Manual Therapy and the Canine Thoracic Spine MANUAL THERAPY LITERATURE

Manual Therapy and the Canine Thoracic Spine

MANUAL THERAPY LITERATURE Manual Therapy REVIEW and the Canine Thoracic Spine The Canine Spine: Laurie Edge-Hughes Advanced Assessment & Treatment BScPT, MAnimSt (Animal Physio), CAFCI, CCRT Techniques The Canine Fitness Centre Ltd www.CanineFitness.com Laurie Edge-Hughes, BScPT, MAnimSt (Animal Physio), CAFCI, CCRT Four Leg Rehab Inc www.FourLeg.com

Introducon Mobilizaon

• Funcon = Mobility with Stability  Form Closure: . Mobilizaon or manipulaon aimed at restoring mobility and/or correcon of osseous alignment. • The Integrated Approach . “If exercise is prescribed first, without firstly restoring – Form Closure joint mobility, the paent’s pain and dysfuncon oen – Force Closure gets worse.” (Lee & Lee 2004) – Motor Control & Timing  Mobilizaon . The gentle coaxing of movement by passive • Manual Therapies rhythmical oscillaons – Mobilizaon & Tracon... ▪ To treat sffness Disturbed Harmony by Giorgio Vaselli ▪ To treat pain (rather than sffness) Maitland et al 2005

Mobilizaon Mobilizaon • Maitland’s Mobilizaon Grading Scale • Maitland’s Mobilizaon Grading Scale • Grade 1: Gentlest. Performed with pressures so light and amplitudes so ny as may be considered ineffecve. Used when pain and more parcularly mm spasms are easily evoked by very ______Available range______gentle passive movement. Beginning R.O.M. Anatomical Barrier • Grade 2: Large amplitude in painless part of joint’s range. Where in ______Grade 1 the range is guided by pain and spasm so as to avoid both. ______Grade 2 • Grade 3: Big amplitude movement and done to ‘knock’ at the limit ______Grade 3______of range. Used when pain is felt at the limit of range and is Grade 4______moderate and is not associated with spasm. • Grade 4: Tiny amplitude: performed with joint at maximal stretch Grade 5______> and used only when examinaon finds the range to be almost full, Grades 1 & 2 have a neuromodulatory / pain relieving effect Grades 2 & 3 have a vascular effect not protected by muscle spasm, and when there is very lile pain. Grades 3 & 4 have a mobilizing effect • Grade 5: manipulaon: An extension of grade 4 – the joint is Grade 5 is a manipulation suddenly moved through a very small amplitude, but at high velocity before paent is aware of it. Maitland et al 2005 Maitland 1966

Neutral Axis Mobilizaon

Flexion • Methodology: Extension – Minimal Symptoms Anatomical Barrier

Elasc Barrier • Staccato technique (like plucking a violin) – Moderate Symptoms Physiologic Zone Anatomical Barrier • Staccato technique (like playing staccato Elasc Zone Elasc Barrier notes with a bow on the violin strings) – Severe Symptoms Elasc Zone • Oscillatory movements of smooth and even nature (a movement with unperceivable changes in direcon)

Maitland et al 2005

Mobilizaon Mobilizaon • Passive Accessory vs. Passive Physiological Mov’ts • Passive & Acve Movements – Preservaon of full ROM PAIVMs (Passive Accessory PPIVMS (Passive Physiological – Preservaon of strength and flexibility of Intervertebral Movements) Intervertebral Movements) periarcular ssue Usually the first choice for manual Use if irritable to touch, or if treatment worsened aer palpaon, or if neurologic signs • Physiological Movements Parcularly useful when loss of Parcularly useful when loss of – Acve or passive FUNCTIONAL movements moon in extension (? Canine moon in flexion (? Canine • Accessory Movements applicaon or not?) applicaon or not?) – Conjunct movements Eg: Dorso-ventral (PA) pressures, Eg: Large movements – flexion, Maitland et al 2005; Tracon, Transverse pressures. extension, side bending, rotaon. • Both are used to mobilize joints Björnsdóttir & Kumar 1997 Maitland et al 2005

Mobilizaon Mobilizaon

• Selecon of techniques • Selecon of techniques based on PATHOLOGY – To OPEN a facet joint – Acute pain or Nerve root symptoms • Rotate or Side bend AWAY from the side of pain • Stac tracon – gentle • Dorso-Ventral Pressures ON the side of pain – Chronic Nerve root symptoms • Transverse Pressures TOWARDS the side of pain • – To CLOSE a facet joint Central D-V pressure, rotaons, tracon • Opposite of above – Discogenic signs • And if using a D-V pressure – direct the pressure medially • Generalized rotaon • Rule of thumb… – Facet joint signs – Try OPENING ﬁrst! • Localized rotaon – Osteoarthris • Large movements throughout range (accessory & physiologic) Maitland et al 2005 Maitland et al 2005

Mobilizaon Mobilizaon

• How bloody long do I do the technique(s) for? • Mechanical – TIME – Restoraon of voluntary movement – If Irritable: then 20 – 30 seconds, repeated 1 or 2 mes – Aids in carlage nutrion – If Non-Irritable: then 1 minute, repeated 4 – 6 mes – Aids in intervertebral disc nutrion – TECHNIQUES PER SESSION – Aids in metabolism of so ssue structures – Add them in, but reassess before and aer each new – Improved rate and quality of tendon repair technique – Zusman 1986; Perform the most eﬀecve technique (again) last Björnsdóttir & Kumar 1997

Maitland et al 2005

Mobilizaon Mobilizaon

• Requirements for a Mechanical Effect • Neurological Effects – Repeve passive joint movements (oscillaons) – Reducon in acute pain need to be carried out at the limit of the joint’s – Inhibion of reflex muscle contracons available range in order to achieve a mechanical effect • i.e. Tissues need to be stretched

Zusman 1986; Katavich 1998; Björnsdóttir & Kumar 1997; Zusman 1986 Zelle et al 2005

Mobilizaon Mobilizaon

• Neurological Effects: • Neurological effects – Repeve (oscillatory) or sustained manual – “cheat sheet” smulaon results in a hysteresis effect: • Inhibitory effect on low threshold mechanoreceptors (group I & II) • Inhibitory effect on high threshold nociceptors (group III & IV) • THUS reducing intra-arcular pressure and peripheral afferent discharge

