The Thorax: An Integrated Approach, 2nd ed.

Lee O. Surrey, BC V4P 2N5, Canada, Diane G Lee Physiotherapist Corp, 2003, paperback (with enclosed CD-ROM), 144 pp, illus, ISBN: 0-9732363-0-2, $63.95.

Diane Lee has significantly updated her text on the thoracic spine. The second edition has a new chapter on spine stabilization exercises and a companion CD-ROM to illustrate evaluation and treatment points in the text. For readers who remember the first version, which was published 9 years ago, the second edition offers some important new material as well as insight into the progression of Lee's clinical understanding over the intervening years. Although the first edition strictly adhered to a biomechanical approach to joint dysfunction, the new edition proposes an expanded model, the "Integrated Model of Function," developed in cooperation with Andry Vleeming and presented in chapter 2, that allows for contributions from motor control and the myofascial system in determination of joint mobility. Lee incorporates the assessment of form and force closure at the thoracic joints, a concept first proposed by Siftjders and colleagues (Snijders C, Vleeming A, Stoeckhart R. Biomechanics of self-bracing of tire sacroiliac joint and its significance for treatment and exercise. Clin Biomech [Bristol, Avon]. 1993;8:285-294) to explain the function of the sacroiliac joints.

The biomechanical emphasis continues to be important in Lee's examination, evaluation, and treatment chapters. and readers will note that a highly developed palpatory sense is required to perform these techniques at an acceptable level. Lee classifies thoracic problems as "stiff joints," "compressed joints," and "fixated joints," with the recommended interventions being joint mobilization, myofascial/muscle release techniques, and joint manipulation, respectively. However, Lee's analysis regarding spine function also relies on the currently popular concepts of the "local" (ie, stabilizing) and "global" (ie, producing motion) muscle systems, and this analysis is backed whenever possible by current references to peer-reviewed evidence on the effectiveness of a combination of early manipulation followed by exercise for spinal dysfunction. Nonetheless, there are large areas of her book, especially in the area of manipulation technique, where evidence simply does not exist.

Lee has organized her text so that the chapters flow from a description of the regional anatomy, to the "Integrated Model of Function," to a description of thoracic biomechanics, to examination (chapter 4), classification, and treatment (chapters 6 and 7). The CD-ROM has video Flips corresponding to chapters 4, 6, and 7, which discuss the biomechanical evaluation, manipulation, and exercise for thoracic dysfunction. The video clips are generally numbered to correspond to figures in the text, although there are occasionally more clips than figures. The videos are particularly useful in illustrating how patient performance changes when appropriate cues are provided by the therapist. One complaint I have is that the video clips lack an audio track, which would have been helpful especially in the exercise section. Another small quibble is that, although the CDROM menu lists the clips by number and name, only the number is displayed while the clip plays. The lack of audio and a text label for each clip requires the viewer to refer to the text to locate the specific topic being displayed. This, however, is not necessarily a bad thing because many of the concepts require more than a single reading to fully grasp them. The lack of audio, however, is an area for future improvement.

The book contains one new test, the prime arm lift, proposed by Linda-Joy Lee and Bill Lyons, that is similar in concept to the active Straight Leg Raising Test for the lumbosacral region but, according to the authors, can he used to test thoracic stability. In this case, they do not provide any references or data as evidence of the reliability and validity of these measurements. The exercise chapter, written by Linda-Joy Lee, approaches treatment from the perspective of motor control and muscle function, but provides a wealth of specific guidelines and hints to make it possible for even newly licensed physical therapists to elicit desired muscle contractions from their patients.

In summary, Diane Lee presents her clinical understanding of thoracic spine and rib function, updated with references to current research. This alone should make the book interesting to clinicians who frequently deal with patients with thoracic dysfunctions. With the exception of Maitland's texts, there is arguably no comparable resource currently available that so clearly presents the personal clinical experience of a well-known physical therapist in an accessible, highly-detailed, and evidence-based format, and there is no such resource dealing exclusively with the thoracic spine.

Roy Bechtel, PT, PhD University of Maryland School of Medicine Baltimore, Md

Dr Bechtel is Assistant Professor in the Department of Physical Therapy and Rehabilitation Science where he leaches classes in biomechanics and spinal orthopedics. His clinical emphasis is in the area of manual physical therapy.