrict u n i lateral
arms may involved). dysfunction
articular, rotation and l ateral hending of the head/neck w i l l
ited to the s i d e of t h e restricted rib (th is motion requi res a superior
glide of the rib at the costotransverse j o i nt) . Full expiration w i l l
also reveal asymmetry of r i b motio n . I f t h e restriction i s intra-artic-
ul ar, the gl ide first rib at costotransverse
wil l be restricted .
The presence o r absence of pain during these tests depends upon

the stage of the pathology (substrate, fibrobl astic, m aturation) and
the irritab ility of the surrounding tissue. The grade of the mobi -
l ization is directed these factors (Chapter 3).
Mobiliza tion techn ique (Fig. 1 3 7) . restore the superior

glide of the first rib at the costotransverse j o i nt, the following tech
nique is used . The patient is supine l ying with the head supported
on a p i llow. The superior of the right transverse process of
Tl is with the thumb. The and m i ddle
of the hand palpate inferior the right
The m i dcervical spine is supported w ith the other hand. 'rhe
motion barrier i s l o cali zed and mobili zed by apply ing a posteroi n
ferior glide to t h e transverse process of Tl t h u s producing a rel a -
tive gl ide of the rib at the costotransverse
m iddle index fingers right hand inferior
This is an arthrokinemat i c i zation
restoring the superior gl ide of the first rib at the right costotrans
verse j o i nt . B y restoring the accessory glide, the osteokinematic
motion (anterior rotation) will be restored . The technique can be
graded to 4.
An active mobil ization (muscle technique)

used to effect a change in the tone of the scalenus anteri o r and
Figure 1 3 7.
Vertebromanub rial region -
un i l ateral anterior rotation
restriction of the right first
costotransverse j o in t .
Mob i lization technique .
Figure 138.
un il a t e r a l an t e r i or rotation
res triction of the r i g h t first
cos totransverse j o int. Active
mobil ization assis t .
Figure 139.
un i l a teral anterior rot a t i on
restriction of t h e right fi rst
costotransverse j o in t . Home
exercise.
m e d i u s m u s c l e s . T h e h e ad/n e c k i s s i d e fl e x e d t o t h e r i g h t
a n d s l i g h t l y fl e x e d w i t h t h e l e ft h a n d w h i l e t h e r i g h t h a n d
m o n i t o r s t h e r e s p o n s e i n t h e s c a l e n e m u s cu l a t u r e ( Fi g .
1 3 8 ) . T h e p a t i e n t i s i n s t r u c t e d t o r e s i s t a g e n t l e s i d e fl e x i o n
fo rce t o t h e h e a d/neck a pp l i e d w i t h t h e l e ft h a n d . T h e i s o
m e t r i c c o n t r a ct i o n i s h e l d fo r u p t o fi v e s e c o n d s fo l l o w e d
b y a period of complete relaxation . The j o i nt i s then pas
s i v e l y t a k e n t o t h e n e w m o t i o n b ar r i e r , t h e t e ch n i q u e i s
repeated three t i m es and fo l l o w e d b y r e - e v a l u a t i o n o f

o s t e o k i n e m a t i c fu n c t i o n .
Home exercise of anterior rotation

right firs t rib (Fig. the m ob i l ity gained,
patient i s instructed posteroinferior aspect of the
first rib with their then righ t rotate the
frequently (up to ten t i mes, ten times per day) . By holding the rib
posteriorly, the transverse process of T 1 gl ides inferiorly rel ative to
the tubercle of the rib (re lative superior glide of the first rib). The
ampli tude . of the exercise should be i n the painfree range and
should n o t aggravate any symptoms.
Unilatera l restriction rotation - first rib
This dysfunction posterior aspect of the first

held superiorly or glide o f the first rib is
ed at the costotransverse dysfunction w i l l restrict
l ateral elevation of s ide, rotation and l ateral
ing of the head/neck to the opposi te s i de of the restricted rib and
ful l inspiration. I f the restriction is i ntra-articular, the i n ferior glide
of the first rib at the costotransverse j o i n t will be restricte d .
T h e presence or absence of pain during these tests depends upon

the stage of the pathology (substrate, fibroblastic, m aturation) and
the irritab il i t y o f tissue. The grade of the
l ization technique factors (Chapter 3).
Mobilization 1 40) . To restore the

gl ide of the first rib costotransverse j o int, the fol lowing
nique i s used . The patient i s s u p i n e lying with t h e h e a d supported
on a p i l l ow. The superior aspect o f the right first rib is palpated
with the l ateral aspect of the MCP of the i ndex finger of the right
hand. The m idcervical and upper t horacic spine i s supported with
the other hand . The spine i s locked by localized sideflexion o f C7,
Tl and T2 to the right and rotation to the l eft. The motion barrier
of the fi rst costotransverse l o ca l i zed and m ob i l i ze d
applying an anteroi nferior tubercle of the rib al
the conj unct posterior occur. This i s an arthrokinematic
m ob i l i zation aimed i nferior glide o f the fi rst
restoring the accessory glide,
osteok inematic rotation) will be restored.
tech n i qu e can be graded from 1 to 5 .
An active mobil ization assist (muscle energy technique) m a y b e

used t o effect a c hange i n the tone o f the segmental muscl es. From
Figure 140.
Vertebro m a nubri al r eg i o n -
u n i l ateral p o s teri o r ro t a t i o n
rest riction o f t h e right first
cos t o t r a n s v e rs e j oint.
M o b i l iza t i o n technique.
Figure 141 .
Vertebro manubrial region -
unil ateral p o s t e r io r rotation

restriction of the r i g h t first
costotransve rse j o i n t . Home
exercise .
the localized motion barrier, the patient is instructed to resist a gen

tle sideflexion force to the head/neck applied with the l eft hand.
The isometric contraction is held for up to five seconds fol lowed
by a period of complete relaxation. The j oint is then passively
taken to the new motion barrier, the technique i s repeated three
times and fol lowed by re-evaluation of osteokinematic function .
Home exercise for a restriction ofposterior rota tion of the

right first rib (Fig. 141) . To maintain the mobility gained, the
patient i s instructed to fix the posterosuperior aspect of the right
first rib with their left hand and to then left rotate the head/neck fre
quently (up to ten times, ten times per day). By holdi ng the rib pos
teriorly, the transverse process of T1 glides superiorly relative to
the tubercle of the rib (relative inferior glide of the first rib) . T he
ampl itude of the exercise should be in the painfree range and
should not aggravate any symptoms.
Vertebrosterna l and vertebrochondral regions
Bila teral restriction of flexion
A lordotic midthoracic region is often indicative of an underlying

breathing dysfunction (Fig. 128). Overactivity of the spinal exten
sors compensates for a hypertonic diaphragm wh ich tends to flex
the thorax . In addition to specifically mob i l izing the m idthorax it is
cruci al that the breathi ng pattern be addressed if a more neutral
Figure 142.
Vertebroste rnal a n d vertebro
chondral reg i o n bila teral
fl e x i o n restriction - longit u d i
n a l traction - p o i n ts o f palpa
tion for the mob i l iz a t i o n tech
n i que.
position o f the spine i s to b e achiev e d . When the m i d thoracic seg

ments (v erteb rosternal region) become fixed in extension, active
mobility tests of forward bending of the trunk w i l l reveal a l i mita
t i o n of the supe r i o r excurs i o n of th e transverse pro cesses b i l ateral
ly. Passive mobility test ing of the superior arth rokinematic glide at
the zygapophyseal j o i n t w i l l be restricted b i latera l l y if the dys
function i s i n tra-articul ar.
T h e p r e s e n c e or a b s e n c e of p a i n d e p e n d s u p o n t h e s t a g e o f
the pathology (substrate, fibrob l astic, maturation) and the
i r r i t a b i l i t y o f t h e s u r r o u n d i n g t i s s u e . T h e g r a d e o f t h e mob i -
Figure 143.
Vertebrosternal and vertebro
chondral region - b ilateral
flexion restriction - specific
longi tudinal trac t i o n .
Mob i l i z a t i o n techniq u e .
lizatio n technique is directed by these factors (Chapter 3).
Mobilization technique. Longitudinal traction will produce

