KINESIOLOGY AND BIOMECHANICS PHTH 7412 Riley Davis SPT

KINESIOLOGY AND BIOMECHANICS PHTH 7412 Riley Davis, SPT Jeremy Corbin, SPT Daniel Horstman, SPT Ian Ekery, SPT Garrett Schwartz,

Thorax and Chest Wall � Bones of the Thorax and Chest Wall � Ribs � Sternum � Vertebrae � Functions of the Chest Wall and Thorax � Base for the muscle attachment of the upper extremities, head and neck, vertebral column and pelvis � Provides protection for the heart and lungs

Thorax and Chest Wall � Rib Cage � 12 pairs of ribs ○ 1 -7 are considered true ribs ○ 8 -10 are considered false ribs ○ 11 and 12 are called floating ribs � Bony Structures � Head � Neck � Costal tubercle (articulation site for the transverse processes of the vertebrae) � Angle of the rib � Costal groove � Superior and Inferior articular facets (articulates with the vertebral bodies)

Thorax and Chest Wall � Sternum � Protective plate for the heart in the medial portion of the body � The sternum is broken up into 3 parts: ○ Manubrium ○ Sternal Body ○ Xiphoid Process � Bony structures: ○ Clavicular notch (articulation site of clavicle) ○ Jugular notch ○ Sternal angle (articulation site of manubrium and sternal body ○ Costal notches (articulation site of costal cartilage with body of sternum)

Thorax and Chest Wall � Vertebrae � Protect the spinal cord � Consists of 7 cervical, 12 thoracic, and 5 lumbar vertebrae � Although each level’s vertebrae are slightly different, they each consist of a spinous process, and transverse processes � Bony Structures: Body Vertebral foramen Spinous process Transverse process (articulates with the tubercle of the rib) ○ Lamina ○ Superior and inferior articular process and facet (articulates with the respective superior and inferior facets on the rib’s head) ○ ○

Thorax and Chest Wall The rib cage is closed chained � Movement of the rib cage is combined with: � � Types and angles of articulation � Movement of the manubriosternum � Elasticity of the costal cartilages The length, shape and angle of each rib pair is unique, therefore, the axis of rotation for each pair is slightly different. � Upper ribs: Ao. R closest to the frontal plane, allowing motion in sagittal plane. � Lower ribs: Ao. R closest to sagittal plane, allowing motion in the frontal plane. �

Thorax and Chest Wall � � “Pump-handle” Motion During inhalation � Occurs predominantly in the sagittal plane � Elevates the rib cage and sternum � Most movement occurs anteriorly � Costocartilage rotates upward, becoming more horizontal with inspiration � The movement of the ribs pushes the sternum ventrally and superiorly � Increases the anterior-posterior diameter of the thorax � Ribs: elevate with a slight rotation � Sternum: elevation; superior and anterior movement � Vertebrae: No movement during this motion

Thorax and Chest Wall “Bucket-handle” Motion � During inhalation � � Elevation of ribs � Occurs about an axis of motion lying more towards the sagittal plane. � Lower ribs have a more angled shape, allowing for more motion at the lateral aspect of the rib cage. � Increases the transverse diameter of the rib cage � Each rib, during this movement, elevates and also has a slight upward rotation during inhalation. � Vertebrae and Sternum have relatively no movement in this motion.

Myology � Muscles of Quiet Inspiration �Diaphragm �Scalenes �Intercostals �Active during all work intensities �Active contraction of diaphragm dedicated totally toward the mechanisms of inspiration �Intercostales and scalenes stabilize and rotate parts of axial skeleton

Diaphragm Dome shaped, thin, musculotendinous sheet of tissue � Origin: � � Costal attachment: ○ Inner surface of lower 6 ribs � Lumbar attachment: ○ Upper two or three lumbar vertebrae � Sternal attachment: ○ Inner part of xiphoid process Insertion: Central tendon � Action: � � Increases vertical diameter of thorax by lowering and flattening dome � Increases intra-abdominal pressure which expands lower ribs laterally � Continued contraction of costal fibers elevate middle and lower ribs

