Spine

The term 'thoracic' will be used in preference to the term dorsal, which has now been largely superseded. If the reader is accustomed to 'dorsal', he will need to make a mental translation at each reference. The thoracic spinal area is more accessible than the lumbar in that the embryological curve is maintained. The facet joints are liable to be involved in mechanical dysfunction syndromes as they are in apposition during normal posture, not just in flexion of the spine. Despite the torsional nature of movement in the thoracic area, disc lesions are much less common than in the other areas. However, when they do occur, they produce equally serious problems. The flexible nature of the thoracic area in rotation means that it is often necessary to use a large element of 'contra-rotation' to produce locking in manipulative technique. This in itself, if excessive or poorly controlled, will be painful and result in over-locking. There can be a tendency to apply more leverage when suitable resistance is difficult to feel, which leads to even more discomfort.

Special precautions for the area must include the possibility of bony weakness such as osteoporosis and secondary deposits. There is potential for damage in cases of advanced osteoarthrosis with ligamentous stiffening, particularly if excessive force is used.

The autonomic chain is very close to the thoracic spine and this means that applying any physical therapy can produce undesired or unexpected autonomic changes in the body. These may include sweating, sense of coldness, fatigue, yawning and breathing and digestive changes. While adverse reactions of this sort are usually temporary, and not too alarming, it is best to be aware of this possibility so that the practitioner can advise the patient accordingly.

Prognostic factors for a poor result include the patient with very 'stringy' muscle tissue in the area. This awareness can allow the practitioner to be more accurate in prognosis early on in a treatment series. 'Stringy' muscle has undergone some partial fibrotic changes, which are by their very nature only partly reversible. This is not uncommon in the thoracic area and it should direct treatment to the cause of the dysfunction, rather than just the painful area.

It is often useful to consider phases of breathing when performing technique in the thoracic area. Most thrust technique is easier if performed as the patient exhales. There are times when this is not the case. If it is necessary to stabilize a very mobile subject, asking them to hold the breath may be of more help. Experimentation is necessary to find the best method for each patient.

17.1 • Harmonic technique prone Use your upper hand to fix or focus the harmonic rocking of the pelvis induced by your lower hand. The amplitude of the harmonic movement will increase depending how far up the thoracic spine you fix as the lever lengthens. See earlier section relating to harmonic technique.

Tips: Although this is a therapeutic procedure, it performs a useful diagnostic test that will rapidly find areas of diminished flexibility.

17.3 • Articulation in sidebending and extension sitting The patient rests her folded arms on the operator's shoulder and upper arm and he is reaching around to clasp the paravertebral regions on each side. Rock into sidebending and, therefore, induce sidebending in the patient. Pull your hands toward yourself against the fulcrum of the shoulder and induce extension into the patient's spine.

Tips: Try adding rotation to either side before or after the other movements to help focus them. Extra considerations: Fix the patient's knees, padded if necessary, against you.

17.2 • Articulation into rotation sitting Fix against the spinous process at a chosen level and rotate the rest of the body back against this level by pulling the shoulder backwards. The natural recoil of the body will take it forward again so that you can move up or down to the next segment and repeat the exercise.

Tips: This can be a diagnostic exercise or a mild therapeutic technique.

17.4 • Articulation into sidebending sitting Sit or stand close to the patient's side and hook your abducted arm over her shoulder. Apply your thumb or thenar eminence against the spinous process and buckle the body into sidebending while using your thumb as a fulcrum.

Tips: Most useful in fairly stiff subjects where only small movement is required. Extra considerations: Try using circumduction movement of the upper body around the thumb to induce other ranges of movement.

17.5 • (top right) Articulation into sidebending sitting The patient sits with hands clasped behind the neck. Clasp the far shoulder of the patient. Hold her near shoulder firmly against your chest and keeping her head directly above her pelvis, buckle the spine over your thumb or thenar eminence applied to a spinous process. Firm compression of the patient against the operator is necessary and the movement comes from a slight flexing of the knees.

Tips: Try adding other ranges of movement to the sidebending to help focus it. Try circumduction.