Zusman 1986; Katavich 1998; Conroy & Hayes 1998; Sterling et al 2001

Mobilizaon Mobilizaon

 Postulated Cellular Level Effects • Postulated Cellular Level Effects . Mechanical / Connecve ssue remodelling – Arcular Carlage Changes ▪ Cellular modulaon • Alter joint lubricaon ▪ Release of enzymes to breakdown cross links ▪ Simulaon of fibroblast synthesis of collagen proteoglycans • Enhance carlage nutrion ▪ Realignment of old fibres • Movement of joint inclusions ▪ Increase interfibre distance (meniscoids) or loose bodies (carlage ▪ Increase interfibre lubricaon fibrillaon) ▪ Alignment of new fibres • Shi hard fragment of intervertebral ▪ Stretching arcular capsule / segmental muscles disc ▪ Breaking intra-arcular adhesions ▪ Vertebral movement Maffey LL 2007 Maffey LL 2007

Mobilizaon Mobilizaon

• Postulated Cellular Level Effects • Postulated Cellular Level Effects – – Neurological effects * Neuromuscular response * • Alter afferent input to effect efferent output – relax • Smulaon of Type I and type II mechanoreceptors muscle • Inhibit transmission of nocicepve impulses • Smulaon of muscle spindle and golgi tendon organ – • Decrease pain percepon reflex inhibion of segmental muscles • Relieve mechanical irritaon of nervous system • Alter segmental (and more distal) muscle acvity • Acvaon of arcular mechanoreceptors • Reflex muscle response locally and at a distance • Smulaon of sympathec nervous system • Decrease spinal segmental facilitaon

* Validated effects Maffey LL 2007 * Validated effects Maffey LL 2007

Mobilizaon Mobilizaon

• Postulated Cellular Level Effects • Postulated Cellular Level Effects – Alter Circulaon – Physiological * • Increase supply of materials required for healing • Increase beta-endorphin levels • Remove chemical irritant (hence decreasing nociceptor • Immune system effects smulaon)

Maffey LL 2007 * Validated effects Maffey LL 2007

Mobilizaon Mobilizaon

• Postulated Cellular Level Effects • Research Examples - Effects of Mobilizaon – Joint Tissue Response – Improved pressure pain threshold in pts with • Increase capsule elascity rheumatoid arthris (12 minute P-A pressures) • Improve arcular carlage nutrion (Dhondt et al 1999) • Improve circulaon – Improved pain (VAS) & immediate neck ROM in pts • Restoraon of joint play / accessory glides with mechanical neck pain • Restoraon of passive / acve movement (Kanlayanaphotoporn et al 2010) • Decreased pain percepon – A rapid onset analgesic response following joint mobs has been proven in rodent models (Grayson et al 2012) Maffey LL 2007

Mobilizaon Mobilizaon

• Research Examples - Effects of Mobilizaon • Research Examples - Effects of Mobilizaon – Unilateral neck mobs facilitated acvaon of deep – DOES NOT Alter sacrum-iIium joint posion (on neck flexor muscle firing & reducon in superficial roentgen stereophotgrammetric analysis) neck flexor acvity. – Manipulaon might influence so ssue structures, (Sterling et al 2001) such as joint capsules, muscles, ligaments, tendons – Improves ROM in the human hip & ankle joints and and postures canine carpus Tullberg et al 1998 (Hoeksma et al 2004; Collins et al 2004; Olson 1987) – Does Not Change vertebral sffness or have permanent effect on passive cervical ROM (Nilsson et al 1996; Goodsell et al 2000; Lee et al 1993; Allison et al 2001)

Mobilizaon Mobilizaon

• Research Examples - Effects of Mobilizaon • THOUGHT: – Pain is improved & FUNCTIONAL disability is reduced for 6 months following 8 sessions of mobilizaons &  IF, in fact, mobilizaons do NOT alter joint posion, non-specific back exercises biomechanics, mobility or long-term sffness, then (Balthazard et al 2012) perhaps we can choose ANY mobilizaon technique – Mulfidus recruitment is enhanced and sustained (within reason…) to result in pain relief, reducon aer lumbar manipulaon which posively impacted of muscle spasm, improve muscle firing, and FUNCTION enhanced funcon… followed by neuromuscular (Fritz et al 2012) retraining.

Mobilizaon Mobilizaons

 Technical Summary of Mobilizaon Treatment Applicaon: . Paent consent received (informed of nature and purpose of mobs, alternate forms of assessment/Rx, associated risks & beneﬁts) . Select starng posion (relaxed and comfortable) . Select starng posion of the clinician . Select treatment grade . Select a sustained oscillatory technique . Select duraon and speed of oscillatory technique (shorter for acute condions) . Increase the intensity and duraon of treatment only when evidence exists that increased dose will not exacerbate pain . Select reassessment technique to use before, during and aer treatment . Select home program to maintain treatment eﬀects

Mobilizaons Mobilizaon

Mobilizaon

• Contraindicaons for Mobilizaon or Manipulaon speciﬁc to the canine paent: – Temperament of the dog • Highly anxious / fearful • Aggressive – Owner anxiety or lack of comprehension of the treatment to be administered

Tracon Tracon

• Tracon may break the “cycle of pain” in radiculopathy caused by herniated discs: – Disc herniaon  – Nerve root entrapment in vertebral foramina  – Nerve root irritaon  – Reﬂexive response to contract adjacent muscles  – Further narrowing of foramina  – Increased pain. Tracon: • reduce inﬂammaon • improving circulaon Jam 2005 • reducing swelling

Tracon Tracon

• Intermient tracon • Findings: – Improves circulaon & reduces swelling of – Human paents with cervical radiculopathy < 12 surrounding ssues and epidural space weeks show less favourable improvement. • Relieves the inflammatory reacon of nerve roots • Early intervenon is more successful • Contributes to resorpon and regression of the herniated disc material – The response to early therapeuc intervenon in – Large extruded discs tend to respond more rapidly large extruded discs is even more favourable. – Creates an alternang stretching and relaxaon of – Benefits to lumbar tracon with acute radicular adjacent so ssue structures pain of less than 6 weeks and concomitant • Prevents adhesions of the dural sleeve neurological deficits.