a superior glide of the zygapophyseal j oint bilaterally. This tech
nique may be done with the patient either supine l y ing or sitting.
With the patient supine, grades 1 and 2 techniques are b etter con
trol led and can be applied for pain rel i ef. The stronger mobil iza
tions can be done with the patient either supine or s itting.
The supine technique is performed as fol lows (Figs . 1 42, 1 43). The
patient is sidelying, the head supported o n a pillow and the arms
crossed to the opposite shoulders . With the tubercle of the scaphoid
bone and the flexed PIP j oint of the long finger, the transverse
processes of the inferior vertebra are palpated. The other hand/arm
lies across the patient's crossed arms to contro l the thorax.
Segmental localization is achieved by flexing the j oint to the
motion barrier with the hand/arm contro l l i ng the thorax. This
local ization is maintained as the patient is rolled supi ne only until
contact is made between the table and the dorsal hand. From this
position, longitudinal traction is applied through the thorax to pro
duce a superior glide of the zygapophyseal joint bilateral ly. This is
an arthrokinematic mobil ization. By restoring the accessory glide,
the osteokinematic motion will be restored. The technique can be
graded from 1 to 5 .
An active mobilization ass ist (muscle energy technique) may be

used to effect a change in the muscle tone segmentally. When the
motion barrier has been local ized, the patient is inst ructed to gen-
Figure 1 44.
chondral region - b i l ateral
flexion restriction - general
longi t u d i n a l tract i o n .
Mob i l ization teCh n ique.
Figure 1 45 .

chondral re gion - b i l ateral
flex i o n re striction . Home
exercise .
t l y elevate their crossed a rms . T h e motion is resisted b y the thera
pist and the isometric co n tract i o n i s held for up to five seconds fol
lowed b y a period o f co m p l ete relaxat i o n . The j o int is then p a s
sively t a k e n to the new m o t i o n barrier, the technique i s repeated
three times and fo l lowed b y re-evaluation of osteok inematic fu nc
tion.
Stro nger d i s tract ive techniques c a n also be d o n e w ith the patien t

sitting w i t h the arms crossed to oppos ite shou lders (Fig. 1 44) . A
sm a l l towel i s p l aced against the spinous process of t h e caudal ver
tebra of the segment to be d i stracted. The towel i s fixed aga inst the
therap ist ' s stern u m . Wi t h both arms wrapped around the patient 's
trunk, the p at i e n t 's elbow which is cl osest to the chest i s gras p e d .
T h e segm e n t i s local ized to ne utral . From t h i s posi t i o n , d istractio n
i s appl ied by rock i n g t h e patient b ackwards a n d s i multaneously
l ifting the tho rax posterosuperio rly. The towel fixes t h e ca u d a l ver
tebra and assists i n localizing the distractive force to the appro
priate segm ent . The technique can be graded fro m 3 to 5.
Home exercise (Fig. 1 45) . To maintain t h e m ob i l i ty gained,

the pat i ent i s i n structed to perform specific m idthoracic fl ex i o n fre
quentl y (up to ten t i m e s , ten times per day) . The amplitude of the
exercise should b e in the p a i nfree range and should not aggravate
any s y m p to m s .
1 22 - Manua l Therapy For The Thorax
Figure 146.
chond ral region - u n i l ateral
flex i o n/ex t e n s i o n res triction
of the l eft zygapophyseal
j oi n t a t TS -6. Po ints of palpa
tion for the mob i l ization tech
n i qu e .
Unila tera l restriction of flexion
A unilateral restri ction of flexion will produce a segmental roto

scol iosis as well as a compensatory multisegmental curve above
and below the restricted leve l . Active forward bending of the trunk
will reveal this asymmetry. A uni l ateral restriction of flexion on the
left at TS -6 will produce a l eft rotation/left sideflex ion position of
TS at the limit of forward bending. The right transverse process of
TS will travel further superiorly than the left . The left transverse
process of TS will be more dorsal than the right. Right rotation and
right lateral bending of the trunk will be restricted and produce a
Figure 1 4 7.
Vertebros tern a l and vertebro
chondral region - u n i l a teral
flexion restriction of the left
zyga p ophyseal joint at TS-6.
Mob i l i z a t i o n tec h n i q u e .
kink in the m idthoracic curve in a consistent pattern i n both the H

and I combined movement tests. The superior arthrokinematic
glide of the left zygapophyseal j oint at TS-6 will be restricted i f the
dysfu nct i on is intra-articular.

the stage of the pathology (substrate, fibroblastic, maturation) and
the irritability of the surrounding tissue. The grade of the mob i
lizat i on technique is directed by these factors (Chapter 3).
Mobiliza tion technique to restore unila teral flexion on the

Left a t TS-6 (Figs. 1 46, 1 4 7) . The patient is right sidel ying , the head
supported on a pil low and the arms crossed to the opposite shoul
ders . With the tubercle of the right scapho id bone and the flexed
P I P j oint of the right long finger, the left transverse process of T6
and the right transverse process of TS are palpated. The other
hand/arm lies across the patient's crossed arms to control the tho
rax . Segmental local ization is achieved by flexing the joint to the
motion barrier with the hand/arm controlling the thorax . This
localization is m aintained as the patient is rolled supine only until
conta ct is made between the table and the dorsal hand. From this
position , a right sideflexion force is applied through the thorax to
produce a superior glide of the left zygapophy seal j oint. This is an
arthrokinematic mobil izatio n . By restoring the accessory glide, the
osteokinematic motion will be restored. The technique can b e
graded from 1 t o S .
An active mobilization assist (muscle energy technique) may b e

1 24 - Manua l Therapy For The Thorax
Figure 1 48.
Vertebrosternal a n d vertebro
chondral re gion - un i la teral
zygapophyseal j o i n t at TS -6.
Active mobil ization assist.
Figure 1 49.
Vertebrosternal and ve rtebro
chondral region - u n i l ateral
zygapophyseal j o i n t at TS - 6 .
Home exercise.

motion barrier has been l ocal ized, the patient is ins tructed to gen
t l y elevate t h e i r crossed arm s . The motion i s resisted by the thera
pist and the isometric contraction is held for up to five seconds fol
l owed b y a period o f co mpl ete re l axation . The j oi n t is then pas
sively taken to the new motion barri er, the te c h n iq u e is re p e a te d
three times and fol lowed by re-evalu ation of osteokinematic func
tion.
When the m y o fascia i s t ho u gh t to be the main cause of the

osteokinematic restriction the fo llowing technique can be useful
(Fig. 1 48). The patient is s itt in g with the a r m s crossed to opposite
shoulders . With the dorsal hand the intertransv erse space i s palpat
ed. The ventral hand is placed on t he contralateral shoulder. The
motion b arrier is localized by flexing and right s i de fl e x i n g the tho
rax . From t h i s p o s i ti on the pa t i ent is instructed to hold s t i l l while
,
t he t he r a p i s t appl i es resi stance to the trunk. The dire c t i o n of the

appl ied resistance is determined by the neurophysiol ogical effect
desired fro m the tech n i que . A hold/relax tec h n i q u e appl ies the
principles of autogenic inhibition and is used pr i m a r i l y fo r a con
trac t ur ed muscle. The involved muscle i s recruited strongly and
then m a x i m a l ly stretched i n the i m m ediate p o s t c ont r ac t i o n re lax
-
ation p h ase . A contract/re lax technique applies the p ri n cip l e s of

re c i p rocal i n h i b i t i o n a n d is used p r i m a r i l y for a h y perto n i c muscle.
The antagonist m uscle is recr u ited gen tly. The contractio n re s u l t s
in reciprocal inhibition of the antago n i s t i c hypertonic mus cle .
The isometric contraction i s held for up to 5 seconds fol lowing

