**2.1 Functional movement**

The thoracic cage is composed of three parts: thoracic spine, ribs, and sternum, which connect to costovertebral and condrosternal joints, and so movement occurs in three dimensions; transverse, antero-posterior and vertical directions (Landel et al., 2005). True ribs (2nd to 8th rib) move more flexibly because of no clavicle obstruction, whereas the 11th and 12th ribs connect to the cartilage, therefore causing less freedom to move.

#### 1. **Flexion and extension**

The basic structure of the costovertebral joint comprises both the angle and neck articulation of the rib with the spine, and is attached to costotransverse and radiate ligaments. In the direction of thorax flexion (Grant, 2001), there is anterior sagittal rotation, when the costovertebral joint moves as anterior gliding that slightly rotates, whereas downward rotation and gliding occur during extension. The lower thoracic spine moves more freely than the upper one. The sternum is composed of the manubrium, body, and xiphoid process, and is anterior with upward expansion when breathing deeply. In fact, when it comes to movement, the manubrium is somewhat fixed to the first rib, whereas the body is more flexible around the 2nd to 7th rib. Thus, movement of the sternum looks like a hinge joint during deep inspiratory and relaxed expiratory phases. For extension, the extensor muscle group is the most active, with a motion range of

2002). Therefore, the technique of chest mobilization helps in chest wall flexibility, respiratory muscle function and ventilatory pumping, and results from this relieve both dyspnea symptoms and accessory muscle use. This technique is still controversial because it lacks clinical evidence, but it does show clinical benefit , especially in COPD by improving

Movement of the thorax is like the pump-handle pattern (Hammon, 1978). Movement of the chest wall is a complex function within the rib cage, sternum, thoracic verterbra, and muscles. Basic observation reveals chest configuration for abnormality of the spine or chest shape, for example, scoliosis, kyphoscoliosis, barrel, or pectus excavatum (Bates, 1987). Normally, in all joint movement at the end of expiration, the intercostal muscles are at a

In assessment, chest stiffness may be caused by muscle structure being applied directly in the supine, side lying or sitting position. Stretching the rib cage, rotating the trunk or lateral flexion of the trunk can be evaluated. Furthermore, suitable lengthening of soft tissue around the chest wall and respiratory muscles is related to the efficency of contraction force and chest movement. In the case of emphysematus lung or air trapping in COPD, abnormal chest configurature and reduced chest movement with shortened muscle length and

Finally, increasing chest movement with stronger contraction of respiratory muscles can help in gaining lung volume, breathing control and coughing efficiency, and reducing symptoms by improving aerobic capacity, endurance, functional ability, and quality of

The thoracic cage is composed of three parts: thoracic spine, ribs, and sternum, which connect to costovertebral and condrosternal joints, and so movement occurs in three dimensions; transverse, antero-posterior and vertical directions (Landel et al., 2005). True ribs (2nd to 8th rib) move more flexibly because of no clavicle obstruction, whereas the 11th

The basic structure of the costovertebral joint comprises both the angle and neck articulation of the rib with the spine, and is attached to costotransverse and radiate ligaments. In the direction of thorax flexion (Grant, 2001), there is anterior sagittal rotation, when the costovertebral joint moves as anterior gliding that slightly rotates, whereas downward rotation and gliding occur during extension. The lower thoracic spine moves more freely than the upper one. The sternum is composed of the manubrium, body, and xiphoid process, and is anterior with upward expansion when breathing deeply. In fact, when it comes to movement, the manubrium is somewhat fixed to the first rib, whereas the body is more flexible around the 2nd to 7th rib. Thus, movement of the sternum looks like a hinge joint during deep inspiratory and relaxed expiratory phases. For extension, the extensor muscle group is the most active, with a motion range of

and 12th ribs connect to the cartilage, therefore causing less freedom to move.

pulmonary function, breathing pattern and weaning from a ventilator.