Constantoyannis et al 2002; Maher 2004; Ozturk et al 2005 Krause et al 2000

Tracon Tracon

• Findings • Contraindicaons: – Physiotherapy which includes tracon for CT scan- – Infecon proven herniated discs and EMG-proven – Neoplasm radiculopathy: – Osteoporosis • 90% good – excellent outcomes and 92% return-to- work rate – Bilateral pars interarcularis defect – Grade 2 or higher spondylolisthesis – Fractures – Spinal instrumentaon

Sal & Saal 1985 Deen et al 2003

Tracon

• Tracon can also be graded using the Maitland Mobilizaon Scale – Grade 1 & 2 have a neuromodulatory / pain relieving effect – Grades 2 & 3 have a vascular effect – Grades 3 & 4 have a mobilizing effect – Grade 5 is a manipulaon (and not recommended with tracon)

The Myofascial System The Myofascial System

Adapted from Paris & Vi 2007 • THE MYOFASCIAL SYSTEM • THE MYOFASCIAL SYSTEM – There is a variance of myofascial states that may Muscle Tone Descripon Treatment Hypertonicity accompany a vertebral dysfuncon Involuntary Muscle response is triggered by nocicepon in Ignore the muscle reacon and – Treatment of the muscle state tends to occur aer splinng an eﬀort to splint the back from further stress treat the cause and injury. treatment of the vertebral dysfuncon. Chemical Also involuntary (as above), it results in the Treatments can include heat, splinng retenon of waste products which give rise to manual muscle therapies, back pain. Overuse can also cause chemical stretching and treatment of the splinng. Muscle retaining waste metabolites underlying cause. will appear to have an elevated resng tone and are tender and doughy to touch. Voluntary Voluntary splinng occurs if nocicepon reaches Treatment involves the splinng the threshold for pain, and the paent prescripon of movement and voluntarily splints the aﬀected part. moon needs to be encouraged.

The Myofascial System The Myofascial System

• THE MYOFASCIAL SYSTEM • THE MYOFASCIAL SYSTEM

Muscle Tone Descripon Treatment Muscle Tone Descripon Treatment Hypotonicity Normal tone / Adapve shortening results from muscles Treatment includes muscle Disuse atrophy The presence of pain or sffness has Treatment is to restore moon, Shortened being held in a shortened posion. elongaon by stretching or resulted in a loss of normal mobility. The heat, and treatments to ssues massage. muscles may feel to have lost bulk, lack encourage circulaon, followed Compartment Hypertrophy can result in muscle restricon Treatment includes mobilizaons normal none and feel somewhat fibrous. by specific exercises. syndrome within their fascial compartments, resulng to vertebral structures and Wasng & The result of neurological or surgical Treatment is to promote in chronic unilateral or bilateral stretching out of the connecve fibrosis interference with normal nerve conducon. circulaon and exercises to train paravertebral back pain. ssue envelope. the remaining muscles.

Adapted from Paris & Vi 2007 Adapted from Paris & Vi 2007

Conclusion On with the show!

• Manual therapies such as mobilizaons / manipulaon and tracon: – Have a proven track record clinically • Both in pracce and in research – Have a limited amount research to validate their cellular eﬀects – Sll need further research to elucidate the full potenal of manual therapy and/or dispel any falsely propagated myths. – The Myofascial system should also be addressed but likely secondarily to the skeletal system

THE CANINE THORAX The Thorax • Thorax = thoracic vertebra, ribs, and sternum + aaching muscles – A biomechanical approach to treatment The Canine Spine: • Requires and understanding of normal funcon • Advanced Assessment & Treatment Integrates joint mobility and stability Techniques – The dog is a good research model for the human thoracic vertebra.... • Hence allowing a transfer of assessment/treatment Laurie Edge-Hughes, BScPT, MAnimSt (Animal Physio), CAFCI, CCRT Laurie Edge-Hughes, BScPT, MAnimSt (Animal Physio), CAFCI, CCRT strategies

Lee 2003; Oda et al 1996; Takeuchi et al 1999

T/S: Anatomy & Biomechanics T/S: Anatomy and Biomechanics

• Bodies of the thoracic vertebra are shorter • The spinous ps of T6 – T9 overlie the bodies than those of the lumbar or cervical spines of the vertebra caudal to them. • T1 – T7/8 spinous processes are massive • T12/ 13 are directly cranial to the bodies. • The spinous processes decline in length • The Transverse processes are short, blunt, and from T1 to T9/10 and are caudally inclined. irregular • T11 is the anclinal vertebra and the transion segment to the thoracolumbar region

Evans 1993 Evans 1993

T/S: Anatomy and Biomechanics T/S: Anatomy and Biomechanics

• The Cranial Thoracic Spine (T1 – T9) • The Cranial Thoracic Spine – T1 – T9 facet joints are horizontal and overlap  Weight bearing is suspected to be the main funcon of the – 63% incidence of unilateral or bilateral facet aplasia in facets in large dogs small dogs (exclusively)  The disc may compensate for the funconal loss of facet – Asymmetry in size of le & right arcular surfaces joints in small dogs • Result of postnatal loading of immature arc. Carlage • Restricted moon may play a role in development (if arches of the  Facet aplasia: adjacent vertebra do not touch)  Does NOT increase the risk of developing IVDD or spondylosis

Breit 2002a Breit 2002a

T/S: Anatomy & Biomechanics T/S: Anatomy & Biomechanics

• The Cranial Thoracic Spine • The Caudal Thoracic Spine (T10 – T13) – In humans: the orientaon of the facet joint (of – T10 – T13 facet joints are vercally aligned the lower C/S and upper T/S) allow for side – This orientaon allows for ﬂexion and extension bending – Vertebral arches and facets are involved in weight – Clinically, lateral bending is accompanied by bearing and transmission of loading forces rotaon to the same side (T1 – T6) – Below T7: the conjunct rotaon is variable