Diaphragm 1. Central tendon � 5. Opening for aorta � 6. Opening for esophagus � � Diaphragm most important and efficient muscle of inspiration

Scalene Muscles � Origin: �Anterior: Transverse processes of 3 rd through 6 th cervical vertebrae �Middle: Transverse processes of 2 nd through 7 th cervical vertebrae �Posterior: Transverse processes of 6 th and 7 th cervical vertebrae � Insertion: �Anterior: 1 st rib �Middle: 1 st rib �Posterior: 2 nd rib � Action: �Elevate the upper ribs and sternum

Intercostals � Origin: Inferior border of the rib above � Insertion: Superior border of the rib below � Action: �External: Draw the ribs superiorly to assist with inhalation �Internal: Draw the ribs inferiorly to assist with exhalation �Elevates and depress the ribs, stabilize intercostal spaces, and prevent an inward collapse of upper thoracic wall

Mechanics of Inspiration

Forced Inspiration � Requires the use of accessory muscles � Each muscle directly or indirectly increase intrathoracic volume � Typically used in healthy people to increase both the rate and volume of inspired air � May also compensate for dysfunction of primary muscles �Frequently employed in people with severe COPD

Muscles of Forced Inspiration � Each muscle action helps increase intrathoracic volume � � Serratus anterior- elevates the ribs Serratus posterior: � Superior- elevates upper ribs � Inferior- stabilizes lower ribs for contraction of diaphragm � � � � Levator costae- elevates upper ribs Sternocleidomastoid- elevates sternum and upper ribs Latissimus dorsi- elevates the lower ribs; requires arms to be fixed Erector spinae- extends the trunk Pectoralis minor- elevates the upper ribs Pectoralis major- elevates middle ribs and sternum Quadratus lumborum- stabilize the lower ribs for contraction of diaphragm

Muscles of Forced Inspiration

Forced Expiration � Forceful expiration is driven primarily by the 4 abdominal muscles � Rectus abdominis ○ Origin: pubic crest and pubic symphysis ○ Insertion: 5, 6, 7 costal cartilages, medial inferiorcostal margin and posterior aspect of xiphoid � Obliquus externus/internus abdominis ○ Origin: externus- anterior angles of lower eight ribs ○ Insertion: externus- Outer anterior half of iliac crest, inguinal lig. , public tubercle and crest, and aponeurosis of anterior rectus sheath ○ Origin: internus- Lumbar fascia, anterior two thirds of iliac crest and lateral two thirds of inguinal ligament ○ Insertion: internus- Costal margin, aponeurosis of rectus sheath (anterior and posterior ), conjoint tendon to pubic crest and pectineal line � Transversus abdominis ○ Origin: costal margin, lumbar fascia, anterior two thirds of iliac crest and lateral half of inguinal ligament ○ Insertion: aponeurosis of posterior and anterior rectus sheath and conjoint tendon to pubic crest and pectineal line Action: flexes the trunk and depresses the ribs Direct effect of contraction rapidly and forcefully reduces intrathoracic volume, such as when coughing, sneezing, or vigorously exhaling � Indirect effect increases intra-abdominal pressure, forcing relaxed diaphragm upward at maximal expiration � � � This prepares diaphragm to initiate a more forceful contraction at the next inspiration cycle � Therefore, abdominal muscles also enhance inspiration

Abdominal Muscles

Transversus Thoracis and Intercostals � Transversus Thoracis � Origin: ○ lower third of inner aspect of sternum and lower three costosternal junctions � Insertion: ○ second to sixth costal cartilages Intercostals � Action of both muscles depress the ribs � Transversus thoracis

