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4/19/2016
1
“Why do the cervical and lumbar
spine get all the glory?” Rehab concepts for the thoracic spine
and sacroiliac joints
Hugo Klaers, PT, DPT
&
Shannon Kelly, PT, DPT
Objectives
• Define the concept of regional interdependence as it applies to spinal pathology and treatment
• Describe the treatment of thoracic spine as it relates to cervical, shoulder, and lumbar dysfunctions
• Review the physical therapy examination of the thoracic spine and SIJ
• Demonstrate manual therapy techniques for the thoracic spine and the SIJ
• Describe application and progression of exercises for the thoracic spine and SIJ
• Apply “sling stabilization” concepts to the SIJ
Incidence of thoracic conditions
• Thoracic spine dysfunction: rare
compared to cervical and lumbar
• Thoracic spine
dysfunction is treated
effectively with manual
therapy techniques
Incidence of thoracic conditions
• Often looked at as an isolated structure
• However, the role of
the thoracic spine is
not typically recognized
in cases of cervical,
shoulder, or lumbar
dysfunction
Regional interdependence
“With respect to musculoskeletal problems, regional
interdependence refers to the concept that seemingly
unrelated impairments in a remote anatomical region
may contribute to, or be associated with, the patient’s
primary complaint.”
~Robert Wainner, PT, PhD, FAAOMPT
Wainner et al, 2007
What it is NOT…
• Treating the source of
radiating/referred pain
• Ignoring the primary
region of complaint
6
What it IS…
• Looking up & down the
kinematic chain
• For neck, shoulder,
and back complaints:
Consider contributions
from the thoracic spine
Regional interdependence
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Biomechanics of t-spine and cervical motion
• Cervical rotation includes segmental
motion through T4 (Sizer et al, 2007)
• T1-4 demonstrate primarily axial rotation (White et al, 1990)
• Same coupling pattern as lower C-spine (White et al, 1990)
• Unilateral sagittal and scapular plane
shoulder elevation (Theodoridis & Ruston, 2002)
• T2-7 segments demonstrated: • Ipsilateral sidebend and rotation coupling
• Extension
• Bilateral shoulder elevation includes thoracic
extension (Edmondston, 2012)
• Bilateral elevation 12.8° thoracic ext
from T3-T11
Biomechanics of t-spine and shoulder motion
• Thoracolumbar junction shows blended
anatomy
• T11-12 demonstrate primarily flexion-
extension, same coupling pattern as L-spine (White et al, 1990)
• Thoracolumbar spine: “principal load-
bearing structure of the body”(Resnick et al, 1997)
Biomechanics of t-spine and lumbar motion
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Examination
Examination
• Posture
Examination
• Posture
• Mobility
•AROM, segmental
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Segmental Mobility Examination
• Posture
• Mobility
• AROM, segmental
•Layers
•Osseous
–Kemp’s test
Examination
• Posture
• Mobility
• AROM, segmental
•Layers
•Osseous
• Inert
–Neural tension, disc,
capsule, ligamentous
Examination
• Posture
• Mobility
• AROM, segmental
•Layers
•Osseous
• Inert
•Contractile
–Resisted isometrics
–Strength
Particular emphasis on
mid/low trap
Core
Examination
• Posture
• Mobility
• AROM, segmental
•Layers
•Osseous
• Inert
•Contractile
•Neuro-mechanical
THE SACROILIAC JOINT
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The Plan… • Rings: remember the anatomy of the pelvis is
a ring, engage the ligaments via the muscles
• Slings: Utilize the muscular slings to improve the stability of the SI joint
• Other things: Address joint and soft tissue issues via manipulations and mobilizations
In 200 patients with low back pain complaints: • 10 found to have solely SIJ pathology • 29 found to have SIJ involvement in
combination with lumbar &/or hip