Breit 2002a; Lee 2003 Breit 2002a,b; Evans 1993

T/S: Anatomy & Biomechanics T/S: Anatomy & Biomechanics

• The Caudal Thoracic Spine (T10 – T13) • The Caudal Thoracic Spine (T10 – T13) – In Normally posioned vertebra (parallel): – T10 – L7 is normal kyphoc • The caudal ps of the caudal arcular process do not – Lordosis can occur with the loss of elascity of the come into contact with the adjoining cranial arcular bowstring construct surfaces • The caudal arcular surfaces adapt to higher body- • Lateral bending is restricted by accessory processes weight by the presence of LARGER arcular surfaces • Rotaon is accomplished only in ﬂexion in this region • Thus creang arcular surfaces not only laterally but also caudally and/or ventrally

Breit 2002b Breit 2002b

T/S: Anatomy & Biomechanics T/S: Anatomy & Biomechanics

• The Caudal Thoracic Spine (T10 – T13) • The Caudal Thoracic Spine (T10 – T13) – Ventrally directed shears cause ventral facets – In humans, arcular asymmetry is highly prevalent • Allows for an increase of loading capacity • Typically 41% – Excessive extension causes caudal facets – The thoracic spine looks like and responds like the • Due to loss of elasc stability lumbar spine – Ventral and caudal facets • An abrupt decrease in the range of axial rotaon (together) create a ball and socket joint • Reduces spinal stability & NOTHING resists axial rotaon

Breit 2002b Singer 2004

T/S: Anatomy & Biomechanics T/S: Anatomy & Biomechanics

• Rib Arculaons • Rib Arculaons – Costal fovea (rib arculaons) are located at the – The tubercles of the ribs arculate with the TvPs cranial and caudal sides of each thoracic vertebra. of the of the T/S at the same number as the rib • “Cranial or caudal costal fovea” – T12 oen lacks a demifacet • “Demifacets” – T12 & T13 have ONE complete fovea on each side – Rib head 1 arculates with T1 body and somemes C7 + C7 /T1 disc

Evans 1993 Evans 1993

T/S: Anatomy & Biomechanics T/S: Anatomy & Biomechanics

• Rib Arculaons • Rib Ligaments – The Radiang head ligament – The costovertebral joints & rib cage = STABILITY • From ventral aspect of the rib head to the bodies of the 2 adjacent vertebrae – Ligamentous support: arcular capsule, radiate – Intraarcular head ligament ligament, intercapital ligament, costotransverse • From the dorsal aspect of the rib head to the dorsal surface of the 2 adjacent vertebra and the intervertebral disc ligament and intra-arcular ligament – Intercapital ligament • From the head of one rib over the dorsal part of the intervertebral disc – RESIST lateral bending and rotaons (but ventral to the dorsal longitudinal ligament) absent at Rib 1 & 11-13 – Injury or surgery to the costovertebral joints = – Ligament of the neck • From the neck of the rib to the ventral surface of the transverse process & LESS stability lateral surface of the vertebral body – Costotransverse ligament Evans 1993, Oda et al 1996, • From the rib tubercle to the transverse process Takeuchi et al 1999, Lile & Adam 2011 Oda et al 1996, Takeuchi et al 1999, Evans & deLahunta 2013

Costotransverse lig. Intercapital lig. T/S: Anatomy & Biomechanics

Intervertebral disc Ventral longitudinal lig. Radiang head lig. • Rib Arculaons – Comparison of bipeds, pseudobipeds & quadrupeds • Humans & pseudobipeds have lateral spinal ligaments (i.e. ligs that run from TvP to Tvp or rib to TvP of vertebra above.

Dorsal longitudinal lig. Intervertebral disc • No lateral spinal ligs were found in quadrupeds Ligament of neck • Query… development in an erect spine & fundamental to Ligaments of vertebral column stability in an erect posture. & ribs, dorsal aspect Ligaments of vertebral column & ribs, ventral aspect

Jiang et al 1995

T/S: Anatomy & Biomechanics T/S: Anatomy & Biomechanics

Table 3.1. Branches of the Spinal Nerves Evans 1993 • Costotransverse joint pain Meningeal Branch Supplies the dura mater, the dorsal longitudinal ligament, the vertebral – (humans report – aer injecon into CTv jt): venous sinus and other blood vessels in the canal. Each annulus fibrosis of the disc is supplied by meningeal branches from two or more spinal nerves. • Deep, dull ache & pressure sensaon. Dorsal Branch Divided into medial and lateral branches. Supply the epaxial muscles and • 3.3 / 10 pt scale skin over the dorsal aspect of the body wall. • Pain paerns superficial to the injected point Ventral Branch Also called intercostals nerves. These are also divided into medial and – Innervaon: lateral branches except in the region of the brachial plexus and lumbosacral plexus or the supply to the tail. The intercostals nerves supply the • Lateral branch of thoracic dorsal rami hypaxial muscles of the body wall and give off lateral and ventral cutaneous • Sympathec innervaon from neighbouring branches to supply the skin of the lateral and ventral aspects of the body sympathec segment & segment cranial to it wall. The Visceral Branch Carries only general visceral sympathec fibers to and from visceral structures.

Young et al 2008 Cord segments T1 – T7 are displaced cranially with respect to their corresponding vertebrae (Breit 2002c)

T/S: Anatomy & Biomechanics

• Key Muscles of the Thoracic Spine • Epaxials – Iliocostalis – Longissimus – Spinalis et semispinalis thoracis et cervicis – Mulﬁdus

T/S: Anatomy & Biomechanics T/S: Anatomy & Biomechanics

Key Muscles of the Thoracic Spine Key Muscles of the Thoracic Spine Epaxial Muscles Epaxial Muscles Iliocostalis The most lateral of the erector spinae muscle group is Iliocostalis, which is divided into Spinalis et These arise from the sides of the spinous processes and insert into spinous the lumborum and thoracic porons. Iliocostalis lumborum originates on the pelvic semispinalis processes cranial to them and extending up as high as C2. They are capable of surface of the wing of the ilium and is joined by fascicles from the ends of all the lumbar thoracis et fixang the thoracic vertebral column and raising the neck. transverse processes. It inserts onto lower ribs. The thoracis poron originates from cervicis each of the ribs (except ribs 1 & 13), and inserts onto the transverse process of C7 and the costal angles of the ribs. Both porons act to fixate the vertebral column or for Mulfidus Mulfidus is an important muscle for control of inervertebral moon and lateral movement when unilaterally contracted. Iliocostalis will also aid in expiraon by fixaon of the vertebral column. It is reported to have 4 different fascicles pulling ribs caudally. (including sacrocaudalis dorsalis medialis), originang as caudally as the sacrum Longissimus The medial poron of the erector spinae, consists of overlapping fascicles from the ilium and terminang as cranially as C2. Fascicles cross anywhere from 2 or more to the head and is the strongest muscle of the trunk. It is also divided into secon by vertebral segments from mamillary or arcular processes of caudal vertebra to locaon: the lumborum, thoracis and cervicis porons. Longissimus lumborum is spinous processes of cranial vertebra. covered by a dense aponeurosis that is separated from the thoracolumbar fascia by fat. It has aachments to each lumbar, thoracic and cervical vertebra as well as each rib. It will act to extend the vertebral column (from above or below), fixate the cervicothoracic And yes… I acknowledge the Rotatores, Interspinales & Intertranversarii muscles as well!  juncon or extend the neck.