Mechanics of Forced Expiration

The Core Most often acts as a stabilizer and force transfer center rather than a prime mover � People usually focus on training their core as a prime mover and in isolation � Once you go into flexion or rotation you’ve lost core control and are operating sub optimally � Better core support, helps reduce the risk of injury and frees up our hips and shoulders for better functional movement habits � Maintaining better posture means better spinal stability �

True Core � � � 4 abdominal muscles Diaphragm Erector Spinae Multifidus Pelvic floor muscles Multifidus Proper core training will also help train the right support to stabilize the spine � End result is the development of a fit, strong, stable, freely mobile spine that makes it easy to support the body and move in any direction �

Pelvic Floor � The pelvic floor consists of three muscle layers: � Superficial perineal layer: innervated by the pudendal nerve � � � Bulbocavernosus Ischiocavernosus Superficial transverse perineal External anal sphincter (EAS) Deep urogenital diaphragm layer: innervated by pudendal nerve � Compressor urethera � Uretrovaginal sphincter � Deep transverse perineal � Pelvic diaphragm: innervated by sacral nerve roots S 3 -S 5 � � � Levator ani: pubococcygeus (pubovaginalis, puborectalis), iliococcygeus Coccygeus/ischiococcygeus Piriformis Obturator internus Supports the spine and downward moving organs during breathing Controls pressure inside abdomen

THE THORAX AND CHEST WALL: ARTHROLOGY What are the articulations of the rib cage? HINT: there are 7!

THE THORAX AND CHEST WALL: ARTHROLOGY Articulations of the Rib Cage § § § § Manubriosternal Xiphisternal Costovertebral Costotransverse Costochondral Chondrosternal Interchondral joints

THE THORAX AND CHEST WALL: ARTHROLOGY Manubriosternal Joint • • • Manubrium and body of sternum articulate at this joint Creates a horizontal ridge at the level of the 2 nd ribs’ anterior attachment Synchondrosis joint Contains fibrocartilaginous disc between hyaline cartilagecovered articulating ends of the manubrium and body of the sternum Similar to the pubic symphysis Ossification occurs in elderly persons

THE THORAX AND CHEST WALL: ARTHROLOGY Xiphisternal Joint • Joins the xiphoid process to the sternal body • Synchondrosis • Tends to ossify by 40 to 50 years of age

THE THORAX AND CHEST WALL: ARTHROLOGY Manubriosternal and Xiphisternal Joints

THE THORAX AND CHEST WALL: ARTHROLOGY Costovertebral Joints § Formed by the head of the rib, two adjacent vertebral bodies, and the interposed intervertebral disc § Synovial joint § Ribs 2 -9 have typical costovertebral joints § The heads of each of these ribs have two articular facets, also known as demifacets.

THE THORAX AND CHEST WALL: ARTHROLOGY Costovertebral Joints

THE THORAX AND CHEST WALL: ARTHROLOGY Costovertebral Joints cont. § The small, oval and slightly convex demifacets of the ribs are called the superior and inferior costovertebral facets. § Adjacent thoracic vertebrae have facets that correspond to the heads of the ribs they articulate with. § Each rib’s superior facet articulates with the inferior facet of the rib above it. § Each rib’s inferior facet articulates with the superior facet of its own numbered vertebrae.

THE THORAX AND CHEST WALL: ARTHROLOGY Costovertebral Joints cont.

THE THORAX AND CHEST WALL: ARTHROLOGY Costotransverse Joints • Synovial joint formed by the articulation of costal tubercle of ribs with a costal facet on transverse process of vertebrae. • 10 pairs, T 1 -T 10; why not T 11 -12? • T 1 -T 6 have slightly concave costal facets on transverse processes of vertebrae; allows for slight rotation • T 7 -T 10, both surfaces are flat and have gliding motions

THE THORAX AND CHEST WALL: ARTHROLOGY Costotransverse Joints cont. • • Surrounded by thin, fibrous capsule Supported by 3 major ligaments: Lateral Costotransverse Ligament -short, stout band between lateral portion of costal tubercle and tip of corresponding transvers process Costotransverse Ligament -shorts fibers that run between neck of the rib posteriorly and transverse process at the same level Superior Costotransverse Ligament -crest of the neck of the rib to inferior border of the cranial transverse process

THE THORAX AND CHEST WALL: ARTHROLOGY Costotransverse Joints cont.