17.6 • Articulation into sidebending sitting The patient sits with folded arms. Lift the further elbow while pressing down on the near shoulder with your axilla. Buckle the spine around your thumb or thenar eminence applied to the near side of a spinous process. It is necessary to have firm compression of the patient into the operator and the sidebending movement occurs as you flex your knees.

Tips: Most useful where it would be difficult for the patient to clasp hands behind the neck.

17.7 • Articulation into rotation sitting The patient folds her arms and the operator reaches either across the folded arms, or through them, to clasp the further shoulder. Compress the patient into your chest and apply a thumb or thenar eminence to one or more spinous processes. Induce a small amount of sidebending away from yourself and rotate the patient's and your body together to focus the force at the contact point.

Tips: Try circumduction instead of simple rotation to address different parts of the dysfunction.

17.8 • (bottom left) Articulation into rotation sitting The patient clasps her hands behind the neck. Reach around to clasp her far shoulder and apply your thumb or thenar eminence to one or more spinous processes. Compress the patient into yourself and induce rotation down to your applied thumb by twisting your body and the patient's as a unit.

Tips: The thumb applied to the spinous process can be on the nearside to push further rotation or on the far side to block rotation below that point. Extra considerations: If the patient is very flexible, an astride sitting position may be more efficient as it limits thoraco-lumbar mobility with the legs abducted in this way.

17.9 • Articulation into extension upper thoracic area sitting The patient folds her arms and rests them on the operator's upper chest. Thread your forearms through her folded arms and using your hands as a fulcrum lever the spine into extension.

Tips: Try making this into a circumduction movement. Brace the operator's thighs against the patient's knees - padded, if necessary.

17.10 • Articulation into flexion sitting The 17.11 • Traction and sidebending articulation patient folds her arms and drops her head forward sitting The operator threads his arms under the onto the operator's chest. Fix the top of her head patient's arms. Lift under the patient's mastoid pro-

with your chin and apply a lateral compression force, cesses with the heels of your hands. The lift also takes to the thorax, through your wrists and forearms. Pull place through the axillae. Lean the patient against up under the angles of a chosen pair of ribs while your chest and while maintaining the lift, introduce bending your knees to induce a localized flexion. circumduction to reach the mid thoracic area.

Tips: Try inducing some sidebending movement Tips: Most useful in smaller patients and children or circumduction. Fix the patient's knees against as the lift can prove hard work if applied to larger the operator's thighs, if necessary. adults.

17.12 • (see facing page, bottom left) Articulation into rotation prone The patient lies prone with her arms folded under the forehead. Fix a thoracic spinous process toward yourself and with your other hand under the patient's folded arms introduce rotation down to the fixing hand. Note that the patient is not being lifted as the operator's upper hand acts as a fulcrum and rests on the table.

Tips: Most useful where it is desired to limit rotation down to a specific segment as the thumb will act as a block to movement below this point. Extra considerations: Try adding different combined forces of sidebending or extension to the rotation.

17.13 • (see facing page, bottom right) Articulation into extension prone The patient lies prone with her arms folded under the forehead. Lift the folded arms, head and thoracic spine into extension while counter-fixing with your other hand.

Tips: Least useful where the patient is very large as considerable effort would be required to perform this technique. Extra considerations: Try introducing sidebending or rotation to help focus the forces.

17.14 • Articulation into extension prone The patient lies prone with her arms folded under the forehead. Lift the folded arms, head and thoracic spine into extension while counter-fixing with your other hand.

Tips: Least useful where the patient is very large as considerable effort would be required to perform this technique. Extra considerations: Try introducing sidebending or rotation to help focus the forces.

17.15 • Springing prone Apply a classical'push and pull' technique by bracing several spinous processes with the heel of one hand to rotate them away from yourself. Brace several adjacent ones above to produce a rotation force between the hands. Naturally, the technique can be used with the hands reversed.

Tips: Try fixing with one hand and mobilizing with the other and vary the patient's head rotation to find the optimum.