T/S: Anatomy & Biomechanics T/S: Anatomy & Biomechanics

Key Muscles of the Thoracic Spine Hypaxial Muscles • Key Muscles of the Thoracic Spine Internal and Part of the hypaxial muscle group. The external oblique runs caudoventral from ribs four to external twelve and from the thoracolumbar fascia. It inserts into the abdominal aponeurosis and • Hypaxials oblique linea alba and caudally to the pubis. The internal oblique runs cranioventrally, and – Abdominals abdominals originates from the ventral iliac crest and fascia and inserts onto rib 13 and 12 as well as the linea alba. Both muscles act to compress the abdominal viscera (which aids in expiraons, • Obliques urinaon, defecaon and parturion), and also enables flexion of the vertebral column • Rectus Abdominis (bilateral acon) or lateral bending of the vertebral column (unilateral acon). Rectus Rectus abdominis originates via a tendon from the sternum, the first costal carlage and rib • Transverse Abdominis abdominus as well as the 9th costal carlage. It inserts onto the pubis. It acts to compress the abdominal viscera, support the abdominal viscera and bring the pelvis forwards or flex the back. Transverse Deepest of the abdominals, it originates from the lumbar vertebrae and the thoracolumbar Abdominal fascia, as well as the medial sides of ribs 12 and 13 and the costal carlages of ribs 8 and 11. It inserts onto the linea alba and abdominal aponeurosis to the pelvis. Its acons are the same as for the obliques. It has been found in humans to have a significant role in control of intra-abdominal pressure, tensioning of the thoracolumbar fascia, stabilizaon of intervertebral moon, as well as support for the sacroiliac joint.(Hodges 2004)

T/S: Anatomy & Biomechanics T/S: Anatomy & Biomechanics

Key Muscles of the Thoracic Spine • Key Muscles of the Thoracic Spine Rib Muscles

• Rib Muscles Internal & Both muscles arise between the ribs and costal carlages. The externals run – External and Internal Intercostals external caudoventrally, while the internals run cranioventrally. They act to assist in intercostals inspiraon and may provide some resistance to twisng movements.

S/S of Thoracic Spine Dysfuncons S/S of Thoracic Spine Dysfuncons

• Human Symptomology:  Canine Symptomology: – Pressure headaches, . Exaggerated kyphosis or lordosis of the thoracic – Aching at the back of the shoulders, over the pelvis, in region, the axilla or medial side of the elbow, . Discomfort to peng over the thoracic region, – Heaviness and redness of the arms or legs, . Expression of pain with jumping or moving while in a – A glove distribuon of symptoms, recumbent posion, wrestling with other dogs, – Traumac girdle pain, . Forelimb lameness or limb favouring, – Scapular / abdominal / kidney pains / chest pain or . Head-down posturing, indigeson, – Upper limb/shoulder mobility restricon, . A reducon in athlecism, – Shoulder impingement-type pain. . Excessive stretching (‘down-dog’). Maitland et al 2005; Hengeveld and Banks 2005 LEH clinical observaons

Palpaon Concepts Palpaon Concepts

•  Postural analysis Posture – Kyphosis, lordosis, scoliosis, body condion . Reveal nothing OR show a segmental rotaon  Mulsegmental sﬀness alters thoracic curve • Temperature . exaggerated kyphosis, reduced lordosis, or scoliosis – Non-inﬂammatory Increase of temp.  Acute zygapophysial joint sprain • Thickening . produces localized pain over the involved joint – Chronic lesions may be thicker in the interspinous  Chronic restricon of either the zygapophysial or space costovertebral joint • Abnormal muscle tone . produces symptoms removed from the source – Hypertonic (acute) or hypotonic (chronic) ▪ (contralateral side of the thorax or at levels above or below). – Atrophy Maitland et al 2005; Hengeveld and Banks 2005 Maitland et al 2005; Hengeveld and Banks 2005

General Moon Tesng Concepts General Moon Tesng Concepts

• Movement awareness • Acve Moon Tesng – Assess the quality (i.e. sensaon throughout – Cookie stretches moon plus the endfeel) • Willingness and/or ability – Assess the quanty (i.e. ROM) • Movement compensaons – Assess for symptoms (i.e. pain responses) • Generally, facet joint movement restricons may be too subtle for the examiner to noce in this manner

General Moon Tesng Concepts General Moon Tesng Concepts

• Joint Play • ARTHOKINEMATICS – The general sense of the moon within a joint. • Arcular funcon (aka “form closure”) – Used to narrow the examiners search for the – HYPOMOBILITIES lesion – An increase in sﬀness in the neutral zone and a – Tested in the joint’s neutral posion harder end feel in the elasc zone are noted on – Light pressure & gentle hands passive tests for arthokinemac funcon. – The sﬀness has a solid stop.

Limited amount of joint play Moderate amount of joint play

General Moon Tesng Concepts

• Adjuncve tests – X-rays may be useful to reveal serious bone disease and signiﬁcant mechanic defects, but rarely provide guidance for manual therapy.

