Symmetry of chest movement. Analysis of the symmetry of the moving chest during breathing gives the therapist information about the mobility of the thorax and indicates indirectly what areas of the lungs may or may not be responding.
Procedure: Place your hands on the patient’s chest and assess the excursion of each side of the thorax […]

Symmetry of the chest and trunk. Observe anteriorly, posteriorly, and laterally; the thoracic cage should be symmetrical.
Mobility of the trunk. Check active movements in all directions and identify any restricted spinal motions, particularly in the thoracic spine.
Shape and dimensions of the chest. The anteroposterior (AP) and lateral dimensions are usually 1:2. Common chest deformities include:
• […]

Examination is the evaluation of the patient with pulmonary dysfunction and determination of a diagnosis, prognosis, and intervention plan are based on the findings derived from a comprehensive examination, including a history, systems review, and specific tests and measures.
Components of the Examination
A comprehensive examination of a patient with known or suspected dysfunction related to primary […]

Pulmonary function tests that measure lung volumes and capacities are performed to evaluate the mechanical function of the lungs. Lung volumes and capacities are related to a person’s age, weight, sex, and body position and are altered by disease. Two or more lung volumes, when combined, are described as a capacity. A basic understanding of […]

The upper and lower respiratory tracts, as a unit, serve the following functions. They:
• Conduct air to and from the alveolar system for gas exchange
• Assist with humidification and trap small particles to clean the air with the mucosal lining
• Warm the air by the vascular supply
• Move mucus upward with the cilia
• Elicit the […]

Upper Respiratory Tract
The structures of the upper respiratory tract are the nasal cavity, pharynx, and larynx. As air is brought into the body, the nasal cavity and pharynx filter and remove particles in the air and begin to humidify and warm it to body temperature. The mucosal lining of these structures has cells that secrete […]

Movements of the Thorax During Ventilation
Each rib has its own pattern of movement, but generalizations can be made. The ribs attach anteriorly to the sternum (except ribs 11 and 12) and posteriorly to the vertebral bodies, disks, and transverse processes, making a closed kinematic chain. The thorax enlarges in all three planes of movement during […]

Inspiration
• Primary muscles: diaphragm, scalenes, parasternals
• Accessory muscles: sternocleidomastoids, upper trapezius, pectoralis major and minor, subclavius, and possibly the external intercostals
Expiration
• Primary muscles: none active during tidal (resting) expiration
• Accessory muscles: abdominals including the rectus abdominis, transversus abdominis, and internal and external obliques; pectoralis major; and possibly the internal intercostals
Parasternal intercostals.  The parasternals, a portion […]

Respiration is a general term used to describe gas exchange within the body and can be categorized as either external respiration or internal respiration. Basic terms are described here but an in-depth discussion of respiratory physiology, including diffusion and perfusion, goes well beyond the scope or purpose of this chapter. The reader is referred to […]

Multiple muscles attaching to the thoracic cage have an impact on the movement of air in and out of the lungs during either the inspiratory or expiratory phases of breathing.
Ventilatory muscles, also referred to as respiratory muscles, are classified as primary or accessory. The primary muscles of ventilation are recruited during quiet (tidal) breathing, whereas […]

Cardiovascular and pulmonary physical therapy is a multifaceted area of professional practice that deals with the management of patients of all ages with acute or chronic, primary or secondary cardiovascular and pulmonary disorders. Although the cardiovascular and pulmonary systems are inherently linked as they interface with all other body systems, the focus of this chapter […]

Exercise
• Short but frequent exercise sessions (four or five times per day).
• Low number of repetitions per exercise.
• Only passive or assisted shoulder ROM exercises and only within the “safe” limits of ranges noted during surgery. Absolutely no end-range stretching.
• Passive external rotation to neutral or to less than 30° to avoid […]

Supine
• Arm immobilized in sling, which is worn continuously
• Elbow flexed to 90°
• Forearm and hand resting on abdomen
• Arm supported at the elbow on a folded blanket or pillow slightly away from the side and anterior to the midline of the trunk
• Forward flexion (10° to 20°), slight abduction, and internal rotation of the […]

Intraoperative
• Insufficient lengthening of a tight subscapularis muscle-tendon unit
• Intraoperative damage to the axillary or suprascapular nerves, affecting the deltoid and supraspinatus/infraspinatus muscles, respectively
• Fracture of the humerus
Soft Tissue-Related Postoperative Complications
• Re-tearing a repaired rotator cuff mechanism
• Postoperative disruption of the repaired subscapularis (detached from the lesser tuberosity for the surgical approach and reattached medially […]

Arthroplasty of the GH joint falls into several categories, the most common of which are total shoulder replacement arthroplasty, in which the glenoid and humeral surfaces are replaced and hemireplacement arthroplasty (hemiarthroplasty), in which one surface, the humeral head, is replaced. Other categories of shoulder arthroplasty include interpositional and resurfacing arthroplasties, which involve less extensive […]