PT Eval: Consider the Lumbar Spine
• Differential diagnoses for the low back: Posterior facet joint, nerve root irritation, discogenic pain, spondylolisthesis
Lumbar Screen:
Range of motion
Repeated motions into flexion/extension
PT Eval: Consider the Hip
• Morgan et al. 2013 – 76% of subjects
presenting with SIJ pain also had radiographic evidence of FAI
• Cibulka et al. 2002 – Evaluated hip ROM in
patients with LBP
– Hip ER/IR ROM values differed in those with SIJ involvement
– A hip screen can help rule in SIJ involvement
Physical Therapy Examination
Looking for the pattern • Subjective:
– Unilateral pain
– Inferior to PSIS
– Pain into the buttock
– Preceded by sudden episodic joint stress/trauma
OR
– Preceded by cumulative/repetitive joint stresses
• Objective:
– Provocation testing to reproduce patient’s primary pain and indicate the SIJ as the pain generator
– Strength
– Motor control assessment
Palpation Based Testing
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Active Straight Leg Raise Pain Provocation Testing
Clinical Prediction Rule
• Laslett et al. 2008
• Patients with LBP have >70% probability of having primary SIJ pain involvement with the presence of:
– Three or more positive SIJ provocation tests
– Centralization of pain is not achieved during a McKenzie evaluation of repeated movements and sustained positions
At the End of the Evaluation…
• Lumbar Spine Involvement: RULED OUT
• Hip Involvement: RULED OUT
• POSITIVE SIJ Provocation Tests
NOW WHAT??
LAB
Treatment Approach
Manual Therapy
Therapeutic Exercise
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Thoracic Rx for Cervical Dysfunction
• Manipulation group better on NDI and NPRS (50.5% and 58.5%) vs. mob group (12.8% and 12.6%)
• C1-2 PROM and craniocervical flexor performance also better in thrust group
• NNT = 1.8-2.3
Dunning et al, 2012
n = 107
Thoracic Rx for Cervical Dysfunction
• Experimental group significantly better on NPRS and NDI
• 31/33 (94%) vs. 11/31 (35%) had GROC of +4 or higher
• NNT = 2
Masaracchio et al, 2013
n = 64
Thoracic Rx for Cervical Dysfunction
1.) Sx’s <30 days
2.) No sx’s distal to shoulder
3.) Looking up does not aggravate
4.) FABQ-PA <12
5.) Diminished upper thoracic kyphosis (T3-T5)
6.) Cervical extension ROM <30°
3/6 present increased probability of success from 54% to 86%
Cleland et al, 2007
Thoracic Rx for Shoulder Dysfunction
• 14% increase in manipulation group vs. 3% in placebo group
• Low trap inhibition secondary to extension limitations T8-T12 (Flynn, 2006)
Cleland et al, 2004
n = 40
Thoracic Rx for Shoulder Dysfunction
• Less pain during: – Neer
– Hawkin’s-Kennedy
– Resisted empty can, ER, IR
– Active ABD
• Improved SPADI
Boyles et al, 2009
n = 56
Thoracic Rx for Shoulder Dysfunction
• No changes in ROM or scap kinematics
• EMG: small, significant increase in middle trap activity
• ***Less pain with impingement tests & flexion AROM
• ***Improved shoulder function
Muth et al, 2012
n = 30
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Thoracic Rx for Lumbar Dysfunction
• Both groups improved NPRS, no sig diff
between groups
• T-manipulation group improved PPT
significantly
Fernando de Oliveira et al, 2013
n = 148
- NDI, NPRS improve with addition of thoracic manipulation to cervical mobilizations
- Manipulation shows better improvements that mobilization
- Can also improve C1-C2 PROM and craniocervical flexor performance
- Thoracic manipulation results in:
• Increased activation of low and mid trap
• Decreased pain with Neer, HK, resisted empty can/ER/IR, active ABD and flexion
• Improved SPADI scores
- Similar decrease in pain regardless of whether lumbar manipulation or thoracic manipulation is performed
- Thoracic manipulation increases pain pressure threshold
Why does manipulation work?