THE THORAX AND CHEST WALL: ARTHROLOGY Sternocostal Joint Compromised of both the Costochondral and Chondrosternal Joints

THE THORAX AND CHEST WALL: ARTHROLOGY Costochondral Joint • Formed by articulation of 1 st-10 th ribs anterolaterally with costal cartilages • Synchdroses; no ligamentous support

THE THORAX AND CHEST WALL: ARTHROLOGY Chondrosternal Joint • Formed by articulations of costal cartilages of ribs 1 -7 anteriorly to the sternum. • Contain capsules that are continuous with the periosteum and support the connection of the cartilage as a whole. • Ligamentous support for the capsule includes anterior and posterior radiate costosternal ligaments. • Sternocostal ligament divides the two demifacets of the second chondrosternal joint; costoxiphoid ligaments connect the anterior and posterior surfaces of the seventh costal cartilage to front and back of xiphoid process

THE THORAX AND CHEST WALL: ARTHROLOGY Interchondral Joints • Synovial joints supported by a capsule and interchondral ligaments. • Ribs 7 -10 each articulate with cartilage immediately above them • For Ribs 8 -10, this articulation forms the only connection to the sternum. • These articulations are similar to chondrosternal joints and become fibrous and fuse with age.

THE THORAX AND CHEST WALL ARTHROKINEMATICS • The movement of the rib cage is controlled by: • the types and angles of the articulations • the movement of the manubriosternum • the elasticity of the costal cartilages

THE THORAX AND CHEST WALL ARTHROKINEMATICS • The costotransverse and costovertebral joints are mechanically linked, with a single axis of motion for elevation and depression passing through the centers of both joints. • Each rib’s axis of rotation is different due to variable sizes and downward angles that they each possess.

THE THORAX AND CHEST WALL ARTHROKINEMATICS • The axes of rotation for the upper ribs lie closest to the frontal plane which allows a motion of these ribs to predominantly occur in the sagittal plane. • The axes of rotation for the lower ribs lie closer to the sagittal plane. This allows for motion to predominantly occur in the frontal plane. • There is no costotransverse joint present for ribs 11 and 12. They have a similar axes of rotation to the lower ribs. These two ribs do not participate in the closed-chain motion of the thorax.

THE THORAX AND CHEST WALL ARTHROKINEMATICS • Upper ribs • Axes of rotation in frontal plane = sagittal plane movement • Lower ribs • Axes of rotation in sagittal plane = frontal plane movement

THE THORAX AND CHEST WALL ARTHROKINEMATICS • The First Rib: The Original Stage 5 Clinger • thicker, larger, and stiffer than the other costocartilages • synchondrosis chondrosternal joint (firmly attached to the sternum) • inferior and posterior to the SC joint • during inspiration, the costovertebral joint moves superiorly and posteriorly, elevating the first rib

THE THORAX AND CHEST WALL ARTHROKINEMATICS • Ribs 2 -7 (What are these called? ) • attach directly to the sternum • increase in length and mobility the more caudal the rib • The costocartilage rotates upward during inspiration, creating a horizontal motion. • That rib motion pushes the sternum ventrally and superiorly. • The sternum moves more than the manubrium because of the first rib’s lack of movement. • With each breath there is movement between the manubriosternal joint, with more movement along the sternal body.

THE THORAX AND CHEST WALL ARTHROKINEMATICS • Ribs 8 -10 (…. and what are these called? ) • the lower the rib, the more of a downward angle shape of cartilage • indirect attachment to the sternum • This allows these ribs to have more of a lateral motion.