which the patient is instructed to completely relax. The new flex-
ion/sideflexion barrier and the mobilization
three times.
Home exercise maintain the mobility

the patient i s instructed specific m i dthoracic right
flexion in s light frequently (up to ten times, ten times per
day). The amp l i tude of t h e exercise should be i n the painfree range
and shou l d not aggravate any symptoms.
Unilatera l restriction of extension
A u n i l ateral restriction of will produce a segmental

scoliosis as w e l l multisegmental curve
and below the Active backward bending
trunk will reveal unilateral restriction of
sion o n the left at a right rotation/right
ion position of backward bending. The
transverse process of T5 w i l l travel further inferiorly than the l eft.
The right transverse process o f T5 w i l l be m ore dorsal than the
right. Left rotation and l eft lateral bending o f the trunk w i l l be
restricted and produce a kink i n the m i dthoracic curv e in a consis
tent pattern i n both the H and I comb ined movement tests. The
i nferior arthro k i n ematic glide of the left zygapophyseal j o i n t a t T5 -
6 w i l l be restricted is i ntra-articular.
The presence or during these tests depends

the stage of the fibroblastic, maturation)
the irritab i li t y of tissue . The grade of the
l i zation tech nique is d irected b y these factors (Chapter 3).
Mobilization technique to restore unilateral extension on

the left a t T5-6 (Figs. 1 46, 1 50) . The patient is right sidelying, the
head supported o n a pil low and t h e arms crossed to the opposite
shoulders. With the tubercle o f the right scapho i d bone and the
flexed PIP j oint o f the left transverse
o f T6 and the right of T5 are palpated. The
h and/arm l ies across crossed arms to control
rax. Segmental ach i eved b y extendi ng the
the m otion barrier contro l l i n g the thora x .
loca l i zation i s is rol l ed supine o n l y
contact i s m ade between the table a n d t h e dorsal hand. From th i s
position, a left sideflexion force (coupled w i th a sl ight dorsal g l i de)
is applied through the thorax to produce an i nferior glide o f the left
zygapopbyseal j oi n t . This i s an arthrokinematic mob i l ization. B y
Figure 150.
Vertebrostern a l and vertebro
chondral region - u n ilateral
extension res trict i o n of the
left z y gapophyseal j o i n t at
TS-6. M ob i l i za t i o n tech
n i que.
restoring the accessory glide, the osteokinematic motion will be

restored . The technique can be graded from 1 to 5 .
An active mob il ization assist (muscle energy technique) m ay be

motion barrier has been l ocal ized, the patient is instru cted to gen
tly elevate their crossed arms. The motion is resisted by the thera
pist and the isometric co ntraction is held for up to five seconds fol
lowed by a period of complete relaxation. The j oint is then pas
sively taken to the new motion barri er, the technique i s repeated
three times and followed by re-evaluation of osteokinematic func
tion.
When the myofascia i s thought to be the main cause of the

osteokinematic restriction the fol lowing technique can be useful
(Fig. 1 5 1 ) . The patient i s sitting with the arms crossed to opposite
shoulders. With the dorsal hand the intertransverse space IS palpat
ed . The ventral hand is placed on the contralateral shoulder. The
motion barrier is localized by extending and left sideftexing the
thorax. From this position, the patient is instructed to hold sti l l
while t h e therapist applies res istance t o t h e trunk. T h e direction o f
the applied resistance i s determ ined by the neurophysiological
effect desi red from the technique. A hold/relax technique appl ies
the principles of autogenic inhibition and is used prim arily for a
contractured m uscle. The invo lved muscle is recru ited strongly and
then maximall y stretched in the immediate post-contracti on relax
ation phase. A contract/rel ax technique applies the principles of
reciprocal inhibition and is used primarily for a hypertonic m uscle .
Manua l Therapy For The Thorax - 1 27
Figure 1 5 1 .
Vertebrostern a l a n d vertebro
chondral region - u n il a t e r a l
extension re s t r i c t i o n of the
l eft zygapo p h y s e a l j o i n t at
T5 - 6 . Act i v e mobil ization
assist.
Figure 152.
chondral region - u n i l a teral
exte n s i o n restrict i o n of the
l eft zyga p o p h y seal j o i n t at
T5 -6. H o m e exercise.
The antagonist m u s cle is recruited gently. The contraction results

in reci proca l in hibition of the antagonistic hypertonic muscle.
The isometric contraction i s held for up to 5 seconds following

wh ich the patient is instructed to completely relax. The new exten
sion/sideftexion barrier i s local ized and the mobilization repe ated
three times.
Home exercise (Fig. 1 52) . To maintain the mobility gained,

the pati ent is i nstructed to perform specific midthoracic left side
flexion in slight extension frequently (up to ten times, ten times per
day) . The amplitude of the exercise should be in the painfree range
and should not aggravate any symptoms.
Unilateral restriction of rotation (posterior or anterior) - ribs 3 to 10
This dysfunct i o n i s seen when the muscles are imbalanced or when

the arthrokinematic glide of the rib is restricted at the costotrans
verse j o int (Figs . 1 5 3 , 1 54) . The clinician m u s t be aware of rela
tive flexibil ity between the thoracic vertebrae and the ribs when
interpreting the findi ngs on habitual movement tests and passive
arthrokinematic m ob i l i ty tests . The di rection of the costotransverse
j oint glide can be either superior or inferior during forward and
backward bending. The patient 's normal pattern must be ascer
tained before the findings can be understood. Respiration produces
the most co nsistent movement pattern and is the most rel i able
Figure 153.
Left rotation of the m i d thorax
i s fa irly free even i n the pres
ence of a m a rked scoliosis
secondary to po l i omye l i t i s .
Figure 154.
Right rot a t i o n of t h e m id tho
rax is b l ocked due to the
i n abi l ity o f the r i g h t sixth r i b
to posteriorly ro t a t e .
habitual movement to test when evaluat i n g osteo k i nematic func

tion o f the ribs. If the d y sfunction is i ntra-articular the arthro k i n e
matic g l i de o f t h e costotransverse j o int w i l l b e reduced.
Active m o b i l ization techniques are useful when the myofascia is

i m b al anced. Respiration m ay produce a s y m metry i n the thorax but
the arthro k i n e m atic g l i de of the co stotransverse j o i n t i s n o rm a l .
Mobiliza tion techn ique t o restore posterior rotation righ t
fifth rib (Fig. 1 55) . When the m y o fasci a is thought to be the m a i r.

cause of t h e o s teo ki nematic restrict i o n t h e fo l l owing technique car;
be usefu l . The patient is sitting w i t h the a rms crossed to opposite
shoulders. With the dorsal hand the fifth rib is palpate d . The ven
tral h and i s p l aced o n the pati e n t 's contralateral s h o u lder. The
m o t i o n b arrier is localized by left s i deftexing and right rotating the
thorax . From this pos i t i o n , the patient is ins tructed to h o l d s t i l l
w h i l e t h e therapist app l i e s resistance to t h e tru n k . T h e direction o f
the applied res i s tance i s determ ined by the neurophysio logical
effect desired fro m the tech n i que . A h o l d/re l a x tech n i que applies
the pri nciples o f autoge n i c i n h i b i tion a n d is used prim ari l y fo r a
contractured musc l e . The invo lved muscle is recru i ted strongly and
then m a x i m a l l y stretched in the immed i ate post-co ntraction rela x
a t i o n phase. A contract/relax tech n i que app l i e s t h e principles o f
reciprocal i n h i b i t i o n a n d i s used p r i m a r i l y fo r a h y perton i c m uscl e .
T h e an tago n i s t m uscle i s recruited gently. T h e co n traction resu l ts
in reciprocal i n h i b i t i o n of the an tago n i s t i c h yperto n i c muscle.
Figure 155.
chondral regi o n - u n i l a teral
restriction of pos t e r i o r rota
tion of the ri ght fi ft h rib.
Ac t i v e mob i l i zation tech
nique.
Figure 156.
restri c t i o n of a nt e r i o r rota t i o n
of t h e right fi f t h rib. Active
m o b i l ization tec h n i q u e .
The isometric contraction is held for up to 5 seconds following