• Biomechanical: Regional interdependence (Wainner et al, 2007; Cleland et al, 2005)
• Neurophysiological
• Stimulation of descending inhibitory
mechanisms (Sparks et al, 2013; Cleland et al, 2005)
• Change in pain modulation via biochemical
response (Plaza-Manzano et al, 2014)
• Stimulation of ANS/DRG’s???
• Placebo??? (Kardouni et al, 2014)
Two Key Elements
Therapeutic Exercise
Manual Therapy
Therapeutic Exercise
Mobility Strength
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Thoracic Ex’s - Mobility
Egan et al, 2011
Mobility
Egan et al, 2011
Mobility Mobility
Mobility Mobility
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Mobility Mobility
Mobility Mobility
Thoracic Ex’s - Strength Strength
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Strength Strength
Mobility & Strength Mobility & Strength
Mobility & Strength Mobility & Strength
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LAB
THE SACROILIAC JOINT: RINGS
Anatomy: Bones
• Part of three different mechanical chains – LE Chain: sacrum,
innominate, lower extremity
– Spine Chain: L4/L5/Sacrum
– Pelvic Chain:
• Picture to demonstrate
Innominate/Sacrum/Innominate
• Form closure
Anatomy: Anterior Ligaments
• Sacrospinous ligament – Blends into the hamstrings
• Iliolumbar ligament
– Blends into quadratus lumborum, erector spinae and multifidi
• Anterior sacroiliac ligament
Anatomy: Posterior Ligaments
• Sacrotuberous ligament – Blends into the hamstrings
• Long dorsal ligament
• Posterior sacroiliac ligaments
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A Common Question: Does it Move?
• Minute amounts of rotation and translation – Goode A. et al. Three-Dimensional Movements of the Sacroiliac Joint:
A Systematic Review of the Literature and Assessment of Clinical Utility. J Man Manip Ther.2008, 16(1):25-38
• The SI joint adapts throughout the life span – Bowen V, Cassidy, JD. Macroscopic anatomy of the sacroiliac joint from
embryonic life until the eighth decade. Spine. 1981, 6: 620-628
• Ossification of ligaments leading to increased stiffness – Rosatelli AL, Agur AM, Chhaya S. Anatomy of the Interosseous Reigon
of the Sacroiliac Joint. J Orthop Sports Phys Ther. April 2006; 36(4):200-208
THE SACROILIAC JOINT: SLINGS
• Form closure
• Force closure
Anatomy Review: Anterior Muscles
Anatomy Review: Posterior Muscles
• Two muscle systems that influence the sacroiliac joint
– Deep muscle system
– Superficial muscle system
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Deep Muscle System • These are the muscle that are most commonly
thought of as stabilizing muscle
• This is the cylinder:
– Top: Diaphragm
– Bottom: Pelvic Floor
– Sides: TrA, IO, Multifidi (Snijders et al, Liebenson et al)
Deep Muscle System
• Supine
• Hooklying
• Prone
• Quadruped
Superficial Muscle System
1. Posterior oblique sling
2. Anterior oblique sling
3. Longitudinal sling
4. Lateral sling
#1 Posterior oblique sling • Muscles involved:
– Latissimus Dorsi – Contralateral Gluteus
Maximus • Mooney et al. (2001)
– 15 healthy subjects: reciprocal relationship between latissimus and glut max.