17.16 • Articulation into rotation prone The operator is working specifically on one segment, taking hold of it as if it were a wing nut. Push toward the table to absorb the spring. Apply the thumb and index finger on opposite sides of adjacent spinous processes. They introduce the rotary force as you pronate your forearm.

Tips: Least useful where the spine is very tender. The force needed to make this technique effective would be too great in cases of severe restriction.

17.17 • (bottom left) Springing postero-anterior prone The patient is lying prone, in this case with her hands folded under her head. Stand at the head of the table and use the pads of your thumbs to spring the chosen level directly anteriorly. Press with the thumbs over the laminae of the vertebrae, not the spinous processes as they can tend to be sensitive.

Tips: Most useful where specific segmental dysfunction is present. Extra considerations: Try springing on one side only, or staggering the thumbs to work on adjacent segments. Try having the patient's arms by her side or over the edge of the table.

17.18 • Thrust starting position supine The patient grasps opposite shoulders without crossing her forearms. The operator has rolled the patient toward himself and is sliding his hand under the spine. He is using a flat hand, but can apply a variety of possible holds to the target segment. Note that the patient's head is left on the pillow and that she is only rolled far enough to allow the hand to be slipped underneath. This has become known as the dog technique after Fryette saw this being done badly and commented, 'I wouldn't do that to a dog!' If he had seen it done well, he would not have made that comment, but the name has stuck since then!

17.19 • Thrust to mid thoracic spine supine

The hold shown in photograph 17.18 is adopted and the patient is rolled over onto the hand. Test for free play in the primary lever direction of traction. Focus all other components of flexion, rotation away from yourself, sidebending toward yourself and slight compression and sideshifting away. If this seems excessively complex, you should simply concentrate on bringing your elbows in toward your sides; this will automatically produce the correct components. The underneath hand performs a small pronation and traction toward the pelvis to help tighten up the levers. At the point of barrier accumulation, emphasize the pronation of the lower hand and apply the thrust through your upper hand and chest into traction pushing her elbows toward her shoulders. It is usually possible to reach from about the third to the tenth thoracic vertebra with this hold.

Tips: This is not a flexion thrust. It is not a compression thrust. The use of all the secondary levers is designed purely to help minimize the amplitude of the primary lever of traction. Extra considerations: Many varieties of hand hold underneath are possible. A flat hand pronated slightly is most comfortable for the patient. The hand can be applied with the fingers loosely clasped. It can be applied using a fist so that the spinous processes fit into the space between flexed fingers and thenar eminence. The underneath hand is as much a part of the technique as the upper hand. If the hold causes pain to the operator in the lower hand, try pushing the hand firmly into the thoracic spine, rather than simply resting it on the table. Leave a small space between the back of the hand and the table so that the wrist is as much part of the fulcrum as the hand. Try using varied quantities of patient head rotation to help focus the technique. Generally rotation away from the operator will tighten the levers.

17.20 • Thrust to mid thoracic spine supine The patient is only crossing one arm over her chest. The operator is using a pad between his chest and the patient's elbow. His upper hand is applied to the pad to direct the force more accurately. It is usually possible to reach from about the third to the tenth thoracic level with this hold.

Tips: Most useful for the patient with a shoulder dysfunction as the painful shoulder can be left out of the hold. All other factors are as the details in photograph 17.19.

17.21 •Thrust mid thoracic area supine The patient clasps her hands behind her neck. Lift her upper body with your upper hand and slip your lower hand under the patient to apply it to the target vertebra. Flex the patient down to the segment and while holding her steady, apply a thrust with your thorax to the patient's elbows. In this variation of the basic technique it is difficult to reach much above the fifth thoracic level in most subjects.

Tips: This is a mobile technique and it is not usually possible to stay in the thrust position for more than a few moments. It is much more difficult to use varied secondary levers with this hold and it tends to become a flexion and compression thrust. As the secondary levers are not used to any great extent, this can become a rather forceful variation. It is more difficult to be specific with this technique and, therefore, it can become a technique for gapping several facets at once. This means that a restricted segment in the midst of a mobile area may not be mobilized effectively.