which the patient is i nstructed to completely relax . The new
motion barrier is localized and the mob i l izati on repeated three
times.
Home exercise. To maintain the mobility gained, the patient

is instructed to perform specific midthoracic left sideflexion and
right rotation frequently (up to ten times, ten times per day) . The
ampl itude of the exercise should be in the painfree range and
should not aggrav ate any symptoms.
Mobiliza tion technique to restore anterior rota tion righ t

fifth rib (Fig. 1 56) . The patient is sitting with the arms crossed to
opposite should ers . Wi th the dorsal hand the fifth rib is palpated.
The ventral hand is pl aced on the patient 's contralateral shoulder.
The motion barrier is local ized by right sideflex ing and left rotat
ing the thorax . From this position, the patient is instructed to hold
still while the therapist applies resistance to the tru nk. The di rec
tion of the appl ied resistance is determ i ned by the neurophysiolog
ical effect desi red from the technique. A ho ld/relax techn ique
applies the principles of autogenic inhibition and is used primarily
for a contractured muscle. The involved muscle is recruited strong
ly and then m aximally stretched in the immediate post-contraction
rel axation phase. A contract/relax technique appl ies the principles
of reciprocal inhibition and is used primarily for a hypertonic mus
cle. The antagonist muscle is recruited gently. The contraction
130 - Manual Th erapy For The Thorax
Figure 1 5 7.
chondral region - unilateral
restriction of anterior rotation
of the right fifth rib. Home
exercise .
results in reciprocal i nhibition of the antago nistic hypertonic mus
cle .
The isometric contract i o n is held fo r up to 5 seconds fol l owing

which the patient i s instructed to completel y relax . The new
motion b arrier is loca l i zed and the m ob i l i zation repeated th ree
times.
Home exercise (Fig. 1 5 7) . To m a i n t a i n the m obi l ity gained,

the patient i s i nstructed to perform specific m i dthoracic right side
flexion and left rotation fre quent l y (up to ten t i m es, ten times per
day). The ampl itude o f the exercise s ho u l d be in the painfree range
and s h o u l d not aggravate any s y mpto m s .
Thoracolumbar j unction
Un ila tera l restriction of flexion
A un ilateral restrict ion of flexion in the thoraco l u m b a r j unction

will produce a segmental rotosco l i o s i s as w e l l as a compensatory
Figure 158.
T h o raco l u m b a r junction -
u n i lateral restriction of flex
ion of the right zygapop hy
seal joint at T 1 1 - 1 2.
Mob i l ization techn ique.
multisegmental curve above and below the restricted l evel . Active

forward bending of the trunk will reveal this asym metry. A unilat
eral restriction of flexion on the right at Tl l - 1 2 will produce a right
rotation/right sideflexion position of T l l at the limit of forward
bending . Left rotation and left lateral bending of the trun k w i l l be
restricted in a consistent pattern in both the H and I combined
movement tests . The superior arthrokinematic glide of the right
zygapophyseal j oint at T l l - 1 2 will be restricted if the dysfunction
is intra-articular.

the stage of the pathology (substrate, fibroblasti c, maturation) and
the irritabil ity of the surrounding tissue. The grade of the mobi
lization tech nique is di rected by these factors (Chapter 3 ) .
Mobiliza tion technique t o restore unilateral flexion o n the

righ t at Tll - 1 2 (Fig. 158) . With the patient i n left sidelying, hips
and knees slightly flexed, the T10-11 interspinous space is palpat
ed. The thoracolumbar spine is rotated through the patient's lower
arm until ful l rotation of T10- 1 1 is achieved. The Ll -2 interspinous
space is palpated and the patient's uppermost hip and knee are
flexed until ful l flexion of Ll-2 occurs . The foot of the upper leg
rests against the popl iteal fossa of the lower leg. The T l l - 1 2 inter
spinous space is palpated and the right zygapophyseal j o int is
localized and mobi lized i nto flexion and left sidefl exion through
either the thorax or the pelvic girdle . The technique can be graded
from 1 to 5 .
Figure 1 59.
T '1 o r a co l u mb a r j unction -
u n i l atera l res t r i ct i o n of flex
i o n of the right zygap ophy
s e a l j o i n t a t T l 1 - 1 2. Home
exerc i s e .
An active mobilization assist (muscle energy technique) may be

motion barrier has been local ized, the patient is i nstructed to gen
tly resist further sideftexion of the trunk. The isometric contraction
is held for up to five seconds followed by a period of complete
relaxation. The j o int i s then passively taken to the new motion bar
rier, the techni que is repeated three times and followed by re-eval
uation of osteokinematic fu nction.
Home exercise (Fig. 159) . To maintain the mobility gained,

the patient is i nstructed to perform specific thoracolumbar flexion
and left sideftexion in a four point kneeling position frequently (up
to ten times, ten times per day). The ampl itude of the exercise
should be in the painfree range and should not aggravate any
sympto ms.
Unila teral restriction of extension
A u n i lateral restriction of extension in the thoracolumbar j unction

will produce a segmental rotoscoliosis as well as a compensatory
multisegmental curve above and below the restricted level. Act ive
backward bending of the trunk will reveal this asymmetry. A uni
lateral restriction of extension on the right at T l l - 1 2 will produce
a left rotation/left sideftexion position of Tll at the l im i t of back
ward bending. Right rotation and right latera l bending of the trunk
w i l l be restricted in a consistent pattern in both th e H and I com
bined movement tests (Fig. 160) . The inferior arthrokinematic
gl ide of the right zygapophyseal j o i nt at T l l - 1 2 will be restricted
Figure 1 60.
Th orac o l u m b a r j un c t i o n -
u n i l a teral restriction of e x t e n
s ion of t h e r i g h t zygapo p h y
seal j o i n t a t T l l - 1 2 w i l l co m
pletely bl ock t h e form a t i o n o f
t h e S c u rv e d u r i n g rotation of
t h e tru n k .
Figure 1 61 .
Thoraco l u m b a r j u nction -
u n i l a te r a l rest riction of e x t e n
s i o n of t h e r i g h t zygapophy
seal joint at Tl l- 12.
Mob i l i z a t i o n tech niqu e .
i f the dysfunction is intra-articular.

the stage of the pathology (substrate, fibroblastic, maturation) and
the irritabi l i ty of the surrounding tissue. The grade of the mobi
lization technique is d irected by these factors (Chapter 3).
Mob iliza tion technique to restore unila teral extension on

the right at Tll -12 (Fig. 1 61) . With the patient in left sidely ing,
h ips and knees slightly flexed, the TlO- l l i nterspinous space is
palpated. The thoracolumbar spine is rotated through the patient's
lower arm until full rotation of T10- 1 1 is achieved. The Ll-2 inter
spinous space is palpated and the patient's upperm ost h i p and knee
are flexed until full flexion of Ll-2 occurs . The foot of the upper
leg rests against the popliteal fossa of the lower leg. The T 1 1 - 1 2
interspinous space i s palpated and the right zygapophyseal j oint i s
local ized and mob i l ized into extension and right sideflexion
through either the thorax or the pelvic girdle. The technique can be
graded from 1 to 5 .
An active mob i lization ass ist (muscle energy technique) m ay be

motion barrier has been localized, the pati ent is i nstructed to ge n
tly resist further sideflexion of the trunk. The isometric contraction
is held for up to five seconds followed by a period of complete
relaxation. The j oint is then passively taken to the new motion bar
rier, the technique is repeated three times and fol l owed by re-eval
uation of osteokinematic function .
Hom e exerc ise (Fig. 1 62) . To m a i n ta i n t h e m o b i l i t y

