Advancing the Understanding and Treatment of the Thoracic Inlet and Incorporation of a New Still Technique—Part 1 Drew D. Lewis, DO, FAAO, FNAOME, FAOCPMR, FAAPMR FAAO THESIS Abstract From the Des Moines University College of Osteopathic The osteopathic profession has long emphasized the importance of Medicine in Iowa. improving homeostasis and overall health through the use of osteo- Financial disclosures: none reported. pathic manipulative treatment (OMT). The respiratory-circulatory model seeks to achieve these goals by resolving somatic dysfunc- Correspondence address: tions (SD) that may restrict venous and lymphatic return. One of Drew D. Lewis, DO, FAAO, FNAOME, FAOCPMR, the most significant somatic dysfunctions to address in this model FAAPMR is the thoracic inlet. Despite the emphasis on this somatic dysfunc- Associate Professor, OMM Department tion, classic treatment approaches of the thoracic inlet remain some Des Moines University College of Osteopathic Medicine of the most challenging corrections. 3200 Grand Ave Des Moines, IA 50312 In this article, an approach to somatic dysfunction of the thoracic (515) 271-1429 inlet (SDTI) with a new application of Still technique principles [email protected] is presented. This technique offers a safe, efficient, and effective Submitted for publication April 24, 2017; final revision treatment approach for patients who may present with substantial received September 7, 2017; manuscript accepted for comorbidities. Considerations for difficult to correct SDTI are dis- publication October 19, 2017. cussed. In addition, a more global approach is presented—with an awareness of the dynamic structural relationships and functionality Dr Lewis prepared this manuscript as one of the of the region—to treat SDTI with enhanced success. requirements to earn fellowship in the American Academy of Osteopathy. The Committee on Fellowship Introduction in the AAO provided peer reviewing for this article, and The thoracic inlet, or most superior aspect of the thorax, is a it was edited to conform to the AAOJ’s style guidelines. body region that holds common and clinically significant somatic Because of the length of this manuscript, it has dysfunctions. Located at the junction between the cervical spine been divided into two parts. The second part will be and the thorax, it is a transition point in which the spine’s sagittal published in the March 2018 issue of the AAOJ. plane curve reverses and therefore is subject to increased stresses and potential for injury.1,2 In addition, it is a region of significant communication of neural, vascular, lymphatic, and musculoskeletal lymphatic drainage, therefore, may start at an area Zink described structures from the head and neck to the trunk and appendages.3 as the site of “terminal drainage,” the thoracic inlet.8,9,3(p50,87),10,11 Many osteopathic manipulative medicine (OMM) treatment Challenge of treating the thoracic inlet region approaches include evaluation and treatment of the thoracic inlet, Successful OMT of SDTI can be challenging, which is one of the perhaps most exemplified by the respiratory-circulatory approach reasons we see so many techniques for the thoracic inlet (Walter C. of J. Gordon Zink, DO.1(p786),3(p111),4,5 Zink detailed the importance Ehrenfeuchter, DO; e-mail communication; March 10, 2015). A of maximizing diaphragmatic respiration for improved homeostasis single technique approach may not always resolve the somatic dys- and overall health. Diagnosis and treatment of SDTI improves not function and ultimately achieve one’s goals. For instance, the SDTI only lymphatic drainage from the head and neck6 but also from the restriction can be myofascial and/or articular in nature and effective entire body.3(p9,87),4(p490),7 A classic treatment approach to enhance (continued on page 20) The AAO Journal • Vol. 27, No. 3 • December 2017 Page 19 (continued from page 19) The aim of Zink’s whole body approach with OMM is to pro- treatment may involve addressing both components (Paul R. Ren- mote effective negative intrathoracic pressure through improved nie, DO, FAAO; e-mail communication; May 15, 2015). bellows mechanism of the thoracic cage and thoracoabdominal diaphragm.16 This approach improves venous and lymphatic Fascial dysfunction of the thoracic inlet can be associated with return and facilitates a return to homeostasis and improved over- everyday microtrauma of abnormal head carriage (eg, head-forward all health.1(p793,799),10,11,14,15 Zink detailed a whole-body structural posture) as well as stresses from the myofascial connections to the evaluation focused particularly on somatic dysfunctions related to shoulders.8 Additionally, there are fascial connections between the abnormal fascial patterns directly affecting