THE THORAX AND CHEST WALL ARTHROKINEMATICS • PUMP-HANDLE MOTION • elevation of upper ribs at costovertebral and costotransverse joints to create an anterior and superior movement of the sternum

THE THORAX AND CHEST WALL ARTHROKINEMATICS • BUCKET HANDLE MOTION • elevation of the lower ribs at the costovertebral and costotransverse joints results in a lateral motion of the rib cage

THE THORAX & CHEST WALL - PATHOLOGIES • Broken (fractured) & Bruised Ribs o Most common chest injury o Usually not life threatening, recovery mostly at home o Middle ribs are most commonly injured • How can you tell? Types of symptoms! o Have pain during breathing, taking shallow breaths o Signs of swelling, tenderness, and bruising of skin • Causes o Most commonly caused by direct impacts o Repetitive trauma • o o Risk Factors Osteoporosis Sports participation Cancerous lesion in a rib Continuous coughing

THE THORAX & CHEST WALL - PATHOLOGIES • Serious Complications: o o Bleeding in chest, ex. Torn or punctured aorta Collapsed/punctured lung Lacerated spleen, liver or kidneys Fluid accumulation • Warning Signs o o Difficulty breathing Blue lips Fever Coughing of blood or heavy mucus

THE THORAX AND CHEST WALL- PATHOLOGIES Types of Tests & Diagnosis • X-ray: o Using low levels of radiation, X-rays are a good tool to visualize bone. But X-rays often have problems revealing fresh rib fractures. • CT Scans: o CT scans can often uncover rib fractures that X-rays might miss. Injuries to soft tissues and blood vessels are also easier to see on CT scans. • MRI: o MRI scans can be used to look at the soft tissues and organs around the ribs to determine if there is any damage to these structures. It can also help in the detection of more subtle fractures. • Bone Scan: o This technique is good for viewing stress fractures, where a bone is cracked after repetitive trauma. Includes a radioactive injection.

THE THORAX & CHEST WALL - PATHOLOGIES • Treatment/Therapy: o Depending on the injury: Eventually heal 1 -2 month if individual is healthy o Eat well & take supplements o Avoid any torso movements… being mobile in rest periods are good o Adapt sleep position o ICE o Inflammatory & correct medication for pain o Ribs can be wrapped but only under medical supervision o Carrying out breathing exercises. Ex. 10 slow/deep breaths every hour o No heavy lifting (10 Ibs) o Increase strength and flexibility • Prevention: o Protect yourself from athletic injuries o Reduce risk of household falls o Strengthen your bones - Calcium

THE THORAX & CHEST WALL - PATHOLOGIES • Scoliosis and Spine Disorders o Has many effects on respiratory function. o Scoliosis results in a restrictive lung disease & decreases lung volumes. o Displaces the internal organs, affects the movement of ribs & the mechanics of the respiratory muscles. o Scoliosis decreases the chest wall & results in extra breathing

THE THORAX & CHEST WALL - PATHOLOGIES • Scoliosis and Spine Disorders • Causes: o o o Genetics Growth Structural and Biomechanical Changes Central Nervous System Changes Equilibrium and Postural Mechanisms • Symptoms: One shoulder or hip may be higher than the other. One shoulder blade may be higher and stick out farther than the other. These deformities are more noticeable when bending over. A "rib hump" may occur, which is a hump on your back that sticks up when you bend your spine forward. This occurs because the ribs on one side angle more than on the other side. o One arm hangs longer than the other because of a tilt in your upper body. o o

THE THORAX & CHEST WALL - PATHOLOGIES • Scoliosis and Spine Disorders • Conservative Treatment: o o o Improve back posture Foster aerobic fitness Maximize range of motion and strength Clarify ways to manage the symptoms of scoliosis Back brace • Surgical Treatment: o o Reducing the deformity (straighten your spine as much as possible) Stopping the progression of the deformity Removing any pressure from your nerves and spinal cord Protecting your nerves and spinal cord from further damage

THE THORAX & CHEST WALL - PATHOLOGIES • Abdominal Hernia o A hernia is the protrusion of an organ or piece of tissue. o It protrudes through a weak area in abdominal wall. o Abdominal wall is made up of different muscles & tissues, and when there is a weak layer the contents of the cavity begin to protrude. o Most common hernias occur in the groin and diaphragm.