Clinical Diagnosc Tests & T/S Palpaon Treatment Techniques  Review:  Speak now or forever hold your peace....  Can you: • Direct palpaon of the spinous processes T1 – T13 • Palpaon of the ribs 1 – 13 Let’s get to the dogs! • Palpaon of the sternum (including the manubrium and xiphoid process) • T10 & T11 are found in the ‘dip’ in the middle of the dogs back Manual testing – What techniques have you been praccing? (Adapted for the canine by L. Edge-Hughes – Do we need to review anything? from D. Lee 2003)

T/S Review – localize the lesion T/S Review – localize the lesion

• Bilateral Transverse Process Posterior – Anterior • Bilateral Transverse Process Posterior – Anterior (Dorso-Ventral) Pressures: (Dorso-Ventral) Pressures: – Use a thumb and index knuckle to do a P-A on the transverse processes / arcular pillars simultaneously. • This may give you informaon as to where along the thoracic spine there is sﬀness (hypomobility). • Be sure to support under the belly or chest. • Assess for quality and quanty of movement, end feel and pain. – Angle slightly cranially above T9/10 and straight up and down for T10/11 and below. Feel for stiffness in the neutral zone – However, to isolate which facet is problemac, you will and the end feel at need to do a unilateral P-A/(D-V). the anatomical barrier Assessment or treatment

Feel for stiffness in the neutral zone and the end feel at T/S Review – localize the lesion T/S Review – localize the lesion the anatomical barrier • Unilateral Transverse Process Posterior – Anterior • Unilateral Transverse Process (Dorso-Ventral) Pressures: Posterior – Anterior (Dorso- – Pressing down directly on one transverse process / Ventral) Pressures: arcular pillar will examine the rotaonal or side bending mobility of the vertebra. – Angle slightly cranially above T9/10 and straight up and down for T10/11 and below. • Be sure to support under the belly or chest. • Assess for quality and quanty of movement, endfeel and pain.

Assessment or treatment

Feel for stiffness in the neutral zone T/S Review – localize the lesion T/S Review and the end feel at the anatomical barrier • Individual side bend / rotaons: • Individual side – Using the side of the spinous processes and bend / rotaons: a) Push the spine away from one side, while pulling the hips or shoulders in the opposite direcon, with the dog in standing or lying b) Push the spinous process towards the ﬂoor with the dog in side lie (Note: This test is most appropriate for the thoracic spine – above the level of T9/T10 usually)

Assessment or treatment

Passive Physiologic Intervertebral Movements Passive Physiologic Intervertebral Movements (PPIVMS) & Treatment Techniques (PPIVMS) & Treatment Techniques • ARTHOKINEMATICS • ARTHOKINEMATICS – Ventral translaon glide (spinal): – Dorsal translaon glide (spinal): • Fix one vertebra via the spinous process (pinch it and • Fix the vertebra below (pinch it and hold it caudally) hold it caudally) and the push the superior vertebrae and then push through the thorax/chest and feel the with a dorsoventral pressure translaon and end feel.

Feel for stiffness in Feel for stiffness in the neutral zone the neutral zone and the end feel at and the end feel at Assessment the anatomical Assessment the anatomical or treatment barrier or treatment barrier

Passive Physiologic Intervertebral Movements Passive Physiologic Intervertebral Movements (PPIVMS) & Treatment Techniques (PPIVMS) – Assessment only... • ARTHOKINEMATICS • ARTHOKINEMATICS – Transverse rotaon glide (spinal): – Lateral Translaon Glide: • Fix the spinous process (pinch it and hold it caudally) of • For segments T3/4 to T10/11 and associated ribs. Compress one vertebra and push laterally on the spinous process one rib (i.e. le rib 6) (from the of the vertebra above. Repeat in both direcons: lateral side or dorsolateral side) and shear the contralateral rib just above (right rib 5) PURELY & medially in the transverse plane. • NORMALLY, there should be Feel for stiffness in lile/if any movement or pain. the neutral zone • The primary structure being and the end feel at tested is the disc! Lateral translaons (stress test Assessment or the anatomical for the disc) treatment barrier Assessment typically… but I use it to treat too!

T/S: Spinal Treatment Techniques T/S: Spinal Treatment Techniques

• CONCEPT – Regarding Dorsoventral Pressures • CONCEPT – Regarding Dorsoventral Pressures • To Stabilize above or below? (T1/2 – T9/10) • To Stabilize above or below? (T9/10 – L6/7) – When performing the D-V pressure you can be – When performing the D-V pressure you can be more specific as to whether you are ‘opening’ the more specific as to whether you are ‘opening’ the facet(s) or ‘closing’ the facet(s). facet(s) or ‘closing’ the facet(s). • If you stabilize the spinous process caudal to the ‘moving’ • If you stabilize the spinous process caudal to the ‘moving’ spinous process, and glide cranially, then you are spinous process, and glide ventrally, then you are closing opening (flexion of) the facet(s) – i.e. Hold T7 caudally (extension of) the facet(s) – i.e. Hold T13 caudally while while gliding T6 cranially gliding T12 ventrally • If you stabilize the spinous process cranial to the • If you stabilize the spinous process cranial to the ‘moving’ spinous process, and glide cranially, then you ‘moving’ spinous process, and glide ventrally, then you are closing (extension of) the facet(s) – i.e. Hold T6 are opening (flexion of) the facet(s) – i.e. Hold T12 caudally while gliding T7 cranially cranially while gliding T13 ventrally

T/S: Spinal Treatment Techniques T/S: Spinal Treatment Techniques

• CONCEPT – Regarding Unilateral Facet Joint • CONCEPT – Regarding Unilateral Facet Joint Restricons. Restricons. • To Block or Assist Side bend/Rotaon techniques? • To Block or Assist Side bend/Rotaon techniques? – When side bending the dog you can either: Assisng Blocking This is what you have • Push the spinous process of the segment to be treated been taught AWAY from the side bend moon (ASSISTING movement) already • BLOCK the spinous process from moving away from the side bend moon (thus stopping further moon down the spine and making the end of moon occur at that This is a new concept speciﬁc segment)

TRY BLOCKING – compare to assisng

T/S: Spinal Treatment Techniques T/S: Spinal Treatment Techniques

• CONCEPT – Regarding Unilateral Facet Joint • CONCEPT – Regarding ANY Facet Joint Restricons. Restricon in the Dog. • For Flexion or Extension lesion? – The problem is usually poor opening of a facet joint. (You can default to ﬂexion techniques if you are – If you think the restricon is of the facet joint that unsure of the lesion) would be opening, then do the side bend/rotaon – If a dog has an increase in pain or exhibits a pain in FLEXION of the spine response (i.e. Yelping &/or root signature stance – If you think the restricon is of the facet joint when tesng the Cervico-thoracic region or Lumbar closing, then do the side bend/rotaon in region), when you are doing an EXTENSION EXTENSION of the spine technique or a BLOCKING technique – you may be dealing with an osteophyte encroaching on the nerve root foramen. TRY in Flexion & Extension