g a i n e d , t h e p a t i e n t i s i n s t r u c t e d t o p e r fo r m s p e c i fi c t h o r a
c o l u m b a r e x t e n s i o n a n d r i g h t s i d e fl e x i o n i n a fo u r p o i n t
k n e e l i n g p o s i t i o n fre q u e n t l y ( u p t o t e n t i m e s , t e n t i m e s p e r
day) . The amplitude of the exercise should b e i n the
Figure 1 62 .
Thoraco l u m b a r j u n c t i o n -
u n i lateral restriction of exten- .
sion of the right zygapophy
seal j oint a t T l 1 - 1 2 . Home
exercise.
p a i n fr e e r a n g e a n d s h o u l d n o t a g g r a v a t e a n y s y m p t o m s .
HYPERMOBILITY WITH O R WITHOUT PAIN
Hypermob i l i ty can be t h e r e s u l t of m aj o r trau m a over a short peri

od o f time o r m i no r repe t i t i v e traum a over a l o n g period of t i m e .
T h e essent i a l obj ective fi n d i n g for class ificat i o n h e r e i s t h e pres
ence o f i n creased osteok i n e m a t i c motion o f e i t h e r the thoracic ver
tebrae o r ribs.
The m o d e of onset may b e either i ns i di o u s o r sudden depen d i n g

u p o n t h e degree of trau m a . T h e i r r i t ab i l ity o f the w o u n d e d tissue
d i ctates t h e intensity of the pain, the amount o f rad i a t i o n , the
degree of p h y s i c a l act i v i ty which tends to aggrav ate i t a n d t h e
a m o u n t o f rest requi red to rel ieve i t . T h e a i m o f the subj ec t i v e
e x am i n ation i s to determ i ne the s t a g e and nature of the p a t h o l o g y
so that treatm e n t m a y be adj usted accord i n g l y (Chapter 3 ) .
An acute s u b l u x a t i o n of e ither a rib o r ' a r i n g ' ( s e e b e l ow) tends to

produce very l o c a l ized pain over the i n v o l ved j o i n t . I n l o n gstand
i n g conditions, the l o cati o n o f t h e p a i n i s p o o r l y l ocal ized t o a spe
cific segme n t a n d tends to radiate over a regi o n o f t h e t h o ra x .
Referral o f p a i n i s vari ab l e a n d can be e i th e r around the chest o r
through i t .
If t h e sympathetic c h a i n i s effected by t h e hypermob i l e segme n t ,

s y m ptom s can b e referred i n to the u p p e r o r lower e x t r e m i ty. T h e s e
p a t i e n ts co m m o n l y r e p o r t tem perature Changes, heavy s ens at i o n s
assocIated w i t h fatigue and nonspecific n u m b ness of the involved
extrem i ty. T h e upper thorax can also refer p a i n i n t o t h e cran i u m
thro u g h t h e s y mpathetic pathway.
Hy perm o b i l e j o i n t s are very i n c o n s i stent in the pattern t h e y present

on hab i tu a l m o v e m e n t test i n g . The active m o b i l i t y tests reveal a n
abnorm a l movement p a t t e r n w h i ch i s variable dep e n d i n g u p o n the
order in w h i c h the com b i n e d movements are perfor m e d . Sp ec i fi c
m ob i l i t y and stab i l i ty test i ng reve a l s the h y p e rm o b i l ity/instab i l i t y
s i nce d i s o rders i n t h i s c l a s s i fi c a t i o n e x h i b i t a l o s s o f arthro k i n etic
fu nct i o n . The n e u ra l/dural mobility tests may b e p o s itive if t h e
mob i l i t y o f the s y m pathe t i c c h a i n i s effected b y a c h a n g e i n p os i
t i o n o f t h e head o f t h e r i b .
S u b l u xation o f t h e costotransverse a n d costovertebral j oi n ts
S u b l u x a t i o n s of t h e costotransverse j o ints are n o t u n c o m m o n a n d

o c c u r secondary to rota t i o n a l t r a u m a o r a d i rect b l ow to the che s t .
The rib will be either superior or

inferior on positional testing and
all movements including the
arthrokinematic g l i des are
blocked . The j o i nt is hypomob ile
until the subluxation is reduced.
Fol lowing reduction of the sub
luxation, the arthrokinetic tests
for stabi l ity reveal the underlying
h y perm o b i l ity of the rib .
Stab i l ization is then requ ired .
The treatm e n t techn ique to
reduce a subluxed costotrans
verse j oint is a grade 5 d istraction
Figure 163. tech n ique .
Vertebro m a n u b r i a l region -
u n i l a tera l superior subluxa Vertebromanubrial region
t i o n of t h e r i g h t fi r s t rib a t t h e
c o s t otra n sverse joint.
Mob i l i za t i o n tech n i q u e .
Mobi lization technique for a
superiorly subluxed righ t first rib
at the costotransverse joint (Fig. 1 63) . To restore the i nferior glide
of the first rib at the costotransverse j o i nt, the fo llowing technique
is used. The patient is supine lying with the head supported on a
p i llow. The superior aspect of the right fi rst rib is palpated with the
lateral aspect of the MCP of the index finge r of the right hand. The
m idcerv ical and upper thoracic spine i s supported with the other
hand . The spine is locked by l ocalized sideftex ion of C7, Tl and
T2 to the right and rotation to the left. The motion barrier of the
first costotransverse j oi n t is localized by apply ing an anteroi nferi
or glide to the tubercle of the rib . From th is position a h igh veloc
i ty, low ampl i tude thrust is app l ied to the first rib in an anterome
dial direction.
If the reduction is successful, the arthrokinematic glide at the cos

totransverse j oint will be restored. An active mobi lization tech
nique (see hypo mobile classification) may be required to attain
myofascial bal ance and optimal osteoki nemati c funct i o n .
Anteriorly, the costochondral a n d sternochondral j o ints can

become hypermobile/unstable and a source of localized anterior
chest pain. Causes include excessive rotational trauma and/or a
direct blow to the anterior chest. There is a palpable step or gap
between the rib/cartilage or the cartilage/sternum, the arthrokinet
ic test reveals a greater ampl itude of movement and is associated
with local tenderness. When the two j oint surfaces are d isplaced or
subluxed , reduction is not possible . The acute joint is treated with
Figu re 1 64.
chondral region - u n ilateral
subluxation of the right fifth
rib a t the costotransverse
joint. Po i n t of palpation for
fixation of t h e rib.
Figure 1 65.
chon dral region - u n i l a teral
subluxation of the right fi fth
rib at the costotransverse
j oi n t . S u p i n e m o b i l i z a t i o n
tech nique.
rest, education regarding lim iting t h e use of the shoulder (to avoid
further separation of the j oint with contraction of the serratus ante
rior and/or pectoralis maj or/m inor muscles), local electrotherapeu
tic modalities for pain relief and control of infl ammation and tap
ing to limit motion of the thorax .
Figure 1 66.
subl uxation of the r i ght fifth
rib at the c o s t o t r a n sv e rse
joint. Prone m ob i l i z a t i o n
techn i q u e .
Vertebrosternal and vertebrochondra l regions
Mobiliza tion technique for th e subluxed right fifth costo

transverse joint (Figs. 1 64, 1 65) . The patient is l eft sidelyi ng, the
head supported on a p i l low and the arms crossed to the opposite
shoulders. With the proximal phalanx of the l eft thumb, the rib is
palpated j ust l ateral to the transverse process of the vertebra to
which it attaches. The other hand/arm supports the patient 's thorax .
Distraction of the costotransverse j o int i s ach i eved by rolling the
patient over the dorsal hand only until contact i s made between the
tab l e and the dorsal hand. Further axial rotation of the thorax
against the fixed rib will distract the costotransverse j o i nt. A very
low amplitude, high velocity thrust applied through the thorax in
axial rotation will reduce the subluxatio n .
Alternately, t h e technique can be done w i t h t h e patient prone l y i n g