THE THORAX & CHEST WALL - PATHOLOGIES • Types of Hernias (abdominal & pelvic floor) Ø Inguinal: o Most common o It’s when the spermatic cord & testicles descend from abdomen through inguinal canal (opening). The opening is suppose to close but muscles that attach to pelvis leave a weak area. o Inguinal hernias are less likely to occur in women, because there is no need for permanent opening. Ø Femoral: o Occur in the opening where the femoral artery & vein pass through the leg. o Femoral hernias occur more frequently in women, because of wider bone structure.

THE THORAX & CHEST WALL - PATHOLOGIES • Types of Hernias (abdominal wall) Ø Epigastric: o Occur because of a weakness in the midline of abdominal wall where two rectus muscles join Ø Umbilical: o Abnormal bulging in the belly button o Very common in newborns o Do not need treatment unless complications occur Ø Incisional: o Occurs after an abdominal surgery where muscles are cut

THE THORAX & CHEST WALL - PATHOLOGIES • Signs/Symptoms: o o o Bulge/Knot Sharp or tearing pain Nausea and vomiting Fever Burning in chest • Treatments: o o o Icing and compression Stretching Muscle retraining Strengthening Manual therapy

THE THORAX & CHEST WALL - PATHOLOGIES • INTERCOSTAL SPRAINS • Causes: o Sharp increases in physical activity or added stress on the muscles in the back o Sudden turning or twisting motions with the upper body • Signs/Symptoms: o o o Back pain or tenderness Sharp pain when inhaling or exhaling Pain when moving or using the back in daily activities Pain or soreness near the ribs Pain that worsens with bending or twisting motions

THE THORAX & CHEST WALL - PATHOLOGIES Grade I – A mild strain, where a few muscle fibers have experienced damage. Grade II – A moderate strain, where more muscle fibers are damaged, but they have not been ruptured. Grade III – A severe strain, where the muscle is ruptured. • Treatment: o o o o REST and ICE Deep breathing exercises Soft tissue massage Strengthening & flexibility exercises Splinting or bracing the affected area The use of NSAIDS (Non Steroidal Anti-Inflammatory Drugs) Steroidal injections to reduce inflammation Pain medication to reduce the discomfort and allow the patient to perform the recommended exercises

THE THORAX & CHEST WALL - PATHOLOGIES • Pelvic Floor Dysfunction: Conditions: o Pelvic organ prolapsed o Urinary incontinence o Bowel incontinence • Pelvic Organs Affected: o o o Bladder Uterus Vagina Small Bowel Rectum

THE THORAX & CHEST WALL - PATHOLOGIES • Pelvic Floor • Causes: o o o Pregnancy or child birth Respiratory problem with chronic long-term cough Constipation Pelvic organ cancers Results from a surgery/removal of uterus • What are the symptoms of Pelvic Organ Prolapse? o o o o A feeling of pressure or fullness in the pelvic area A backache low in the back Painful intercourse A feeling that something is falling out of the vagina Urinary problems such as leaking of urine or a chronic urge to urinate Constipation / rectal pain Spotting or bleeding from the vagina

THE THORAX & CHEST WALL - PATHOLOGIES • Pelvic Floor • Diagnosis: Ø Pelvic exam Ø Imaging Tests o Urinary Tract X-ray o CT Scan o Ultrasound o MRI