the four diaphragms scalenes, first and second ribs, and more directly between the scale- to quickly determine “problem areas that inhibit diaphragmatic nus minimus, pleura, and Sibson fascia. Because of these significant breathing.”14 connections, scalene hypertonicity itself may contribute to conges- tion and provide further a challenge to correcting the elevated first Zink’s common compensatory pattern rib component of the thoracic inlet.12,13 When examining fascial patterns related to the major diaphragms, Zink found that a majority of patients had common findings.8,14 Viscerosomatic relationships with organs in the thoracic cage as Found at the transitional areas, the common fascial patterns, or well as organs of the head and neck may, through facilitation, common compensatory pattern (CCP), were found to alternate introduce strain and SD in the upper thoracics. This may confound when viewed from top-down or bottom-up (Figure 1). These com- one’s diagnosis or even contribute to atypical patterns (which Zink mon fascial patterns were related to normal torsional movements termed disparent) that do not follow the common compensatory (continued on page 21) alternating fascial patterns.14 An example would be a patient with a chronic cardiac condition who may have left-sided paraspinal Figure 1. Alternating fascial patterns of CCP at transitional zones. changes and segmental dysfunction of the upper thoracics which may alter or add a layer of dysfunction to the more common com- pensatory pattern of right-sided rotation (G. Bradley Klock, DO, FAAO; e-mail communication; March 10, 2015). Newer approaches for treatment of the thoracic inlet Newer OMM techniques for thoracic inlet have expanded the possibility of treatment options from the more traditional direct approaches with muscle energy (ME) and high-velocity, low- amplitude (HVLA) to newer indirect approaches. Increasing the pantheon of treatment choices provides more options: a) for the clinician who may feel his or her skill-set matches best with a par- ticular treatment; and b) for the clinician who is comfortable with all technique styles but who feels a particular technique may be best suited for a particular patient encounter. It also serves to provide a more comprehensive approach for a highly clinically relevant and sometimes challenging somatic dysfunction. Respiratory-Circulatory Approach to Treatment/CCP Respiratory-circulatory model of treatment Following in the traditional teachings of Andrew Taylor Still, MD, DO, the respiratory-circulatory model seeks to use OMT to help maximize the body’s own healing potential. A primary focus is on allowing the body to optimally deliver cellular nourishment through circulation of oxygenated arterial blood and the removal of cellular waste products.12 A key component is the movement of low-pressure fluids, eg, the lymphatic system.15 Page 20 The AAO Journal • Vol. 27, No. 3 • December 2017 (continued from page 20) cussion of treating the obstetric patient, Zink proposed his treat- of the body as in the walking cycle and were felt to contribute to ment sequence of starting with addressing the thoracic inlet, the postural balance.2 While a goal for Zink was to return patients to upper thoracic vertebra and ribs and then the lower, the thoraco- the physiologically perfect “holographic image” (neutral, free of abdominal transitional area, the lumbosacral transition area, and SD), patients in CCP were at least in a more posturally balanced, then proceeding to treat the cervical region before moving to the compensatory pattern. extremities. 10 CCP for the thoracic inlet Biomechanics: CCP findings for the SDTI include the first thoracic vertebra Relationship Between Structure and Function rotated and sidebent right with the first rib elevated on the left.18 This somatic dysfunction may be appreciated on a supine patient Relevant anatomy of the thoracic inlet when palpating the most superior aspect of the first rib in the In the anterior region of the thoracic inlet is the articulation of the supraclavicular region. In CCP, the left side will be statically more first rib with the manubriogladiolar junction of the sternum. Poste- superior, and it will resist dynamic inferior pressure. Palpation riorly, the first rib articulates with T1 by a unifacet, and the second of the costoclavicular region just lateral to the manubrium and rib has two demifacet articulations, connecting it with T1 and T2.3 more laterally to the infraclavicular region will feel more posterior or “concave” and dynamically compress posteriorly more on the The anatomical thoracic inlet is defined as being bounded by the right.14 manubrium of the sternum anteriorly, the first thoracic vertebra posteriorly, and the right and left first ribs laterally.8,9,20