(Fig. 1 66) . To distract the righ t fifth rib, the left transverse process
es of T4 and T5 are fixed with the left hand . With the other hand,
the fifth rib is palpated j ust l ateral to the transverse process of T5 .
If the subluxation is superior, the cranial aspect of the rib is pal
pated. If the subluxation is i nferior, the caudal aspect of the rib is
palpated. The rib is distracted at the costotransverse j o int by apply
ing a posteroanterior pressure while fixing the transverse process
es of T4 and T5 . A h igh velocity, low amplitude thrust is applied
through the rib i n a superior or i nferior direction depending upon
the direction of the subluxation.
If the reduction is successfu l , the arthrokinematic gl ide at the cos-

totransverse joint will be restored . An active mobilization tech

nique (see hypomob ile cl assification) may be required to attain
myofascial balance and optimal osteokinematic function.
Anteriorly, the costochondral and sternochondral j o ints can also

become hypermob ile/unstab le and a source of localized anterior
chest pai n . The causes, findings and treatment have been discussed
in the vertebrom anubrial section.
Thoracolumbar junction
Subluxation of the eleventh or twelfth ribs at the costovertebral

joint is not common given the flexibility of the region. A sudden
contraction of the ful ly stretched quadratus lumborum muscle
(hyperextension from the fully flexed position) can sublux the
twelfth rib inferiorly. Excessive rotation of the trunk while ful ly
flexed can also sublux these j o i nts.
When acute, the patient presents with a lateral shift of the trunk
localized to the thoracolumbar j unction. All active movements are
blocked at the thoracolumbar j unction. Any attempt to correct the
lateral shift meets with resistance and an increase in the patient 's
pai n . The lumbar myofascia is hypertonic on the side of the later
al sh ift. The subluxed costovertebral joint is extremely tender to
local palpation of the soft tissue overly ing the joint. Specific
mob ility testing reveals a reduction in the arthrokinematic gl ide of
the zygapophyseal j o ints between Tl 1 - 1 2 or T1 2-Ll and a com-
Figure 1 6 7.
T h o r a co l u m b a r j unction -
u n i l a teral subl u x a t i o n of the
right twe l fth rib at the cos
t o v e r te b r a l joint.
Mob i l ization technique.
1 40 - Manual Therapy For Thorax
plete block of any glide b etween the suhluxed rib and its associat
ed vertebra, The treatment technique to red uce a subluxed cosIo
transverse j o int is a grade 5 distracti o n technique.
Mobiliza tion techn ique to reduce a subluxed right twelfth

costovertebral joint (Fig. 1 67) . With the patient i n sidelying,
h i ps and knees slightly flexed, the T 1 2-Ll i n terspinous space is
palpated. The thoracolumbar spine i s rotated through the patie n t 's
lower arm until ful l rotation of T 1 2-LI is ach ieved . The LI -2 i n ter-
spinous is and patient uppermost and
are flexcd u n t i l ful l flcxion of Ll-2 occurs. The foot o f the upper
leg rests against the pop liteal fossa of the lower leg. The right side
of the spinous process of TI2 i s palpated w i t h t h e therapist's cra-
n i al hanet The twelfth is palpated and fixed w i th
thumb and i ndex of the therapist's left hand. The right cos-
tovertebral j o i n t between t h e twelfth rib a n d T 1 2 i s d istracted w i t h
a h igh velocity, low amplitude thrust technique by a x i a l l y rotating
the spinous process T I 2 away from the fi xed r i b .
I f the reduction i s successfu l , t h e arthrokinematic glide a t the cos

totransverse j oi n t w i l l be restored . An active m ob i l izati o n tech-
n ique hypomobile classification) be to
m y o fascial balance and optimal osteokinematic function.
Subluxation of the ' rung'
Thi s subluxation i nvolves the entire ' ring' which i ncludes two
adj acen t thoracic vertebrae , the i n tervertebral d i sc , the two ribs and
their associated anterior and posterior j o ints and the sternum . Th is
subluxation occurs primaril y the vertebrosternal region
occasionaHy i n the vertebrochondral region. It can occur when
excessive rotation i s appl ied to the unrestrained thorax or when
rotation of the thorax i s forced against a fixed rib cage (seat helt
i nj u ry). the l im i t right rotati o n in m i dthorax the
vertebra has transl ated to the left, the left rib has translated pos
tero laterally and the right rib has transl ated anteromedially such
that a functional U j o i n t is produced (Chapter 2) . Further right rota
tion in right lateral tilt 0 t h e superior v e rtehra .
Subluxation of the superior vertebra occurs when the left lateral
translation exceeds the physio logical motion barrier and the verte
hra i s unable to return to i ts neutral position For the subluxation to
occur proposed a horizontal cleft through posteri o r
of t h e i n tervertebral d i s c m ust occur (Fig. 1 68).
Positionally, the follow i ng findi ngs are noted with a left l ateral
shift subl uxation the sixth (T5 -T6 and the ribs),
Ve rt e b ral Body ------...
S u p e ri o r
Costove rt e b ra l
Figure 1 68.
R i b ----r-,.,,;.;.
Anatomy of the lateral shift
lesion It is p ro p osed that a
.
horizontal c left occ u rs

through the poste r ior 1/3 of
I nfe r i o r the intervertebral disc confl u
Costov e rt e b ra l J o i n t ent w i t h the s u p e r i o r cos
tovertebral j o i nts bilateral l y
allowing t h e su p erior vertebra
H o ri z o n t a l
to sublux laterall y .
I nt ra-d i scal C l eft -
Figure 1 69.
This patient sustained a left
l ateral s h i ft of T5 and the left
and right sixth ribs in a motor
vehicle accident one month
prior. Note the com p lete
block of right rotation a t the
subluxed segment.
Figure 1 70.
Mobilization tech n ique for a
left latera l shift of the sixth
ring. Stron g d istraction must
be m a i n t a i ned t h roughout the
tec h n i que.
T6 is right rotated in hyperflexion, neutral and extension, the right

sixth rib is anteromedial posteriorly and the left sixth rib is pos
terolateral posteriorly. All active movements produce a ' kink ' at
the level of the subluxation, the worst movement i s often rotation
(Fig . 169). The passive tests of arthrokinematic funct ion of the
zygapophyseal and costotransverse joi nts are reduced but present.
The right mediolateral tran slation mobil ity test is completely
blocked.
Prior to reduction of the subluxation the arthrokinetic tests for sta

bility are normal . Subsequent to reductio n, the arthrokinetic tests
of anteroposterior costal stabil ity are normal, the right rotational
test of TS -T6 is positive and there i s excessive left lateral transla
tion of the ring.
Mobilization technique for a left lateral shift of the sixth ring (Fig. 1 70)
The patient is in left sidelying, the head supported on a pi llow and

the arms crossed to the opposite shoulders. With the left hand, the
right seventh rib is palpated posteriorly with the thumb and the left
seventh rib is palpated posteriorly with the index or long finger. T6
is fixed by compressing the two seventh ribs towards the m i dline.
Care must be taken to avoid fixation of the sixth ribs wh ich must
be free to glide relative to the transverse processes of T6 . The other
hand/arm lies across the patient's crossed arms to control the tho
rax . Segmental local ization is achieved by flexing and extending
the joint until a neutral position of the zygapophyseal joints is
achieved. This localization is maintained as the patient is rolled
s u p i n e o n ly u n t i l c o n t a c t i s m a d e b e t w e en t h e t a b le a n d
th e dors a l h a n d.
Fr o m t h i s p o s i t e ft a n d r i g h t s i x t h r i
tra n s l a t e d l at e r a through t h e t h o r ax
m o t i o n b a r r i e r. n a l d i s tr a ct i o n i s
through t h e t h e application of
v e l o c ity, l o w The thrust is in a
d i re c t i o n i n t h e t r a n s v e r s e p l a n e . T h e g o a l o f t h e t e c h
n i q u e i s t o l a t e r a l l y t r a n s l a t e T 5 a n d t h e l e ft a n d r i g h t
sixth ribs r e lative to T6.
Fo l l o w i n g r e d u c t i o n o f t h e s ub l u x a t i o n , t h e a r t h r o k i n e t i c
t e s t s fo r m e d i o l a t e r a l t r a n s l a t i o n w i l l r e v e a l t h e u n d e r l y
i n g i n s t ab i l i t y ization is then req
S TA B I LI ZAT I O
In addi t i o n to the thorax, cum