Severe deterioration of one or both surfaces of the GH joint, causing significant pain and loss of upper extremity function, or an acute or nonunion fracture of the proximal humerus often must be addressed with surgical intervention. Underlying pathologies, causing advanced joint destruction, include late-stage osteoarthritis (OA), rheumatoid arthritis (RA), traumatic arthritis, cuff tear arthropathy, […]

Related Pathologies and Etiology of Symptoms
Overuse Syndromes. Overuse syndromes of the AC joint are frequently arthritic or post-traumatic conditions. The causes may be from repeated stressful movement of the joint with the arm at waist level, such as with grinding, packing assembly, and construction work, or repeated diagonal extension, adduction, and internal rotation motions, as […]

Progressively Increase Flexibility and Strength
• Stretching and strengthening exercises are progressed as the joint tissue tolerates. The patient should be actively involved in self-stretching and strengthening by this time, so emphasis during treatment is on correct mechanics, safe progressions, and exercise strategies for return to function.
• If capsular tissue is still restricting ROM, vigorous manual […]

When symptoms are subacute, follow the guidelines emphasizing joint mobility, neuromuscular control, and instructions to the patient for self-care.
NOTE: For normal shoulder joint mechanics, there must be good scapular posture and control, and the humerus must be able to externally rotate. To avoid suprahumeral impingement, passive stretching above 90° should be avoided until there is […]

Control Pain, Edema, and Muscle Guarding
• The joint may be immobilized in a sling to provide rest and minimize pain.
• Intermittent periods of passive or assisted motion within the pain free/protected ROM and gentle joint oscillation techniques are initiated as soon as the patient tolerates movement in order to minimize adhesion formation.
Maintain Soft Tissue and […]

To make sound clinical decisions when managing patients with shoulder disorders, it is necessary to understand the various pathologies, surgical procedures, and associated precautions and to identify presenting impairments, functional limitations, and possible disabilities.
JOINT HYPOMOBILITY: NONOPERATIVE MANAGEMENT
Glenohumeral Joint
Restricted mobility of the glenohumeral joint may occur as a result of pathology such as rheumatoid arthritis or […]

Common Sources of Referred Pain in the Shoulder Region
Cervical Spine
• Vertebral joints between C3 and C4 or between C4 and C5
• Nerve roots C4 or C5
Referred Pain from Related Tissues
• Dermatome C4 is over the trapezius to the tip of the shoulder.
• Dermatome C5 is over the deltoid region and lateral arm.
• Diaphragm: pain perceived […]

Scapulohumeral Rhythm
Motion of the scapula, synchronous with motions of the humerus, allows for 150° to 180° of shoulder ROM into flexion or abduction with elevation. The ratio has considerable variation among individuals but is commonly accepted to be 2:1 (2° of glenohumeral motion to 1° of scapular rotation) overall motion. During the setting phase (0° […]

Scapulothoracic Articulation
Normally there is considerable soft tissue flexibility, allowing the scapula to slide along the thorax and participate in all upper extremity motions.
Motions of the Scapula
Motions of the scapula are:
• Elevation, depression, protraction (abduction), and retraction (adduction), with clavicular motions at the SC joint are also component motions when the humerus moves.
• Upward and downward […]

The shoulder girdle has only one bony attachment to the axial skeleton. The clavicle articulates with the sternum via the small sternoclavicular joint. As a result, considerable mobility is allowed in the upper extremity. Stability is provided by an intricate balance between the scapular and glenohumeral muscles and the structures of the joints in the […]

The design of the shoulder girdle allows for mobility of the upper extremity. As a result, the hand can be placed almost anywhere within a sphere of movement, being limited primarily by the length of the arm and the space taken up by the body. The combined mechanics of its joints and muscles provide for […]

The function of the temporomandibular joint (TMJ) is closely related to the function of the upper cervical spine and posture. Because of this close relationship, a brief description of impairments and interventions related to the TMJ are included.
Signs and Symptoms
Pain from a variety of sources is often cited as part of the temporomandibular joint (TMJ) […]

As described, symptoms in soft tissues, including muscles, can occur as a result of direct trauma (tears/contusions), strain from sustained or repetitive activities, or as a protective mechanism (guarding/spasm) from injury to joints or other tissues.
Management During the Acute Stage: Protection Phase
Pain and Inflammation Control
Use appropriate modalities and massage to control pain and inflammation. Passive […]

Some patients benefit from spinal manipulation during the early stages of intervention. A clinical prediction validation study determined that those most likely to benefit from spinal manipulation presented with: (1) symptom duration of less than 16 days, with no symptoms distal to the knee; (2) at least one hypomobile lumbar segment; (3) at least one […]

Patients with segmental instability—including hypermobility; ligamentous laxity; diagnoses such as spondylolysis, spondylolisthesis, or poor neuromuscular control of the core and stabilizing musculature—require interventions that improve stability. Some of the patients may have a history of trauma, repeated manipulations, or early signs of spondylosis. Mobility testing of the spinal segments reveals increased mobility at one or […]