THE THORAX & CHEST WALL - PATHOLOGIES • Pelvic Floor • Treatments: Ø • Pelvic Floor Physical Therapy: o Skin rolling o Deep tissue massage o Trigger-point therapy to release tight spots or “knots” o Nerve release o Joint mobilization • Pelvic Floor (Kegel) Exercises • Surgery • Lifestyle Changes • Medications

THE THORAX & CHEST WALL - PATHOLOGIES • Transplants • o o Why a transplant? Organ failure Disease / infection Birth defects Trauma • o o o Transplant Areas within Ventral Cavity: Thoracic Abdominal Pelvic

THE THORAX & CHEST WALL - PATHOLOGIES • Transplants • Organs / Tissues that can be transplanted: o o o Heart Liver Pancreas Lungs Kidneys Intestines Skin Heart valves Bone Blood vessels Connective tissues

THE THORAX & CHEST WALL - PATHOLOGIES • Transplants • Body Structures Affected: o o o Sternum/Chest Bone Ribs Muscles tissue Cartilage Blood Vessels Nerves • Before the Transplant: Ø Determine donor/recipient compatibility o Blood Type o Tissue Type o Antibody Screen o Medical Conditions • Why Compatibility? o Reduce the risk of transplant rejection

THE THORAX & CHEST WALL - PATHOLOGIES • Transplants • Post Transplant Process: o Be aware & report side effects o Manage medications o Treatment to increase: Mobility, Flexibility, Strength, Breathing, Endurance o Stay healthy o Lifestyle changes o Recovery resources o Keep all wellness checkups & undergo recommended testing

THE THORAX & CHEST WALL - PATHOLOGIES • Thoracic Outlet Syndrome-TOS Ø It’s a condition whereby symptoms are produced by compression of nerves and/or blood vessels in the upper chest. • Symptoms: o Neck pain o Shoulder/Arm pain o Numbness of fingers o Discolorations from circulation problems Ø Who is a risk factor for TOS? o Risk factors include occupations that involve heavy usage of the upper extremities against resistance.

THE THORAX & CHEST WALL - PATHOLOGIES • Thoracic Outlet Syndrome-TOS • Treatments: Ø Physical Therapy: o Postural abnormalities and muscle imbalance o Deep heat (therapeutic ultrasound) o Electric stimulation o Superficial heat (heat packs) o Stretching exercises o Postural correction exercises o Strength and endurance exercises

REFERENCES Primary Reference: Neumann, D. A. (2010). Kinesiology of the musculoskeletal system: Foundations for rehabilitation. St. Louis, Mo: Mosby/Elsevier. Secondary: Levangie, P. K. , Norkin, C. C. , & Levangie, P. K. (2011). Joint structure and function: A comprehensive analysis. Philadelphia: F. A. Davis Co. Oatis, C. A. (2009). Kinesiology: The mechanics and pathomechanics of human movement. Baltimore: Lippincott Williams & Wilkins.

REFERENCES Secondary References: http: //www. mayoclinic. org/diseases-conditions/broken-ribs/basics/riskfactors/con-20029574 http: //www. scoliosisjournal. com/content/7/1/7 http: //www. allaboutbackandneckpain. com/understandingconditions/scoliosi s. asp http: //www. medicinenet. com/hernia_overview/article. htm#what_is_an_abdo minal_hernia http: //twinboro. com/body/spine/thoracic/muscleligament/conditions/intercostal-strain-nj. html http: //www. moveforwardpt. com/symptomsconditionsdetail. aspx? cid=b 6 f 216 23 -ecb 5 -41 a 6 -9774 -8 d 48711075 d 9#. Vi. V-OXld. HIU

REFERENCES Secondary References: http: //www. medicinenet. com/thoracic_outlet_syndrome/article. htm http: //emedicine. medscape. com/article/96412 -treatment http: //www. clearpassage. com/what-we-treat/chronic-pain/abdominal-pain/ http: //emedicine. medscape. com/article/316715 -treatment#d 13