**3.1 Soft tissue flexibility**

402 Chronic Obstructive Pulmonary Disease – Current Concepts and Practice

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

Fig. 4. Rotation of the trunk and thorax, with rib cage and costovertebral joint movement.

Trunk rotation is a complex movement that involves many joints. For example, during rotation to the three left events are shown as; 1) rib rotation with costotransverse posterior gliding on the rotating side, whereas anterior rotation of the rib and gliding are on the opposite side, 2) thoracic body that is elevated and depressed in each segment, and 3) vertical asymmetrical torsion. Upper thoracic spine can move like pure axial rotation as well as thoracolumbar and cervicothoracic rotation. However, sometimes movement of the upper and lower thoracic spines also co-move with lateral flexion or rotation. Thus, articular facet

In conclusion, the chest wall, which is composed of spine, sternum, and ribs, moves in synchronization, no matter whether it is lateral flexion, flexion, extension, or rotation. However, the quality of movement affects individual direction because the costovertebral joint makes contact with the vertebral body, so that lateral expansion is affected more than anterior movement. Whereas, the 2nd to 8th ribs connect to the sternum anteriorly, thus expanding the chest in an anterior direction with pumping handle or anterior and superior motion, as well as bucket handle with lateral and superior motion (Norkin & Levangie,

The chest mobilization technique is preferred in cases of COPD or chronic lung disease, with the basic theory of mainly improving ventilation. In addition, aging, prolonged use of a ventilator and chronic illness with neuromuscular dysfunction also concern chest wall

Rib torsion, passive stretching, trunk rotation, back extension, lateral flexion and thoracic

between high and low spines is a sliding movement (Grant, 2001; Lee, 2002).

1992) that occur in regular breathing (Greenman, 1996).

mobilization are practiced to improve chest flexibility.

the head of the rib glides in the opposite direction (Figure 4).

(Grant, 2001; Lee, 2002)

**3. Trunk rotation** 

mobility.

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 muscles, limits chest expansion.

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


Chest Mobilization Techniques for Improving

**Upper costal chest expansion** (Figure 6)

**Middle costal chest expansion** (Figure 6) Position: Sitting or lying supine.

**Lower costal chest expansion** (Figure 6)

Position: Sitting.

Position: Sitting

following chest expansion.

following chest expansion.

following chest expansion.

Direction: Lower costal expansion should be outward.

Handling: Palm placed to cover all sternum (head and body).

Command: Gentle compression and order the subject to breathe deeply.

during sternum (head part) movement.

**Sternocostal Movement Evaluation** (Figure 6)

Position: Sitting.

Ventilation and Gas Exchange in Chronic Lung Disease 405

Handling: All finger tips are placed at the upper trappezius with whole plamar on

both thumbs close to the midline at the mid- sternum line. Command: Gentle compression and order the subject to breathe in deeply and release

Results: Approximate calculation of different distances between the tips of thumbs in centimeters (cm) before an after full inspiration. Direction: Upper costal expansion should be upward with anterior expansion.

Handling: All finger tips placed at the posterior axillary line with tips of both thumbs

Command: Gentle compression and order the subject to breathe in deeply and release

Results: Approximate calculation of different distances between the tips of thumbs in centimeters (cm) before an after full inspiration. Direction: Middle chest expansion should be outward and slightly up ward.

Handling: All finger tips placed at the anterior axillary line with tips of both thumbs

Command: Gentle compression and order the subject to breathe in deeply and release

Results: Approximate calculation of different distance between the tips of thumbs in centimeters (cm) before an after full inspiration.

Result: Anterior expansion during sternum expansion, then upward expansion

middle chest area (4th to 6th rib anteriorly at the mid-clavicle line).

the upper chest above the 4th rib at the mid clavicle line, and the tips of

close to the horizontal mid line. The whole plamar should be placed on the

close to the horizontal mid line. The whole plamar placed on the lower chest area (below the scapular line and not lower than the 10th rib posteriorly).