**2. Biomechanics of chest movement and thoracic spine** 

suitable length before contraction during inspiration.

weakness are experienced (Malasanos et al., 1990).

life.

**2.1 Functional movement** 

1. **Flexion and extension** 

approximately 20-25 degrees. Thorax extension presents the opposite movement to flexion, with backward sagittal rotation by posterior translation and slight distraction of the spine (Neumann, 2002).

Fig. 1. Anterior rotation of the spine during flexion, and posterior rotation during extension. (Grant, 2001; Lee, 2002)

Fig. 2. Extension of the thorax; showing the movement in superior upward and posterior gliding of the costotransverse joint. (Grant, 2001; Lee, 2002)

#### 2. **Lateral flexion**

In flexion direction, the thoracic body rotates slightly on the flexion side, while the posterior rotates in the opposite direction so that the costovertebral joint is opened and inferior

Fig. 3. Biomechanics of lateral flexion to the right; showing the movement of thoracic body and costovetebral joint on both sides. (Grant, 2001; Lee, 2002)

Chest Mobilization Techniques for Improving

**3.1 Soft tissue flexibility** 

muscles, limits chest expansion.

1. Scoliosis or kyphosis (Leong et al., 1999)

5. Myofacial pain or chest pain (Wise et al., 1992)

Ventilation and Gas Exchange in Chronic Lung Disease 403

The theory of Laplace's law suggests that the length of muscle relates to the maximal force of either diaphragm or intercostal muscles, which affect ventilation in the lung (Kisner et al., 1996; Grossman et al., 1982). Previous evidence showed that stretching the anterior deltoid and pectoralis major muscles, including the sternocleidomastoid, scalenes, upper and middle fibers of trapezius, levaytor scapulae, etc., can increase vital capacity (Putt & Paratz, 1996). In the case of a patient with COPD, the lower diaphragm is depressed horizontally in a contracted length, thus, the resting length is insufficient for contraction. Tachypnea and dyspnea is then a common sign (Cane, 1992). This phenomenon still presents in patients who use a mechanical ventilator for a long period of time (Guerin, 1993). Muscle around the chest wall can be divided into two dimensions; anteriorly with pectoralis major and internal or external intercostal muscles; and posteriorly with erector spinae, latissumus dorsi, serratus posterior superior or serratus posterior inferior muscles, which are important for lung ventilation (Kacmarek et al., 2005). Thus, retraction or spasm of these soft tissues, or

Fig. 5. Pump-Bucket pattern of chest movement. (Greenman, 1996)

**Impairment or disease relates to ineffective chest wall movement** 

4. Skin disease such as scleroderma, multiple sclerosis etc. (Woo et al., 2007)

6. Post thoracic surgery for lung or heart operation (Macciarini et al., 1999)

9. Proloned bed rest (Suesada et al., 2007) or aging (Chaunchaiyakul et al., 2004)

7. Prolonged use of a mechanical ventilator (Gillespine et al., 1985)

10. Other factors; pain, posture, diaphragm dysfunction (Vibekk, 1991).

2. Osteoporosis or ankylosing spondylitis (Neill et al., 2005) 3. Nerve injury as spinal cord injury (Baydur et al., 2001)

8. Chronic lung disease or pneumonia (Hoare & Lim, 2006)

gliding occurs to increase rib space. Mobility of the thorax on flexion, either to the right or left, is found more in lower than upper thoracic parts. Thus, stretching of the lower thorax is rather more successful than that of the upper part. A normal range of motion is approximately 45 degrees: 25 degrees at the thorax and 20 degrees at the lumbar spines. During flexion to the left, the inferior facet of T6 on the left side moves above the superior facet of the T7 spine. In thorax movement, lateral flexion directly affects the rib space in both approximation and stretch away (Figure 3), which results in the transverse process, when the head of the rib glides in the opposite direction (Figure 4).

Fig. 4. Rotation of the trunk and thorax, with rib cage and costovertebral joint movement. (Grant, 2001; Lee, 2002)
