Ribs & Thoracic Segments Evaluation by Jerry Hesch, MHS, PT
Evaluation & Treatment of First Rib Movement Dysfunction: Much More Than Just Elevation
Contrary to popular seminars and writing, the mechanics of the first rib are much more complicated. In essennce you need to evaluate anteriorly through the clavicle which over shadows the anterior first rib. You have to evaluate laterally, and posteriorly. It angulates at about a 35-45 degree angle, uniquely different than the other rib joints as it joins the transverse process, vertebral body of T1. It often acts like a cam, hinging T1, interfering with successful mobilization to reduce a T1 rotational restriction. Important motions to evaluate and restore are superior glide, inferior glide, anterior and posterior glide, anteromedial glide and anterolateral glide, and lateral glide, as well as lateral inferior glide. Sometimes it is much easier to resolve faulty mechanics of the C7-T1 joints and the costoclavicular after addressing the first rib thoroughly.
Jerry Hesch
Jerry Hesch
RE Diagnosis: T4 Syndrome by Marquand B in PT Magazine
Dear Editor,
In response to the well written article titled Diagnosis: T4 Syndrome by Barbara Marquand (January 18, 2010), I have a few comments regarding thoracic (T-spine) mobilization and manipulation. Whether unilateral or bilateral restrictions in the thoracic spine are treated, there is always one other important consideration that rarely makes it to print. That is, the inextricable mechanical link between the ribs and the thoracic spine. The costocorporal and costotransverse joints act as long levers on the T-spine, and the opposite is also true. There is dense connective tissue connecting the ribs and T-spine, thus any mobilization or manipulation of the T-spine should also address the rib joints. If the ribs have restricted motion, they may require direct treatment with sustained creep, as opposed to a Grade V quick thrust.
The sympathetic chain is attached to the heads of the ribs, and thus a mechanical dysfunction can have a direct influence on the sympathetic chain. One other consideration is the fact that any T-spine segment that is restricted in flexion or extension will, over time, induce a restriction in a segment further up the chain; specifically, in the cervical spine. The secondary restriction is compensatory, thus it ocurrs in the opposite direction. Treating the foundational T-spine dysfunction can in fact reflexively or biomechanically release the compensatory cervical restriction. This is a frequent clinical phenomenon. These are additional explanations as to why thoracic manipulation sometimes reduces cervicogenic headache.
Thank you for letting me share these additional thoughts.
In response to the well written article titled Diagnosis: T4 Syndrome by Barbara Marquand (January 18, 2010), I have a few comments regarding thoracic (T-spine) mobilization and manipulation. Whether unilateral or bilateral restrictions in the thoracic spine are treated, there is always one other important consideration that rarely makes it to print. That is, the inextricable mechanical link between the ribs and the thoracic spine. The costocorporal and costotransverse joints act as long levers on the T-spine, and the opposite is also true. There is dense connective tissue connecting the ribs and T-spine, thus any mobilization or manipulation of the T-spine should also address the rib joints. If the ribs have restricted motion, they may require direct treatment with sustained creep, as opposed to a Grade V quick thrust.
The sympathetic chain is attached to the heads of the ribs, and thus a mechanical dysfunction can have a direct influence on the sympathetic chain. One other consideration is the fact that any T-spine segment that is restricted in flexion or extension will, over time, induce a restriction in a segment further up the chain; specifically, in the cervical spine. The secondary restriction is compensatory, thus it ocurrs in the opposite direction. Treating the foundational T-spine dysfunction can in fact reflexively or biomechanically release the compensatory cervical restriction. This is a frequent clinical phenomenon. These are additional explanations as to why thoracic manipulation sometimes reduces cervicogenic headache.
Thank you for letting me share these additional thoughts.
Letter to the Editor: 3rd Rib, T2 & T3
See commentary: (non published) submitted October 2008 Dear Editor,
RE: Krauss J, Creighton D, Ely J. D., Podlewska-Ely J. The Immediate Effects of Upper Thoracic Translatoric Spinal Manipulation on Cervical Pain and Range of Motion: A Randomized Clinical Trial. J Man & Manip Ther 2008: 16(2):93-99.
