Thoracic and Ribs Somatic Dysfunction Lecture Flashcards
Thoracic Spine Introduction
- The Thoracic Region is the Central connection both the Cervical and Lumbar Spines, as well as the Upper Extremities and Thoracic Cage
- Diagnosis and treatment of the Thoracic Spine is INTERDEPENDENT with these Regions, and should NOT BE CONSIDERED separately in the evaluation of a patient with Thoracic Complaints!!!
Heart and Lungs
- Heart and Lungs are located in the THORACIC CAGE
- Problems with the Thoracic Cage can be signs of LIFE THREATENING PROBLEMS
- Optimal movement of the Thoracic Cage is necessary for Normal Function (Lymphatics, Involves over 100 Joints)
Sympathetic Nervous System
- Much of the Sympathetic Nervous System outflow arises from the Thoracic Spine
- Can MIMIC Life-Threatening Problems
Thoracic Anatomy
- 12 Thoracic Spinal vertebrae
- 12 Pairs of Ribs
- Sternum
- The clavicle and the Scapula are often involved in Thoracic injuries and pain Syndromes, but are properly considered a part of the upper extremity
Sternum
3 parts:
1) Head/ Manubrium
- Articulates with the Clavicles
2) Body/ Gladiolus
- Joined to the Manubrium at the Sternal Angle or ANGLE OF LOUIS
3) Tail/ Xiphoid
- Small portion at the INFERIOR ASPECT of the Sternum
Thoracic Vertebrae
- Divided into three Anatomic Regions:
1) Upper (T1-4)
2) Middle (T5-8)
3) Lower (T9-12)
Rules of Three
T1-3:
- Spinous process is on the same level as the Vertebrae
T4-6:
- Spinous process is have way down to the Vertebrae under
T7-9:
- Spinous process as at the Vertebrae below
T10:
- Same as T7-9
T11:
- Same as T4-6
T12:
- Same as T1-3
Thoracic Spine and SYmpathetics
- Osteopathic physicians often utilize the Function Division
- VISCERAL AFFERENT (Usually Nociceptive) NEURONA follow the Same Pathway as the SYMPATHETICS
- Visceral disturbances often cause INCREASED MUSCULOSKELETAL TENSION in Somatic Structures INNERVATED from the corresponding Spinal Level
- OMT can reduce Somatic Afferent Input, which REDUCES SOMATOSYMPATHETIC activity to the Organ
Thoracic Vertebrae
Four FUNCTIONAL DIVISIONS
1) T1-4: Sympathetics to the HEAD and NECK
- T1-6 INNERVATES the HEART and LUNGS
2) T5-9: Sympathetics to the UPPER ABDOMINAL VISCERA
- Stomach, Duodenum, Liver, Gall Bladder, Pancreas, and Spleen
3) T10- 11: Sympathetics to most of the LOWER ABDOMINAL Viscera
- Remainder of the Small Intestine, and Kidney, Ureters, Gonads, and Right Colon
4) T12-L2: Sympathetics to the REMAINDER of the LOWER ABDOMINAL Viscera
- Left Colon and PELVIC Organs
Thoracic Biomechanics
1) The motion capabilities in the Thoracic Spine is generally LESS THAN the Cervical and Lumbar Spine
- Spinal motions follow FRYETTE’s PRINCIPLES of Spinal Motion
- Costal Cage mechanics affect all planes of Motion
2) General Body shapes and movement are also affected by Growth, Aging, and Lifestyle Factors
- Adaptations to Work, Athletics, Postural decompensation
- Changes in one area affect motion in other areas
Thoracic Biomechanics Cont
Abnormalities affection Motion (AP)
- Kyphosis