m i cr o t r a u m a c a n lead t o postural changes, a l t e r e d move
m e n t p a t t e r n s a n d a s s o c i a t e d fu n ct i o n a l i ns t ab i l i t y .
S t ab i li z at i o n t h e rapy i s a concept w h i ch considers t h e
i n t e g r a t e d r e l a t i o n s h i p b e tw e e n t h e l e g s , p e l v i c g i r d l e ,
t r u n k a n d u p p e r e x t re m i t y . T h e c e n t r a l f e a t u r e o f t h i s
concept i s t h a t t h e tru n k muscles m u s t h o l d the vertebral
column stable ependent upper and
extre m i ty m ove a n d a l s o t h a t l o ad m
t r a n s fe r r e d fro t r c m i t y t o t h e g r o u n d2
E s s e n t i a l l y, t h e to specifica l l y recru
t ru n k m u s c l e s y d then to mainta
brace a s t h e y m o v e the u p p e r a n d lower e x trem i t i e s i n d e
p e n d e n t l y . I n i t i a l l y, t h e b a s e o f s u p p o r t i s v e r y s t a b l e .
T h e p r o g r a m i s p r o g r e s s e d b y i n cr e a s i n g t h e d e g r e e o f
d iffi c u l t y b y r e d u c i n g t h e b a s e o f s u p p o r t , b y m a k i n g t h e
b a s e m o r e u n s t a b l e a n d/o r b y i n c r e a s i n g t h e l o a d w h i c h
must be control led The program is directed by the
p at i e n t ' s n e e d s only b y the therap
imagination . Th asti c ball s , rol ls , b
boards and pu 1 tabi l i za t i o n therapy
e ffe c t i v e , f u n allenging. Figures
1 9 1 i l l u s tr a t e rci ses used i n stab i l
t h e r a p y . T h e r e a d e r i s r e fe r r e d t o I r i o n 26 a n d S a a 1 27 fo r
fu r t h e r i d e a s o n s t a b i l i z a t i o n t r a i n i n g w h i c h i n v o l v e s t h e
t o t a l m u scu l o s k e l e t a l s y s te m .
Figure 1 71 .
Tru n k bracing - level 1 . Th e
patient is taught to co-con
tract the a n terior a n d poster i
or trunk mu scles isometrical
ly without excess ive posterior
pelv i c t i l t i ng. When done cor
rec t l y t h e lower cos t a l m a r g i n
should be level with the
pelvic gird l e u n l i ke t h e m o d e l
i n t h i s i l lustration who is p o s
teriorly t i l t i ng h i s pelvic g i r
dle too much. A pressure
b i ofee d b ack u n i t o r a blood
press ure cuff p l aced in the
lumbar region c a n be a useful
tool for e d uca t i o n . Proper co
contract i o n o f the trunk mus
cles will elevate the pressure
i n the cuff 10 to 1 5 points on
t he pre s s u re gauge.
Figure 1 72 .
T r u n k braci n g - level 2. The
p a t i e n t is i n s tructed to m a i n
t a i n the co-co ntraction as i n
level l a n d t o flex the h i p a n d
knee t o 90 d egrees. T h e pres
s u re gauge s h o u l d rem a i n at
the same level if the co-con
tract i o n is m a i n t a i ned proper
ly.
N O R M A L M O B I LI T Y W I T H PA I N
P a t i e n t s p r e s e n t i n g w i th p a i n i n t h e t h o r a x w i t h o u t o bj e c
t i v e m e c h a n i c a l f i n d i n g s c a n b e a c h a l l e n g e to t r e a t .
G i v e n t h e n a t u r e o f v i s c e r a l r e fe r r a l o f p a i n t o t h e t h o r a x ,
a team appro ach t o t h e p rob l em i s b e s t . I f all m e d i c a :
c o n d i t i o n s a r e r u l e d o u t and t h e re i s n o s p e c i f i c a r t i c u l ar,
m u s c u l a r , n e u r a l o r d u r a l m o b i l i t y d y s f u n c t i o n t o be
fo u n d t h e n a p o s t u r a l a p p r o a c h fo l l o w i n g the p r i n c i p l e s
Figure 1 73.
Trunk bracing - level 3 . From
the starting pos i t i o n of level
2, the patient i s i n s t ructed to
maintain the co-cont raction
of the trunk and to bring the
opposite h i p and knee to 90
degrees w i t ho u t l o s i n g t runk
contro l .
Figure 1 74.
Trunk bracing - l evel 4. From
the starting p o s i t i o n of level
3 , the patient i s instructed to
maintain t he co-co n traction
of the trunk and slowly
extend o n e l e g w i t h o u t l o s i n g
trunk con t ro l .
of s t ab i l i z a t i o n t h e r a p y c a n be t r i e d . R e p e t i t i v e o v e r u s e
o f t h e a r t i c u l a r a n d m y o fa s c i a l t i s s u e w i l l r e s p o n d t o t h e
ap p r o p r i a t e co r r e c t i o n o f r e s t i n g a n d w o r k i n g p o s t u r e s
t o g e t h e r w i t h a n e x e r c i s e p ro g r a m a i m e d at b a l a n c i n g t h e
trunk musculature and restoring optimal movement pat
t e r n s . D i l i g e n c e a n d co m m i t m e n t o n t h e p a r t o f t h e
p a t i e n t a n d t h e r a p i s t i s r e q u i r e d t o a c h i e v e s u c c e s s fu l
r e h ab i l i t a t i o n .
146 - Man u a l Therapy For The Thorax
Figure 1 75.
Trunk bracing - level 5. From
the starting position of level
4 , the patient is instructed to
m a i n t a i n the co-contraction
of the t ru n k and s lowly
extend both legs without los
ing trunk contro l .
Figure 1 76.
Trunk control with an unsta
ble base. The patient is
i nstructed to co-contract the
trunk, tighten the b u t tocks
(recr u i t the gl uteus max
imus), press the inner thighs
together (recruit the adduc
tors if there is an unstable
pubic symphysis) and then to
use the hamstrings to l i ft the
trunk off of the table. The l ift
should occur at the scapular
l ev e l and not through the
uns table segment. This exer
cise is p rogressed by i ncreas
i ng the height of the eleva
t i o n . O nce fu l l l i ft is
achieved, the patient is
i nstructed to rol l the ball from
s ide to side w i t h contro l .
Figure 1 77.
Tru n k c o n trol w i t h an u n s t a
ble base. I f t h e pa t i e n t is
u na b l e to l i ft the trun k with
out r e p ro d u c i n g symptoms
the b a s e m a y be a l tered b y
placing t h e pa t i e n t o n a 1/2
ro l l . With t h e trunk b raced , a
vari e t y of e x e r c i s es m a y be
perform e d such as u n i l ateral
or b i l a teral e l ev a t i o n o f the
arms, u n i l ateral or b i l ateral
elev a t i o n of t h e feet or roll ing
a ball w i t h o n e or two fee t .
T h e therapist c a n in crease t he
c h a l l enge by app l y i n g re sis
tance to the stick held
between the pa t i e n t s h a n d s .'
The d i rect i on of the resis

