The Thoracic Ring Approach – Connect the Whole Body & Optimize Performance Created by Dr. Linda-Joy (LJ) Lee Support & Reflect Function of Multiple Systems in the Whole Person – Musculoskeletal, Neurological, Vascular, Respiratory, Emotional … and Desired output for the Task = “Beautiful movement” Original Material Created & Developed by: Dr. Linda-Joy (LJ) Lee, PhD www.ljlee.ca @ 1LJLee Facebook.com/LJLeeConnected A Healthy System has Choice “My hips feel stiff” “My right side feels wrong” “My right ankle pinches” “My right hip hurts when I squat” “I leak when I squat with high loads” Specific to Task & to Individual It depends on what is “driving” the strategy... How do we figure that out? Where is the true “driver”? You’ll make his right hip feel better, but he’ll get pain somewhere else…or change will be temporary Dr. Linda-Joy Lee Physiotherapist Corp. © synergyphysio.ca ljlee.ca Twitter @1LJLee The Thoracic Ring Approach – Connect the Whole Body & Optimize Performance Created by Dr. Linda-Joy (LJ) Lee Correcting the Right Hip Makes the Upper Thorax Translate Left/Rotate Right, and makes the Left Foot Loading Non-Optimal 4th/ 3rd Ring Correction, Thorax Driven Hip The Thoracic Ring Approach You’ll make his right hip feel better, but he’ll get pain somewhere else…or change will be temporary How do we Find the Driver to Change Strategies? It depends on what is Vision? Need clinical reasoning models to find “driving” the strategy... the driver for non-optimal strategies & Treatment determine where in the body is toprescriptive, focus Lumbar based on the underlying treatment & motor control training Spine? impairments Foot? Thoracic Driven Recurrent Hamstring Pain 6/10 to 0/10… does this fit with what we know from chronic pain sciences? What is happening here? Changing Strategies for Posture & Movement is a way to change their experience of their body & reconceptualize pain Changing how you live and move in your body changes your relationship to your body… Dr. Linda-Joy Lee Physiotherapist Corp. © synergyphysio.ca ljlee.ca Twitter @1LJLee The Thoracic Ring Approach – Connect the Whole Body & Optimize Performance Created by Dr. Linda-Joy (LJ) Lee “I have very restricted left rotation – that’s why I wonder how I can function without pain in my thorax” But she has pain in other places… “I can release and massage my posterior hip muscles to relieve my groin pain, but the pain keeps coming back when I ride my bike” Multiple possible mechanisms to explain these clinical observations – LJ’s hypotheses in The Thoracic Ring Approach ? When it is painful minimal data ? When it is dysfunctional sometimes helpful, sometimes not, sometimes makes you worse - doesn’t guarantee results, decreases pain but pain still present Dr. Linda-Joy Lee Physiotherapist Corp. © synergyphysio.ca ljlee.ca Twitter @1LJLee The Thoracic Ring Approach – Connect the Whole Body & Optimize Performance Created by Dr. Linda-Joy (LJ) Lee ? When it is painful minimal data ? When it is dysfunctional sometimes helpful, sometimes not,information sometimes makes Is this enough to you worse - doesn’t guarantee results, guide your clinical decreases pain but pain stilldecisions? present Options…. - Assess everything and treat any dysfunction you find - Treat the thorax if local treatment isn’t getting results Alternately… Use a series of tests to assess whether dysfunctional and painful areas are linked… generate a hypothesis around whether the thoracic dysfunction is contributing to the pain experience / underlying pain mechanisms But… What if the altered thoracic biomechanics are compensatory – ie. trying to unload a painful structure above, below, beside.. they could get worse…. • New way of assessing and treating the thorax – the functional spinal unit of the thorax is a “ring”, specific manual techniques to assess integrated “ring” function during tasks & “ring” treatment techniques, integrates neuromuscular control with other system impairments (articular, visceral, myofascial) that can affect ring function And determine Whether intervention directed to the thorax will impact their strategies for function and performance • Clinical reasoning framework to determine when and when not to treat the thorax to restore optimal function and performance for whole body tasks – when is the thorax “the primary driver” for distal pain & whole body function? these principles became part of the ISM (Lee & Lee 2008) Dr. Linda-Joy Lee Physiotherapist Corp. © synergyphysio.ca ljlee.ca Twitter @1LJLee The Thoracic Ring Approach – Connect the Whole Body & Optimize Performance Created by Dr. Linda-Joy (LJ) Lee • Thoracic spine - largest region of the vertebral column ~ 20% of overall body length (vs. lumbar spine 12%, cervical spine 8%) • “thorax” - complex arrangement of vertebrae, ribs, cartilage, sternum/ manubrium – plus internal cavity (Gray’s anatomy) “Thorax” = Thoracic Spine + Ribcage