17.22 and 17.23 • Thrust upper thoracic area supine The patient clasps her hands behind her neck. The operator makes a loose fist and slips it under the patient to fit the spinous processes into the palm. Flex the patient's elbows and apply all the usual components. The thrust is performed into traction and some compression when the levers have focused. Tips: Most useful for upper thoracic area from second to fifth levels.

17.22 and 17.23 • Thrust upper thoracic area supine The patient clasps her hands behind her neck. The operator makes a loose fist and slips it under the patient to fit the spinous processes into the palm. Flex the patient's elbows and apply all the usual components. The thrust is performed into traction and some compression when the levers have focused. Tips: Most useful for upper thoracic area from second to fifth levels.

17.24 and 17.25 • Thrust mid thoracic supine single arm lever The operator is using one or other arm of the patient, crossed over the chest. It is perfectly possible to make the technique work with one arm only, but this will be a little more difficult. All the usual components are available although more compression will probably be required.

Tips: Most useful in cases where any problem with one shoulder or the other makes the normal hold impossible.

17.26 and 17.27 • Thrust mid thoracic area from same side The patient crosses her chest with her arms in the usual way avoiding crossing the forearms. Roll the patient away from you to slide your hand under the spine from the nearside. Roll the patient onto your hand and apply your forearm to her folded arms. (Note that the completed hold is shown from the other side for clarity.) Test for free play in the primary lever direction of traction while adding the secondary components to bring the target joint to the optimum thrust focus.

Tips: Most useful in very large subjects where it may be impossible to reach all the way around. This hold can also be used for costo-vertebral and costo-transverse joints, it is also a useful method when an operator, for any reason, finds use of one particular hand a problem, as it means that the same hand can be used from both sides, whereas with the conventional hold he would need to change hands to reach the other side.

Supine Translation Traction

17.28 • Thrust using crossed hands mid thoracic area prone The patient lies prone with her arms over the sides of the table to spread the scapulae. Apply your crossed hands to opposite sides of the spine. The far hand is slightly supinated to bring the pisiform into contact with a transverse process. The near hand is pronated to bring the hypothenar eminence into contact with a transverse process of the same or adjacent vertebra. The thrust is applied after the slack has been taken out of the tissues with a downward pressure and a small element of sidebending.

Tips: Most useful in fairly flexible subjects. Extra considerations: Try changing the hands to make the far hand push toward the head and the near one push toward the feet. It may be necessary to change the applicator to use the thenar eminences for some operators. The thrust is usually coincident with exhalation to avoid rib damage. Try varying the patient's head rotation to find the optimum.

17.29 • Thrust mid thoracic area sidelying The operator is using his lower arm to stabilize the pelvis in this modified lumbar roll position. The upper, or fixing, hand is maintaining a downward pressure to produce a compression force. The actual thrust is applied with a direct compression force into the table and against the transverse process of the level desired.

Tips: Most useful in cases where compressive forces on the chest might be undesirable for any reason. Extra considerations: Although this position might seem difficult, or even impossible for the purpose intended, it needs remarkably little practice to be made into an efficient technique. The control of the two very long levers is critical. Careful study of the photograph will reveal the compres-sive and torsional forces being applied. Try varying the phase of breathing to find the optimum tension.

17.30 • Thrust mid thoracic area sidelying, shown on skeleton The hold shown in photograph 17.29 is applied here to the skeleton for clarity. Note that the lower hand is applied to the transverse processes and the ribs. The lower elbow is applied to the lateral aspect of the pelvis. The upper hand is pushing the shoulder back slightly, but mostly down into the table.

17.31 • Thrust mid thoracic area sitting The patient clasps round her chest gripping opposite shoulders. She has not crossed her forearms. Pull in toward yourself on her elbows using a pad, if necessary, as a fulcrum between your chest and the desired level of the patient's spine. You need to pull in on the elbows to produce a compression while engaging the barrier in a traction, flexion, sidebending and opposite rotation direction. The thrust is an accentuation of the primary lever of traction. Extra considerations: Lateral compression is available simply by the operator bringing his elbows toward his sides. If the elbows are staggered slightly one above the other, an automatic sideshift will be introduced. Note that the patient is sitting astride the table in this illustration. This is not an essential part of the technique but may help fix the pelvis in a very mobile subject. Try varying the phase of breathing to find the optimum.