– Patients with SI pain showed increased activity of the gluteus on the involved side
Posterior Oblique Sling Exercises Posterior Oblique Sling Exercises
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Posterior Oblique Sling Exercises Posterior Oblique Sling Exercises
Posterior Oblique Sling Exercises Posterior Oblique Sling Exercises
#2 Anterior Oblique Sling
• Muscles involved:
– External oblique
– Transverse abdominus
– Contralateral internal oblique
– Contralateral adductors
• Attach through the abdominal sheath on the anterior aspect
Anterior Oblique Sling Exercises
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Anterior Oblique Sling Exercises Anterior Oblique Sling Exercises
Anterior Oblique Sling Exercises
#3 Longitudinal Sling
• Muscles involved:
– Thoracolumbar fascia
– Erector spinae
– Multifidi
– Hamstrings
Longitudinal Sling Exercises Longitudinal Sling Exercises
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#4 Lateral Sling
• Muscles involved:
– Hip abductors
– Internal Oblique
– Contralateral quadratus lumborum
Lateral Sling Exercises
Lateral Sling Exercises Lateral Sling Exercises
ADD FULL SIDE PLANK PIC
Combinations
• At this point in working the different slings, you are only limited by your imagination
• Combine different movements to activate different slings and different muscle groups
• Train muscles to work together and in unison
Tensioning the ligaments
• Utilizing the ligaments to increase the stability of the joints
• Done via the muscular and fascial attachments
– Sacrotuberous and Biceps Femoris
• Van Wingerden et al. (1993)
– Long Dorsal Ligament and Erector Spinae and TLF
• Vleeming et al. (1996)
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OTHER THINGS
The Hamstrings & Gluteus Maximus
• Vleeming et al (2012) discussed the hamstrings’ pull on the pelvis
• Arab et al (2011) investigated the relationship between hamstring length and gluteal muscle strength
– Tightness in the hamstrings seen in conjunction with gluteal weakness
– Clinical takeaway: don’t stretch the hamstrings without strengthening the gluteals
The Hamstrings & Gluteus Maximus
• Hungerford et al (2003) used EMG to record hip and trunk muscles activation in those with SIJ pain compared to those without
– Clinical takeaway: timing is key for stability, getting the right muscles to fire at the right time
• Hoissen and Nokes (2008) identified poor gluteus activation during gait in a subject with SIJ pain
MANIPULATIONS
MOBILIZATIONS
SOFT TISSUE
MANUAL THERAPY
• Tullberg et al (1998) showed that a manipulation did not alter the position of the joint
– The subjects did report decreased pain
• Kamali and Shorkri (2011) provided lumbar and SIJ manipulations and showed decreased pain
• Cibulka et al (1988) created bilateral innominate rotation with a manipulative technique
– Pain was not assessed in these subjects
Is SIJ Manipulation Beneficial? Sacroiliac Joint Manipulation
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Sacroiliac Joint Mobilizations
Soft Tissue Manual Therapy
• Iliopsoas
• Piriformis
• Tensor fascia lata
• Lumbar paraspinals Adductors
• Gluteus medius
• Quadratus lumborum
STABILIZATION BELTS
TAPING TECHNIQUES
ALTERNATIVE OPTIONS
Stabilization Belts
• Recommended wear time will vary from patient to patient
• Can perform stabilization exercises with the belt on
Taping Techniques
• Kinesiotape
• Leukotape
LAB
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Summary
Principles of PT Management
Summary thoughts • Rings: remember the anatomy of the pelvis as
a ring, engage the ligaments via the muscles
• Slings: Utilize the muscular slings to improve the stability of the SI joint
• Other things: Address joint and soft tissue issues via manipulations and mobilizations
Principles of PT Management
• REGION SPECIFIC TREATMENTS!!!
Cervical
๏Manual traction
๏Segmental mobility
๏Cervical flexor endurance
๏STM
Lumbar
๏Directional preference
๏Axial separation
๏Core stab
Principles of PT Management
• REGION SPECIFIC TREATMENTS!!!
Principles of PT Management
• REGION SPECIFIC TREATMENTS!!!
• Manual therapy techniques - manipulation,
mobilization
• Neuromuscular re-ed
• Emphasis on thoracic extension and rotation
• Strengthen
• Periscapular & postural musculature
• Heavy emphasis on mid/low trap!!!
Thoracic References
1. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in
the treatment of musculoskeletal pain: a comprehensive model. Manual Ther. 2008;doi:10.1016/j.math.2008.09.001.
2. Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moore JH, et al. The short-term effects of
thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Manual Ther.
2009;14:375-380.
3. Cleland J, Selleck B, Stowell T, Browne L, Alberini S, St. Cyr H, et al. Short-term effects of thoracic
manipulation on lower trapezius muscle strength. J Man Manip Ther. 2004;12:82-90.
4. Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T. Immediate effects of thoracic manipulation in
patients with neck pain: a randomized controlled trial. Manual Ther. 2005;10:127-135.
5. Cleland JA, et al. Development of a clinical prediction rule for guiding treatment of a subgroup of
patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Phys
Ther. 2007; 87:9-23.
6. Dunning JR, Cleland JA, Waldrop MA, Arnot C, Young I, Turner M, et al. Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: a
multicenter randomized controlled trial. J Orthop Sports Phys Ther. 2012;42:5-18.
4/19/2016
20
Thoracic References
7.Edmondston S, Ferguson A, Ippersiel P, Ronningen L, Sodeland S, Barclay L. Clinical and
radiological investigation of thoracic spine extension motion during bilateral arm elevation. J Orthop Sports Phys Ther. 2012;42:861-869.
8.Egan W, Burns S, Flynn TW, Ojha H. The Thoracic Spine and Rib Cage: Physical Therapy Patient Management Utilizing Current Evidence. In: Hughes C, ed. Current Concepts of Orthopaedic
Physical Therapy, 3rd edition. La Crosse, Wisc: Orthopaedic Section, APTA; 2011:1-33.
9.Fernando de Oliveira R, Liebano RE, da Cunha Menezes Costa L, Rissato LL, Costa LOP.
Immediate effects of region-specific and non-region-specific spinal manipulative therapy in patients
with chronic low back pain: a randomized controlled trial. Phys Ther. 2013;93:748-756.
10.Flynn TW. Thoracic spine and rib cage dysfunction. In: Placzek JD, Boyce DA, eds. Orthopaedic
Physical Therapy Secrets. St. Louis, Mo: Elsevier Mosby; 2006: 484.
11.Kardouni JR, Shaffer SW, Pidcoe PE, Finucane SD, Cheatham SA, Michener LA. Immediate
changes in pressure pain sensitivity after thoracic spinal manipulative therapy in patients with
subacromial impingement syndrome: a randomized controlled study. Manual Ther. 2014;xxx:1-7.
12.Masarrachio M, Cleland J, Hellman M, Hagins M. Short-term combined effects of thoracic spine
thrust manipulation and cervical spine nonthrust manipulation in individuals with mechanical neck pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2013;43:118-127.
13.Muth S, Barbe MF, Lauer R, McClure P. The effects of thoracic spine manipulation in subjects with
signs of rotator cuff tendinopathy. J Orthop Sports Phys Ther. 2012;42:1005-1016.
Thoracic References
14.Plaza-Manzano G, Molina F, Lomas-Vega R, Martínez-Amat A, Achalandabaso A, Hita-Contreras F.
Changes in biomechanical markers of pain perception and stress response after spinal manipulation. J Orthop Sports Phys Ther. 2014;44:231-239.
15.Resnick DK, Well SJ, Benzel EC. Biomechanics of the thoracolumbar spine. Neurosurg Clin N Am. 1997;8:455.
16.Sizer PS, Brismée JM, Cook CE. Coupling behavior of the thoracic spine: a systematic review of the
literature. J Manipulative Physiol Ther. 2007;30:390-399.
17.Sparks C, Cleland JA, Elliott JM, Zagardo M, Liu WC. Using functional magnetic resonance imaging
to determine if cerebral hemodynamic responses to pain change following thoracic spine thrust
manipulation in healthy individuals. J Orthop Sports Phys Ther. 2013;43:340-348.
18.Theodoridis D, Ruston S. The effect of shoulder movements on thoracic spine 3D motion. Clin
Biomech. 2002;17:418-421.
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examination model whose time has come. J Orthop Sports Phys Ther. 2007;37:658-660.
20.White AA, Panjabi MM. Clinical Biomechanics of the Spine, 2nd Ed. Philadelphia, Pa: JB Lippincott;
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• Van Wingerden, JP, Vleeming, A, Snijders CJ et al. A functional-anatomical approach to the spine-pelvis mechanism: interaction between the biceps femoris muscle and the sacrotuberous ligament. Eur Spine J, 1993 Octl 2(3): 140-4
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