Thoracic Ring Approach LJ Lee 1999 - present 5th ring = T4-T5, right and left 5th ribs, anterior attachments to sternum Around 9th ring – smaller attachment to superior vertebra, but still strong radiate ligaments T1 T1 AxR T7 Slump Upper AP Man Man T7 AxL St AxR Axilla AP Axilla Lat AxL St 9R 9L T12 9R 9L Lower Lat Military upper AP & lower lat Rotation upper AP & 4th AP L3 L3 S2 Diameters upper and 4th AP lower lat abdo AP 4th Upper AP Axilla Lat lat Axilla AP 9L Lower Lat Umb Abdo AP Abdo AP Lee LJ, Chang AT, Coppieters MW, Hodges PW Changes in sitting posture induce multiplanar changes in chest wall shape and motion with breathing. Respir Physiol Neurobiol 2010 Lee LJ, Chang AT, Coppieters MW, Hodges PW Changes in sitting posture induce multiplanar changes in chest wall shape and motion with breathing. Respir Physiol Neurobiol 2010 Dr. Linda-Joy Lee Physiotherapist Corp. © synergyphysio.ca ljlee.ca Twitter @1LJLee AxL The Thoracic Ring Approach – Connect the Whole Body & Optimize Performance Created by Dr. Linda-Joy (LJ) Lee Functional Spinal Unit = Ring Vertebra-disc-vertebra, 2 ribs (left and right), anterior attachments to sternum Fact The thoracic spine and ribcage function in a very integrated manner “Thoracic Ring Approach” Developed by LJ Lee Thoracic Ring Approach LJ Lee 1999 - present From D Lee 1996 Manual Therapy Regional Movements LROT F LSF RROT RSF E Is this a hypomobile R Zt Joint (decreased inferior glide)? Lee LJ 1999 Dr. Linda-Joy Lee Physiotherapist Corp. © synergyphysio.ca ljlee.ca Twitter @1LJLee The Thoracic Ring Approach – Connect the Whole Body & Optimize Performance Created by Dr. Linda-Joy (LJ) Lee Benefits: Farther from axis of rotation of segment greater amplitude of motion to detect, less soft tissue to palpate through, able to assess 3D integrated function of the true FSU – due to strong anatomical attachments the lateral palpation reflects the vertebral motion LJ Lee 2002 Thoracic Ring Palpation Identifies Non-Optimal Translation of 8th Ring on Initiation of Arm Load This cannot be an articular impairment Dr. Linda-Joy Lee Physiotherapist Corp. © synergyphysio.ca FLT = Non-optimal Alignment, Biomechanics, and/or Control for the specific task & individual being assessed ABCs ljlee.ca Twitter @1LJLee The Thoracic Ring Approach – Connect the Whole Body & Optimize Performance Created by Dr. Linda-Joy (LJ) Lee Test for segmental thoracic control evolved into Thoracic Ring Approach – differential diagnosis in upper quadrant, how thorax drives lumbopelvic pain, foot pain, hip pain… etc • Thoracic spine is most commonly manipulated area of the spine • Thoracic spine is most commonly manipulated area of the spine (Adams & Sim 1998) (Adams & Sim 1998) • Commonly believed that the ribcage makes the thoracic spine inherently stable and stiff but biomechanical studies support that the disc is most important to passive integrity of the FSU in the thorax • Commonly believed that the ribcage thoracicthen spineWhy Is If it makes is Stiffthe & Stable inherently stable and Control stiff but Neuromuscular Needed? biomechanical studies support that the disc is most important to passive integrity of the FSU in the thorax Physio Athlete Screening – “Stiff Thorax” pre-injury If it is truly stiff how can it change so quickly? Dr. Linda-Joy Lee Physiotherapist Corp. © synergyphysio.ca ljlee.ca Twitter @1LJLee The Thoracic Ring Approach – Connect the Whole Body & Optimize Performance Created by Dr. Linda-Joy (LJ) Lee What is underlying impairment? Inability to Produce Optimal Biomechanics - Why? Most common impairment in the thorax is non-optimal patterns of neuromuscular control and muscular imbalances The Thorax is Inherently Flexible 13 joints per typical ring = 136 joints that move & thus require neuromuscular control Primal Pictures Dr. Linda-Joy Lee Physiotherapist Corp. © synergyphysio.ca ljlee.ca Twitter @1LJLee The Thoracic Ring Approach – Connect the Whole Body & Optimize Performance Created by Dr. Linda-Joy (LJ) Lee How do you Decide When to Treat the Thorax? It depends on what the patient wants to do… You Need to Assess Tasks that are Based on: • Painful or Aggravating Activities • Difficult Movements • Functional Goals LJ Lee, Canadian Orthopaedic Symposium, Montreal 2008 It’s all about the story… Dr. Linda-Joy Lee Physiotherapist Corp. © synergyphysio.ca ljlee.ca Twitter @1LJLee The Thoracic Ring Approach – Connect the Whole Body & Optimize Performance Created by Dr. Linda-Joy (LJ) Lee Use thoracic ring analysis & correction - determine if correcting thoracic rings have an impact on changing the rest of the kinetic chain & an impact on performance of the task Compare to changing other areas (eg. foot, pelvis, glenohumeral joint, neck, etc.) Pain related to excessive extension at TL junction/ upper lumbar spine – extension “give” controlled with correction of rotational dysfunction upper thoracic rings Release