tance is d ic t a t e d by the
p a t i en t ' s needs.
Figure 1 78.
Tru n k control in fo ur p o i n t
knee l i n g . Pro p ri ocep t i o n
from t h e s upport i n g su rface i s
decreased thus i n c r e a s i ng the
diffi c u l t y of the e x e rcise . The
pa t i e n t is i n s t r u cted to find
their n e u t ra l t h o raco l u m b a r
pos i t i o n .
Figure 1 79.
Tru n k control in fo u r p o i n t
k n e e l i ng . The p at ie nt is
i n structed to ma i ntain their
n e u tral t r u n k pos i t i o n and to
s i t back w i t h o u t flex i n g or
' b re a k i n g ' through their
u n s t able regi o n .
Figure 180.
Re-education of the s e g m e n
t a l neutral p o s i t i o n . An u n s t a
b le s egm e n t oft e n re m a i n s
kyphosed w h e n t h e rest o f t h e
vertebral col u m n extends.
Specific e x t e ns i o n exercises
over a ball (ro l l ing fo rward
and backward) t o gethe r w i t h
a 50 Hz m uscle s t i m u l a t i n g
curre n t over t h e i n volved seg
ment can help to res t o r e the
appropr i a t e m o t i o n .
Figure 1 81 .
Trunk control with i ndepen
dent arm movemen t . A p ro
gression to the above exercise
is to i n struct the patient to
u n i laterally ab d u c t or
elevate
one arm while m a i n taining a
stable tru n k .
Figure 182.
Tru n k control w ith indepen
dent arm movement. A fur
ther progression to the above
exercise is to i n struct the
p at ient to l ift one arm for
ward, the other arm backward
and to s pecifica l l y e x tend the
as they roll forward on
tru n k
the bal l . The arm pos i tion is
then reversed as t h e y rol l
back.
150 - Man u a l Th erapy For Th e Thorax
Figure 183.
Taping for p roprio cep t ive
input. When the segmental
myofascia is unable to control
excessive angular or linear
motion, tape can be a useful
temporary rem i nder as to
which movements the p atient
s h o u l d avo id . Flexi o n and
rotation can be controlled but
not preve nted by app l y i ng
tape obliquely across t h e
unstable region.
Figure 1 84.
Tru nk control with i n d epen
dent arm and leg movement.

The patient is instructed to
maintain their neu tral trunk
pos ition and to u n i latera lly
elevate one arm and extend
the opposite leg.
Figure 1 85 .
Tru nk control with indepen
dent a r m and leg movement
on a n unstable base. The dif
ficulty of the above exe rcise
can be increased by decreas
ing t he base of support with
two 1/2 rolls.
Figure 1 86.
Tru n k control - s i tting. The
p a t i e n t is taught to ach ieve a
n e u t r a l t r u n k pos i t i o n while
s i t t i n g o n a bal l . The exercise
is progressed b y having them
move the ball backwards, fo r
wards and sideways while
m a i n t a i n i n g t r u n k contro l .
Figure 188.
Tru n k control - s t a n d i n g . The
patient is i n s t ructed to co
contract the trunk and to
m ove the body w e i g h t for
wards, backwards, s i d ew a y s
a n d arou n d w h i le s t a n d i n g o n
a wobb l e board .
Figure 1 8 7.
Tru n k control - si tting. The
exercise is progressed b y hav
i n g t h e patient s l owly lower
the contro l l ed t ru n k i n to a
supine s u pp o r t e d pos i t i o n
fro m t h e seated posi t i o n . Care
is taken to e n s u re that the
unstable segment does not
fl e x or t r a n s l a te d u r i n g t h i s
exercise.
Figure 1 89.
Tru n k con t rol - s t a n d i n g and
ro t a t i n g . The patient is
i n s tructed t o co-co n t ract the
t r u n k a n d to m o v e t h e body
through ro t a t i o n by turning
around the weight bearing
fem u r . T h i s exercise requi res
control o f the t r u n k and t h e
h i p rotators . Resista nce m a y
be added t hro u g h pu l l ey s o r
res i s ti v e tub i n g .
Figure 1 90.
Tr u n k control - s t a n d i n g a n d
p u s h i n g/pu l l i n g. The p a t i e n t
is i n s tructed to co-con tract
t h e trunk a n d t o push/p u l l a
load by using the l ow e r
extrem i t i e s . Care is taken to
ens ure that the u n s t a b l e seg
ment does not fl e x or translate
d u r i n g t h i s ex erci s e .
Figure 1 9 1 .
Trun k contro l - s t a n d i n g . T h e
p a t i e n t is i nstructed to s t a n d
on a 1 /2 ro l l , to co-contract
the t r u n k and then to u n i later
ally and b i l a t eral l y e l ev a t e
t h e i r arms. T h e exercise can
be progressed by toss i n g a
ball to the p a t i e n t v a r y i n g t h e
speed and t h e d irec t i o n of t h e
t h row .
154 - Manual Therapy For Thorax
REFERENCES
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THERAPY

DIANE LEE BSR MC PA COMP

In the literature pertaining to back pain, the muscul oskeletal com

A biomechanical approach to treatment of the thorax requires an

The clinical investigation began 1990 when Jan Lowcock prc

The chapter reviews anatorny of the thorax as pertains

I would l ike extend gratitude and recognition Mr. Fra n k

British Col umbi a, D.L

MEDICAL MODEL OF C LASSIFICATION 51

MANUAl TIIERAPY MODEL

Passive physiological mobility

Passive stability tests of

HYPOMOBILITY WITH OR WITHOUT PAIN 105

HYPERMOBILITY WITH OR WITHOUT PAIN

Subluxation of the costotransverse and

STABILIZATION THERAPY 143

NORM AL MOBILITY WITH PAI N

The thorax can be divided into four regions according to anatomi

(Fig. 4). Like the zygapophy

The superior aspect of the ver

The manubrium (Fig. 6) is a broad triangular shaped bone which

The vertebrae in th is region (T3 to T7) have long, thin, overlapping

nal orientation of the superior articular processes resists pos

The transverse processes, located at the dorsal aspect of the pedi

tubercle glides inferiorly relative to the transverse process. In the

The posterolateral corners of both the superior and inferior aspects

The n eck of the rib l i es parallel to the transverse process, joined by

The vertebrae in this region (T8, 9, 1 0) differ from the verte

The m ateri a l been previousl y published,

A biomcchanical to the assessment and treatment of

Reference to the l i terature reveals very that is known ab out

Saumarez8 noted that there can be considerable independent move

To facilitate the subsequent discussion, the terminology used

Flexion Anterior Translation

axis, traction/compression along a vertical axis, and anteroposteri

Arthrokinematics 12 refers to the study of motion of joints regard

Flexion of the thoracic vertebrae occurs during forward bending of

During forward bending of the mobile thorax, forward sagittal

Arthrokinematically, the inferior facets of the superior thoracic

In the vertebrosternal region of the thorax, the anterior rotation of

tubercle results in anterior rotation of the neck of the rib. Once

In the vertebrochondral region of the thorax (T8 - T10) the costo

exhausted, the thoracic vertebrae continue to flex o n the stationary

the vertebrochondral region 33), the facets of costo-

of the ligaments posterior to including the posterior half

Extension of the thoracic vertebrae occurs during backward bend

The osteokinematic motion of the ribs that occurs during backward

Extension Posterior Translation

During extension of the mobile thorax, backward sagittal rotation

Arthrokinem atically, the i nferior facets of the superior thoracic

plane. The inferior motion of the inferior articular processes fol

In the vertebrosternal region of the thorax, the posterior rotation of

In the vertebrochondral region of the thorax (T8 - Tl0) the costo

tinue to extend on the stationary ribs (Figs. 38 , 39). The arthrokine

All of the l igaments anterior to and including the posterior longi

tribution of each to st a b i l i ty in extension . In ex t en sion they found

Right Sideflexion Right Tra n s l ation

Lee 5 , 6 with perm ission.

Sideflexion of the thoracic vertebrae occurs during lateral bending

It is i n teresting t o postulate on what produces this coupling o f

Clinical hypoth esis

stops fi r s t , the thoracic verte

In the vertebrosternal region (T3 to T7), this slight increase i n r ight