- Costal Cage Symmetries (Pectus Excavatum and Carinatum)
- Osteoarthritis or Osteoporosis
- Cardiopulmonary conditions INCREASING Chest Wall Diameter
- Postural Problems
- Cervical and Shoulder Influences
Thoracic Biomechanics
Wolff’s Law
- Bones and soft tissues deform (are strained) according to the stresses (forces applied over an area) that are placed on them
- Scoliosis, Kyphosis, Arthritides, Leg length inequalities
Thoracic Biomechanics
Flexion and Extension
FLEXION is GREATER THAN Extension
- Due to the normal Kyphotic curvature and Gravity
- Rotation is Greater in the Upper and Middle portions (Second only to the Atlantoaxial Joint, AA Joint)
- Lower Thoracic spine moves similar to the Lumbar Spine
Thoracic Biomechanics
Sidebending
- SIDEBENDING is limited by the RIB CAGE
- Abnormalities affecting motion (Latera)
1) Scoliosis +/- Kyphosis
2) Upper and Lower Motor Neuron lesions
3) Repetitive motion activity effects
- tethering affect of Myofascial Tissues
Thoracic Biomechanics
General
- Tendency towards Spinal Flexion
- Gravity, Posture, etc
- Small muscles of the back are often involved in Postural Stress
- Often responsible for maintaining Non-neutral and Neutral Somatic Dysfunction of the Vertebral Units
Thoracic Biomechanics
Dysfunctions
- Spinal dysfunctions result from many things
1) Neurological pathological conditions
2) Trauma
3) Visceral Disease
4) Intrinsic mechanical Asymmetries
5) Chronic asymmetric motions or activities
The Ribs
- 12 sets of Ribs correspond to the Thoracic Vertebrae
- Bony rib connected to the Thoracic Vertebrae at the Costovertebral Articulations
- 2 through 9 articulate with Vertebrae ABOVE and BELOW
- 1, 10 though 12 have UNIFACETS that Articulate with the corresponding Vertebrae ONLY!!!!!!!
Landmarks
1) Rib One
- Anteriorly attaches INFERIOR to Clavicle
- Posteriorly attaches CEPHALAD to BODER of SCAPULA
2) Rib Two
- Anteriorly articulates with MANUBRIUM and Body of STERNUM
3) Rib Three
- Posteriorly at the level of SCAPULAR SPINE
4) Rib Seven
- Anteriorly attaches at XIPHISTERNAL JUNCTION
-Posteriorly at level of INFERIOR ANGLE of Scapula
5) Rib Ten
- Cartilage at lowest part of THORACIC Cafe at MIDCLAVICULAR LINE
Typical Ribs: Ribs 2-9
- Head, neck, tubercle, body is thin and flat
- Head has TWO FACETS (Body of same for body above)
- COSTOVERTEBRAL ARTICULATION*
- Tubercle articulates with TRANSVERSE PROCESS
- COSTOTRANSVERSE ARTICULATION***
Atypical Ribs: Ribs 1, 10-12
Rib ONE:
- Flattest, shortest in length, greatest curve
- Subclavian Groove: Superior Surface
- Head articulates with T1 ONLY!!!!!!
Rib TEN:
- Articulates with T10 ONLY!!!!
Rib ELEVEN and TWELVE:
- No neck or Tubercles, articulates with associated Vertebra, 12 (NO COSTAL GROOVE)
Costovertebral Joint
- Vertebral Body (same level nd one above)
- Vertebral Disc (ANNULUS FIBROSIS)
- Facets
- Ligaments
a) Radiate
b) Interosseous
Costotransverse Joint
- Tubercle and Transverse process
- Ligaments:
a) Superior, Lateral, Intertransverse, and Costotransverse
b) Superior ligament connects TRANSVERSE PROCESS to Next LOWER RIB!!!!