the Non-Optimal Strategy & Restore Alignment Teach a New Strategy for Function & Performance Remove Barriers Based on Meaningful Task Cognitive Emotional Physical Directed to the Primary Driver Re-wire a new neural network for better strategies for whole body movement directed by Meaningful Task The Clinical Puzzle and its Systems Integrated Systems Model for Disability & Pain Physical Impairments - the rest of the puzzle - “Manual Magic” • Stack the rings - most common are neural and visceral vectors that pull the rings into “unstacked” position and prevent optimal neuromuscular control • Release is focused to the vectors pulling on the driving ring – eg. Ring Stack & Breathe (LJ Lee), Release with Awareness (RWA) (Lee & Lee) • Manipulation, Mobilization, dry needling, muscle energy, PNF, neuromyofascial release, acupuncture (desensitize SNS) Dr. Linda-Joy Lee Physiotherapist Corp. © synergyphysio.ca ljlee.ca Teach “Thoracic Ring Stack & Breathe” Twitter @1LJLee The Thoracic Ring Approach – Connect the Whole Body & Optimize Performance Created by Dr. Linda-Joy (LJ) Lee Avoid – “Pull your shoulder blades back and down, Sit really tall, lift your chest” Cue – “Soften your chest, imagine balloons under your armpits, float your shoulder blades, salsa your ribcage, let your shoulders widen, float your thoracic rings” R = Release A = Align C = Connect Teach a New Strategy for Function & Performance Based on Meaningful Task M = Move Segmental, Inter-regional, Postural Equilibrium/ Whole Body Use imagery to facilitate recruitment of deep muscles – determine success by palpating for change in resting alignment in control during initiation of movement and loading Correct position, increase proprioception for improved motor control, increase compression/ stability Both figures show taping to correct a right ring shift Dr. Linda-Joy Lee Physiotherapist Corp. © synergyphysio.ca ljlee.ca Twitter @1LJLee The Thoracic Ring Approach – Connect the Whole Body & Optimize Performance Created by Dr. Linda-Joy (LJ) Lee Maintaining Stacked Rings while Adding Load Integrate Coordination & Timing of Deep & Superficial muscles Rotational challenge while maintaining alignment and stability of the ring(s) Pulley exercises: • Bow & Arrow • Unilateral Cable Push • Rotation with feet pivot Modified Down Dog – Inversion Position Good to Change Pressures, Changes Forces on PF & Diaphragm, Opens up Thorax & Posterior Buttocks, Works on Hip Seating – Don’t Progress to Legs Straight too soon! Walking Lunges with Rotation Etc… Dr. Linda-Joy Lee Physiotherapist Corp. © synergyphysio.ca ljlee.ca Twitter @1LJLee The Thoracic Ring Approach – Connect the Whole Body & Optimize Performance Created by Dr. Linda-Joy (LJ) Lee Key Factors Required for Facilitating Neuroplastic Change Teach a New Strategy for Function & Performance • Finding ‘the way in” to re-wire the neural networks – using principles of neuroplasticity • Focused attention is essential it’s all about awareness • Focused Attention – seems critical • Training tasks that have MEANING • Massed practice – high quality “Neurons that fire together • Sensory input – normalize wire together” Hebb • Positive feedback • In ‘thorax-driven’ cases – the thorax is your ‘key’ to unlock change in strategies Use neuroplasticity to • Importance of Specificity principle create new neural • Prescribe visualization of meaningful task with optimal networks – make new, or, strategy and without pain wake up, brain maps • The FSU of the thorax is the thoracic ring (10 rings in total) and needs to be assessed and treated as an integrated ring • It is a myth that the thorax is inherently stiff & stable – this is most commonly caused by altered neuromuscular control consider how this affects treatment planning for the thorax need to include ways to assess and change neuromuscular control patterns for the thoracic rings and integrate into whole body movement consider how this affects interpretation of current assessment and treatment techniques for the thoracic spine and ribs/ ribcage Dr. Linda-Joy Lee Physiotherapist Corp. © synergyphysio.ca ljlee.ca Twitter @1LJLee The Thoracic Ring Approach – Connect the Whole Body & Optimize Performance Created by Dr. Linda-Joy (LJ) Lee • The Thoracic Ring Approach (LJ Lee) contributes key concepts to The Integrated Systems Model (Lee & Lee) • Both frameworks consider that multiple systems can impact function and the patient’s experience of their body in their Meaningful Task, along with psychosocial features of the person in the middle of the puzzle • These frameworks are based on knowledge from multiple sources Thanks to…. Thanks to…. Assoc. Prof. Michel Coppieters Prof. Paul Hodges www.uq.edu.au/ ccre-spine Prof. Karim Khan Prof. Paul Hodges www.uq.edu.au/ ccre-spine Dr. Linda-Joy Lee Physiotherapist Corp. © synergyphysio.ca ljlee.ca Twitter @1LJLee
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