17.32 • Thrust mid thoracic area sitting (taking up the hand hold) The operator is clasping the patient's wrists. Ask her to interlace her hands behind her neck. Taking up the hold in this way avoids having to thread your hands through her elbows, and makes the grip much easier to access.

17.33 • Thrust mid thoracic area sitting The operator has taken up the hold in the way shown in photograph 17.32. Place a pad if necessary between your chest and the patient's spine. Pull her into flexion down to the segment desired, compress toward your chest and induce some sidebending and opposite rotation. The thrust is applied with a combination of a lift of your body from the knees, and an increase of compression of the patient against your chest. The forces are produced by pulling in on her arms at the same time as the lift.

Tips: Least useful where a shoulder problem might make the hold painful or difficult. Try a lateral compression of the chest in mobile subjects to absorb the free play in the thorax. Try making the thrust after a circumduction of the patient's body so that the technique becomes a movable procedure rather than just a lifting exercise. Extra considerations: Note that the patient is astride the table in this illustration. This is not essential to the technique. Nevertheless, in mobile subjects the astride position will help to absorb excessive free play in the lumbar spine. Note that the patient's elbows remain pointing forward; if they are allowed to splay to the side the patient's shoulders may be strained. Try varying the phase of breathing to find the optimum tension for the thrust.

17.34 • Thrust mid thoracic area sitting, knee fulcrum The patient is sitting with hands clasped behind her neck. Thread your hands through the arms and grip the patient's wrists to pull her into flexion down to the level desired. Apply your padded knee to the spinous or transverse process. The thrust is performed with a small lifting force through the patient's arms, against a very small increase of pressure with your knee.

Tips: Note that the patient's elbows remain pointing to the front; they are not allowed to splay out as this can strain the shoulders. This is a very powerful technique, and if performed with excessive force could very easily become traumatic. Try varying the phase of breathing to find the optimum tension for the thrust.

17.35 • Thrust mid thoracic area sitting patient's arms across chest The patient clasps opposite shoulders without crossing her forearms. Grip her elbows and pull her into your chest over a suitable pad, if necessary, applied to the desired spinal level. Apply a lateral compressive force to absorb the free play in the thorax. Stagger your arms slightly to produce a small component of sideshift as you squeeze the thorax. The patient leans back against you and you flex her spine until the barrier accumulates. The thrust is performed with a small increase of the compression coinciding with a lift directly into traction. Small vectors of sidebending and rotation can be introduced as necessary.

Tips: Try varying the phase of breathing to find the optimum barrier. Note that in this photograph the patient is sitting across the table. If the table is very wide, this will mean that she is too far from the operator to make the technique efficient. Either a narrower table would be necessary or she could sit astride the table. Another alternative might be to use a stool.

17.36 • Thrust mid thoracic area standing The patient clasps opposite shoulders without crossing her arms. Pull her into your chest with a suitable pad interposed if necessary. Grip her elbows and pull her into compression, some sidebending and opposite rotation. Flex down to the segment desired and then lean her back against you as you drop your weight onto your back leg. The patient has been told what to expect. At the optimum tension, apply a small increase of compression at the same time as a small lift by shrugging your shoulders.

Tips: At all times the patient remains in some flexion. This is not so much a lifting force as a resistance to dropping of the segments above the fulcrum. The primary lever is a traction force.

17.37 • Thrust mid thoracic area standing, hands clasped behind neck The patient clasps her hands behind her neck. Pull her against your chest with a suitable pad interposed if necessary. Warn her that she is to be pulled off balance. Apply a compression, sidebending and opposite rotation force while pulling her into flexion down to the segment desired. At the point of optimum tension, perform the thrust with a small shrug of your shoulders.

Tips: Note that the patient's elbows remain pointing to the front. If they are allowed to splay, there is a possibility of straining her shoulders.

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