T/S: Spinal Treatment Techniques T/S: Spinal Treatment Techniques

• Any zygapophysial restricon – Posion the animal standing or sing. – At the site of the lesion (localized with assessment for tenderness), press on the side of the spinous process, one direcon at a me. Note the degree of discomfort and mobility of each direcon. – Work with the direcon that is most sﬀ (and oen most uncomfortable) • Firstly apply a pressure in the opposite direcon to the spinous process of the vertebra cranial and then to the one caudal. • One of which will exaggerate the discomfort and one of which will relieve it / be less reacve. • Chose to mobilize whichever of these two direconal forces NEW... that relieves the symptoms / is less reacve. Try it!

T/S: Spinal Treatment Techniques T/S: Tracon

• Tracon: • Tracon: – This technique restores a bilateral restricon of With the dog in sternal recumbency, flexion. kneel beside the dog or straddle over it (facing the same direcon as – Cervical tracon with the head and neck the dog). posioned in flexion should address the upper Now with your thumbs push away thoracic spine on the back of the dog’s skull (on either side of the occiput). – Lumbar tracon (i.e. a standing tracon) will Go very slowly and the dog should target the mid thoracic spine and all vertebral lower its head to rest its chin on the floor. segments caudally. Maintain a slow and steady pressure. Neck tracon in sternal recumbency

T/S: Tracon T/S: Tracon • Tracon: • Tracon:

With the dog laying on his/ Posion the animal (and yourself) so her side and the head flat on that the dog’s neck can be supported the floor. over your thigh (standing or lying depending upon size of the dog). Use one hand just under the dog’s muzzle to prevent the With a wide pinscher grip, grasp head from being pushed into behind the skull and slowly push it flexion and the other hand away. on the back of the skull to create the tracon. The other hand braces the animal’s shoulders or withers.

Neck tracon over the examiner’s thigh Neck tracon in side lying

T/S: Tracon T/S: Tracon

• Tracon: • Tracon: – Tail pulls: Grasp the base of the tail and gently – One-man standing tracon: Straddle the dog, facing backwards. Have your pull back on it, in an arch that matches the arch of legs posioned just behind the shoulder the dog’s rump. Hold the animal’s pelvis so as to blades and allow your own heels to maintain it in posion. touch each other under the torso of the dog. Bend over and place your hands in front of the dog’s pelvis (hands wide spread – using the web space border again. Be careful not to dig into the groin of the animal). Straighten your legs (to squeeze the animal) and push the pelvis away from you.

T/S: Tracon T/S: Tracon

• Tracon: • Tracon: – Small dog hanging tracon: Slowly and gently pick up the dog so that its spine is – Speciﬁc tracon: Grab one against your chest. Hold it in a ‘bear hug’ spinous above the site to tracon with two arms if necessary (i.e. heavier dog) and one spinous process below (if or with one arm to hold and the other arm to support under the bu or under the legs the area is too tender, then raise depending on the comfort of the animal). and/or lower the vertebra used to Straighten up or stand up, so that the tracon through so as to be animal’s feet come oﬀ of the ground and further away from the painful the weight of the lower body is traconing the spine. You can allow wiggly dogs to area) and pull apart (distract). touch the ground with their toes or if you want to add extension into your tracon.

T/S: Rib Techniques - Review T/S: Rib Techniques - Review

• Assessing the posion of the ribs: Palpate both • Ribs Dorsal glide Ventral glide dorsally and ventrally and compare the posion from side to side and also in comparison to the ribs adjacent cranially and caudally. Palpate for tenderness also. (Best done in standing) • Assess ‘general’ mobility of the ribs. Push downward from the top at the costovertebral juncon. Pull up from below at the sternocostal juncon or costochondral juncon • Mobilize: Dorsal glide & Ventral glide

T/S: Rib Techniques – New Concept T/S: Rib Techniques – New Concept

• Ventral translaon glide (with improved speciﬁcity): • Dorsal translaon (with speciﬁcity for the sternocostal juncon): • Stabilize the two associated NOTE posion of the ribs spinous processes (i.e. T4 + (ventral surface) looking for T5) away from the rib to be a step deformity, or a gap in mobilized the joint line at the • With your other hand push Stabilizing sternocostal juncon. Mobilizing ventrally on the rib to be hand • Stabilize the sternum hand treated (i.e. Rib 5). and push on the ventral aspect of the costocarlage/rib and push dorsally (upwards).

T/S: Rib Techniques – New Concept T/S: Rib Techniques - Review

• Cranial – caudal rib glides: • Ribs 1 - 4 localizaon – Fix the corresponding spinous process (pushing it – NOTE: to the contralateral side) and push cranially or – RIB ONE can be accessed adjacent to the sternum caudally on the corresponding rib to assess the and working one’s way inwards towards the glide at the costotransverse joint. cervical spine.(Midpoint between the manubrium and the greater tuberosity of the humerus) – RIBS 1 - 3 (and somemes 4) are located under the scapula but can be accessed (at the rib angle) by maneuvering a ﬁnger or thumb under the caudal aspect of the scapula with the shoulder joint in a slight degree of ﬂexion.

T/S: Rib Techniques - Review T/S: Rib Techniques - Review

• Assessing Rib one: – With the dog in sing: Simultaneously assess both first ribs with either fingers or thumbs lying overtop of these ribs, located by moving dorso-caudo-medially from either side of the manubrium (towards C7). – Feel for posion and/or push ‘downward’ (caudal) individually on the top of these ribs to assess for discomfort and sffness.

T/S: Rib Techniques - Review T/S: Rib Techniques – New Concept

MOBILIZE: • Rib One Push down on the one that is • – Caudal glide with improved specificity ‘high’ (caudal glide) – Glide rib one caudally (first fixate the T1 spinous process by pushing it to the contralateral side). Feel for end feel and sffness.