The recent article provoked some thoughts I would like to share. The authors are to be commended for adding to the knowledge base by showing pain reduction and motion gains, in clients with cervical pain treated with thoracic manipulation. This is an important relationship and this study, along with other similar ones, should guide contemporary practice. In the discussion section the authors mentioned several ideas for future studies on the same topic. I would like to add to that list. The relationship of the costal joints to thoracic and cervical spinal motion might be appropriate for inclusion in future studies. A few unknowns being: what is the pre-treatment mobility of the ribs that articulate with the thoracic segments that are being manipulated, and do these rib joints contribute to motion restriction of the thoracic and cervical segments? I would submit that there are times in which a restriction of rib mobility is released as a co-treatment effect when the relevant thoracic segment is manipulated. Other times, the rib joints may require separate treatment. The costo-transverse and costo-corporal joints are very close to the thoracic facet joints, particularly at the 3rd thoracic segment. They are inextricably linked to thoracic movement. While the thoracic facets respond well to manipulation, it is my opinion that the rib joints do not, but rather; they respond optimally to lesser forces over a greater span of time (creep). For example, upon taking up the slack, pressure is maintained against a movement barrier for 2 minutes or more. This of course is not described in the 5-point joint mobilization scale, yet is a valid theoretical technique, based on viscoelastic principles of connective tissue. While studies do have to limit their focus, it seems relevant to mention the relationship of costal segmental mobility to thoracic segmental mobility, especially as published studies such as this one do contribute to the guidance of clinical practice. As stated earlier, the authors might be influencing rib joint mobility, and therefore, pre and post assessment of rib mobility may be informative, and provide an additional treatment option.
Thank you very much.
Sincerely Yours,
Jerry Hesch, MHS, PT
[email protected]
Recent articles support thoracic spine manipulation for clients with cervical pain and movement dysfunction. Here are a few:
http://www.ncbi.nlm.nih.gov/pubmed/18692428?
http://www.jospt.org/issues/articleID.2153/article_detail.asp
http://http//www.ncbi.nlm.nih.gov/pubmed/18692428?
Ongoing multi-site study:
http://clinicaltrials.gov/ct2/show/NCT00128869
RE: Krauss J, Creighton D, Ely J. D., Podlewska-Ely J. The Immediate Effects of Upper Thoracic Translatoric Spinal Manipulation on Cervical Pain and Range of Motion: A Randomized Clinical Trial. J Man & Manip Ther 2008: 16(2):93-99.
The recent article provoked some thoughts I would like to share. The authors are to be commended for adding to the knowledge base by showing pain reduction and motion gains, in clients with cervical pain treated with thoracic manipulation. This is an important relationship and this study, along with other similar ones, should guide contemporary practice. In the discussion section the authors mentioned several ideas for future studies on the same topic. I would like to add to that list. The relationship of the costal joints to thoracic and cervical spinal motion might be appropriate for inclusion in future studies. A few unknowns being: what is the pre-treatment mobility of the ribs that articulate with the thoracic segments that are being manipulated, and do these rib joints contribute to motion restriction of the thoracic and cervical segments? I would submit that there are times in which a restriction of rib mobility is released as a co-treatment effect when the relevant thoracic segment is manipulated. Other times, the rib joints may require separate treatment. The costo-transverse and costo-corporal joints are very close to the thoracic facet joints, particularly at the 3rd thoracic segment. They are inextricably linked to thoracic movement. While the thoracic facets respond well to manipulation, it is my opinion that the rib joints do not, but rather; they respond optimally to lesser forces over a greater span of time (creep). For example, upon taking up the slack, pressure is maintained against a movement barrier for 2 minutes or more. This of course is not described in the 5-point joint mobilization scale, yet is a valid theoretical technique, based on viscoelastic principles of connective tissue. While studies do have to limit their focus, it seems relevant to mention the relationship of costal segmental mobility to thoracic segmental mobility, especially as published studies such as this one do contribute to the guidance of clinical practice. As stated earlier, the authors might be influencing rib joint mobility, and therefore, pre and post assessment of rib mobility may be informative, and provide an additional treatment option.
Thank you very much.
Sincerely Yours,
Jerry Hesch, MHS, PT
[email protected]
Recent articles support thoracic spine manipulation for clients with cervical pain and movement dysfunction. Here are a few:
http://www.ncbi.nlm.nih.gov/pubmed/18692428?
http://www.jospt.org/issues/articleID.2153/article_detail.asp
http://http//www.ncbi.nlm.nih.gov/pubmed/18692428?
Ongoing multi-site study:
http://clinicaltrials.gov/ct2/show/NCT00128869