Muscles of Respiration
INHALATION:
a) Intercostals (Particularly the Externals)
b) Diaphragm
- Crura anchor at L1,2,3
- Attachments to Lower Ribs and Sternum
EXHALATION:
a) Rectus Abdominus
b) Internal and External Oblique
c) Transverse Abdominus
Accessory Muscels of Respiration
INHALATION:
a) Sternocleidomastoid
b) Scalenes
EXHALATION:
a) Passive Recoil
b) Abdominal Muscles contribute
Effects of Respiration
- Elevation fo Sternum
- Elevation of Ribs
- Increase Transverse, Superior/ Inferior and Anterior/ Inferior Diameter
- Ribs move in THREE MOTION PATTERNS
Respiratory Motions of Ribs
1) PUMP HANDLE Motion
- Analogous to Flexion/ Extension
- Rib moves ANTEIRIORLY
- Increase in A/P Diameter
- Rib 1 has 50% PUMP HANDLE!!!!!!!!!!!
- Ribs 2 to 6 Predominantly PUMP HANDLE!
2) BUCKET HANDLE MOTION
- Analogous to Abduction/ Adduction
- Rib moves LATERALLY
- Increase TRANSVERSE DIAMETER
- Rib 1 is 50%!!!!!!
- Rib 7 to 10 Predominantly BUCKEY HANDLE!!!
3) CALIPER MOTIONS
- Analogous to Internal and External Rotation
- Pivoting Motion (No Anterior Attachment)
- Ribs 11 and 12!!!!!!!!!!
Respiratory Research in OMM
A.J. MURPHY
- A.J. MURPHY looked at PULMONARY FUNCTION and OMM
- Found an INCREASE in TIDAL VOLUME and RESPIRATORY RATE after Treatment
- Found an INCREASE in LUNG PERFUSION after Treatment
- INCREASE in Gas Exchange (Oxygen, CO2, Nitrogen)
Respiratory Research in OMM
DORAN
- Doran looked at RESPIRATOR FUNCTION and LUMBAR LORDOSIS
- Found that Treatment DECREASED LORDOSIS and INCREASED TIDAL VOLUME
- Found INCREASE of Abdominal component to RESPIRATION after Treatment
Harmonics Mechanics
- Respiration requires SMOOTH FUNCTION
- Dysfunction to any component
a) DECREASE in Chest Wall Expansion
b) DECREASE in Oxygenation
c) INCREASED risk of ATELECTASIS
- Visceral function of Chest
a) Refer to SOMA (BODY)
Trauma
1) CHEST WALL CONTUSION
- Air bags
- Seatbelt (Shoulder Harness)
2) RIB FRACTURES
- Decrease Chest expansion due to Pain
- Increase Risk of Infection
- NO RIB BELTS
Costochondritis
- Inflammation of COSTOCHONDRAL JUNCTION
- Unable to put area to Rest (REsp Rate 14/ min = 20,160 Resp Cycles/ Day)
- Pin point tenderness at area involved
- Pain increased with LARGE INHALATION
- Treatment:
a) NSAIDS
b) OMM (Ribs, Thoracic, Sternum, Lymphatics)
Pneumonia
- Viscerosomatic Reflex at T2-4
- Cough (Productive or Non-productive)
a) Rib Dysfunction
b) Lumbar Dysfunction (Crura L1,2,3)
c) Thoracic Dysfunction - Treatment (Lymphatics to Area One)
- QUADRATUS LUMBORUM*
- Functionally an Extension of Diaphragm
- Trigger points/ spasm effects quality of Diaphragm Excursion (DECREASE Lymph Pumping Action)
Iatrogenic Causes
1) Thoracotomy
- Lobectomy
2) Sternotomy
- Coronary Bypass Grafting
3) Effects are locally and produce Compensatory changes elsewhere
Metabolic Causes
OSTEOPOROSIS
- Decrease Strength to Matrix
- Fractures easily
- Use caution with some techniques (Some Contraindicated)
Metastatic Disease
Common site for Metastasis
- Breast
- Prostate
- Lung
Summary
- Smooth Functional Excursion of the Chest Wall is dependent on Proper Mechanics of Thoracic Spine, Ribs, Sternum, and Clavicles
- Area of Dysfunction have effect on Respiration and Lymphatics
- May expand to Body Physiology as a whole