Caudal glide of rib 1

• Yipe!

T/S: Rib Techniques – New Concept T/S: Rib Techniques – New Concept

• Rib One (for a rib in a cranial posion) • Rib One In humans – with elevated rib one • Cranial glide (for a caudally displaced ‘rib one’ that is issues, the Scalenes are oen ght or tender on palpaon) shortened and can ‘hold’ rib one in a cranial posion. • From under the axilla place your thumb against Stretch Scalenes by pressing caudally the caudal border of rib 1, (downwards) on rib one while turning and then glide the spinous the dogs head to the contralateral side. process of T1 caudally. • Feel for end feel and You may also want to massage in the sﬀness. same region to release the tension in the Scalenes.

T/S: Rib Techniques – New Concept T/S: Rib Techniques – New Concept

• Ribs – Generic Treatment Technique • A distracon mobilizaon or manipulaon – Localize the angle of the rib and posioning your thumb at this spot. – Your other thumb is placed across the ipsilateral side of the spinous processes of the two corresponding vertebra to stabilize. – The mobilizaon / manipulaon occurs by creang a lateroventral pressure with the thumb on the corresponding rib at the ‘rib angle’.

T/S – Force Closure T/S – Force Closure

• Neuromyofascial funcon (force closure) – In humans, this test would be a prone arm li, watching for the paent’s method of thorax stabilizaon. – A similar construct could be created in the dog, with a standing unilateral front leg li (watching for stabilizaon and control of balance), or a diagonal leg stand. – The thorax should not rotate, side bend, ﬂex, extend or translate, and the scapula should not move on the weight bearing side.

T/S – Force Closure T/S – Force Closure

• Neuromyofascial funcon (force closure) • Neuromyofascial funcon (force closure) – The deep small stabilizer muscles of the thorax (such as mulfidus and the intercostals) can atrophy subsequent to injury to the thorax. • Firmly palpate the ‘guer’ between the spinous process and the transverse process (mulfidus) and feel for firmness and size of the muscles (comparing side to side and above and below),

• Then palpate between each palpable rib (intercostals) Palpaon of mulﬁdus between the Palpaon of the intercostals between and compare with adjacent and contralateral sites. spinous process and transverse the ribs process

T/S: Neural Conducon & Mobility T/S: Neural Conducon & Mobility

• Neural conducon and mobility • Neural conducon and mobility – The adjacent muscles (the epaxials, hypaxials, and – In the human, a dural slump test might reveal intercostals) can be palpated for appropriate muscle thoracic pain, which is relieved by head and neck bulk and tone. Segmental facilitaon leads to extension. hypertonicity (inially) and reduced motor funcon – It has been determined that vertebral column which causes atrophy (secondarily). flexion in the dog can create a very small gliding distance at the T13 – L1spinal levels. – Hyperaesthesia can be one of the first signs of a (Gruenenfleder et al 2006) neurological interference and tend to occur long – Other thoracic segments have not been tested, but before sensaon becomes reduced. it is reasonable to hypothesize that the dura at other thoracic levels could be put into tension in a full flexion posion

T/S: Neural Conducon & Mobility T/S: Force Closure and Motor Control

• Force Closure and Motor Control: – The four muscles of interest for the stabilizaon of the lumbopelvic region are the diaphragm, transverses abdominis, deep fibres of mulfidus and the pelvic floor. – Based on the anatomy of the thoracic region, it is hypothesized that the deep segmental muscles (i.e. mulfidus) will have a similar funcon in the thoracic region.(Lee LJ 2003)

Dural tension test: vertebral column ﬂexion

T/S: Force Closure and Motor Control T/S: Force Closure and Motor Control

• Force Closure and Motor Control: • Stabilizaon training – Restoring tonic funcon of these muscles is – 3-leg standing, liing one front leg oﬀ the ground, essenal for regaining segmental stability. while cueing the segmental muscles (mulﬁdus) by – Stretching, elongang and/or relaxing larger more palpang & rubbing just adjacent to the spinous dominant global muscles that could be over-acvely process in the ‘guer’ between the spinous process aempng to stabilize the thorax may need to be and the erector spinae muscles OR by cueing the addressed for normalizaon of movement and abdominals. This exercise can be progressed by funcon. having the animal perform it on an uneven surface – Addionally, the most common component lost in such as a wobble board or balance disc. human paents with thoracic dysfuncon is lateral costal expansion.(Lee LJ 2003)

T/S: Force Closure and Motor Control T/S: Force Closure and Motor Control

• Stabilizaon training • Rotaons in standing: – 3-leg standing... – In a stable standing posion, impart a rotaon (twist) to the thorax with your hands spread out wide over the torso (one moves ventrally and the other moves dorsally). – The animal must stand and acvely resist this force. This can be done as an isometric hold technique in order to acvate mulﬁdus and/or the intercostals.

3-leg standing smulaon 3-leg standing smulaon of of mulﬁdus abdominals

T/S: Force Closure and Motor Control T/S: Force Closure and Motor Control

• Stretches: – Stretching out of the dominant global muscles in the thoracic spine can help to normalize an over acve stabilizing mechanism. – Key muscles to evaluate for over-acve resng tone or adapve shortening are the erector spinae, rhomboids, the lassimus dorsi, the rectus and both oblique abdominal muscles.

Torso rotaons in standing

T/S: Force Closure and Motor Control T/S: Force Closure and Motor Control

Stretching Examples • Lateral costal expansion: – Ulizing a cardiopulmonary therapy technique, posion the paent in sing or standing, and as the paent exhales, gently compress the lateral ribs a bit further. – The technique occurs either in one compression movement or a succession of two or three compressions that build in compression force. Stretch of the cervical ﬁbres of – Then quickly release your hands, smulang a rhomboids greater inhale and lateral costal expansion. – Stretch of the thoracic ﬁbres of The praconer should try to me the technique rhomboids with the normal breathing paern.

T/S: Force Closure and Motor Control The Thoracic Spine

• Key Points to Return to Acvity and Strengthening – Focus ﬁrst on low loads and control of movement – Avoid fast ballisc movements in early stages – Progress from stable to unstable surfaces – For upper and middle thoracic control, incorporate greater arm movements – Work on high load and high speed acvies at the end stages. Lateral costal expansion

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