The next area I'd like to go through is the background. So I always try to begin teaching an area, especially a region of the body, to give some background of some significant anatomy. Now, there was a, when I was beginning my studies to go into medical school, my father told me about the, had surveyed all the physicians from Harvard, and they did a study and said, well, how much of all your pre-med studies are really relevant, and kind of the preclinical time that really affect clinical practice? And I think they said they felt they could get it down to about 16 weeks. So, you know, in other words, they said, if we look at all the stuff we're doing, you know, but it takes years to develop. So we're not going to make it 16 weeks. But the idea was they kind of condensed it down. And that is there's really key things you have to know. And there's a lot of things we learn, but there are key things you're doing. So when I teach an area, I really try to just go to those key, salient things that honestly are relevant to that area and going through it. So a few things I want people to understand. You know, one is I look at the anatomy with this, that there's a lot of structure. So why is this very important? And part of it you get in the audience is, why is this area even important to look at? Well, you know, because anatomy, there's a lot of important structures themselves. It also looks at, you know, vasculature, lymphatics, trachea itself. One thing that's confusing with people is they heard the term thoracic inlet in a condition called thoracic outlet. So everyone gets really kind of uncertain with this. So what you try to explain to people is say, look, anatomically, when we look at that cervical thoracic junction, because that's the anatomically area itself, that refers to this thing called thoracic inlet. But if there's clinical issues that have an implication that goes to themself, then they're referred to as thoracic outlet. So thoracic outlet, because there's symptoms that come out of it. Thoracic inlet is based, again, on the anatomy to the area themselves. So when we see musculoskeletal changes themselves, they may affect the whole function of these structures themselves. And then, you know, it's not critical to go through each structure and point out and go through each thing. But to identify them, say, look, there's a lot of things there that are both vascular, neurologic, pulmonary GI, lymphatic. So all of these areas are impacted from this area. The one you may spend more time with ought to be more the lymphatic, because we can see that there's drainage from the head and neck and the upper extremity that are really impacted by the cervical thoracic junction. So that's why a lot of times in board exam questions around this, this is one area they'll say if there's problems with the head and neck, this is the one the primary should be treating. Part of it's because improving motion in this area has an impact upon the upper extremity and the head and neck. We'll get more into that. I also take certain areas that we teach are good times to begin a teaching point on a major concept. So one of the major concepts that comes out of this area I try to do is transition areas. So when a lot of individuals look at treating a patient and using as manipulation, a very pedestrian initial approach is I have a structural problem and I treat an area. This section honestly moves us to two different levels that look a little bit higher with that. And one thing when you're teaching this area is to get the idea of transitions, that areas between the head, the occiput, and the cervical spine, cervical thoracic, thoracolumbal, lumbosacral, these are all part of transition areas. And these areas where most motion restriction occurs. And so a lot of individuals, these are key areas that we focus in on treating. And these area themselves that we may see more areas of dysfunction. So the other thing is it's an area of compensation. This became most prominent by someone named G. Gordon Zink. And Dr. Zink was looking at transition areas and developed what we call a common compensatory pattern. Because he saw that these transition areas would follow a certain pattern commonly in patients. And because of that, he identified that if he focused on treating those transition areas, he was more effective. And he could treat people more rapidly. So when teaching an area like that, one thing I try to do is I try to do something that's kind of an interesting story. I mean, talk about transition areas, I'm sure is very exciting. But honestly, it's more exciting to talk about Dr. Zink, as someone who was doing, someone who noted that initially and how he found himself. And the story I like to use with him is he initially started in rural Pennsylvania. He had a small town area that the people agriculturally based, they didn't have a lot of money. But he had to find a way to kind of make it in his office. But also, he couldn't charge people a lot of money. But they had injuries. He found to be focused on transition areas and treated those common areas that he could treat people very rapidly. He could give a full treatment in 5 to 10 minutes. Because he identified these quarries, treat them, and get them out and have low cost to patients and keep the lights on in his office. So again, I try to use a story that's kind of important that maybe kind of get the idea across with that. So I always think of Dr. Zink when I look at this, and I kind of share that. The other thing to understand is that sometimes, if you affect one part of the body, they have to compensate for the others. So if you have a problem in the lower back, patients may note, I don't know, the low back is spiking. But now I don't know why my neck is bothering me. Why the space in my neck? Well, that's because it's compensating for those changes. So if they understand transitions, they'll understand the fact that how this whole compensatory model may work. The other key model of cervical thoracic, which is a good time to talk about transition, is the fact that there is a functional diaphragm associated with that. And the cervical thoracic diaphragm is a key area themself. And because of that, the Simpsons fascia is the very top of themself. And there's a copy of the lung themself. It almost acts like a functional diaphragm. So when the thoracodontal diaphragm descends with inspiration, this moves superiorly themself. And so they work together to create that negative interthoracic pressure, which allows low-pressure systems like venous lymphatic to return. And so when you look at it, you look at the relation of this, that this diaphragm also is relevant. Because the thoracolumbar diaphragm, everyone's really much aware of that as a major diaphragm. But also, like with the urogenital pelvic diaphragm, the cervical thoracic is a much more subtle anatomical feature. But it still functionally acts like a diaphragm. And they work synergistically. And that is part of also the respiratory circulatory model and how improving that function improves that respiratory and circulatory function. And I think also is looking about, talking about the fascia there and how that fascia works themself and all that goes into the cervical area themself. And those are very important things. Again, talking about dynamically. So I try to explain that sometimes using some just motion that when you take a deep breath in. So using your hands to describe and enhance that negative interthoracic pressure. Get that conceptual model across and doing it. And then I think people understand a lot more as you're presenting it and going through that. And the whole lymphatic system is then, trying to show this chart of lymphatics, to say, look, when those functions well, what takes these low-pressure systems of lymphatics and returns themself here? And that helps with structural problems. And that's why this is a key area to treat, basically head and neck, because it affects the whole lymphatic drainage that comes along with that. And that's why this is a key area when we're looking again at that whole respiratory circulatory model. And so when we're treating somatic dysfunction in these areas and we improve that, that itself helps improve the diaphragms, how they function, it helps that respiratory circulatory function. So biomechanically it works better. Also respiratory circulatory, it helps work better. And those are important things. And then the advantage of this is that it takes a look at, again, that whole drainage themself, when we're treating it, we're impacting the structures themself, from the head and neck, as well, and going through that. Also with anatomy, see there's multiple muscles that occur through this area. The scalene, the trapezius, levator, all go through there themselves. In each one, there may be some key points. And again, the scalene is impacted because that first rib, the second, which are part of that cervical thrombotic junction, are key attachments that go along for that. That's a key thing with respiratory function themselves. So if someone has respiratory disorders and they're using accessory muscles like this to breathe, having dysfunction in those first two ribs can have a major impact. And that's important. The trapezius, the big thing to point out is, realize the trapezius has a multiple effect. It starts in the occiput, down to T12, but also anteriorly to the clavicle, and posterior to the spine and the scapula. So a point when you're teaching is say, look, this one muscle, onsi, affects a huge area. It affects the cervical area, down to the lower thoracolumbar area, to the upper extremities, and both attachments to the clavicle, and to the scapula. So understanding that is that, and the key center point with that is over the cervical thoracic junction. So lots of retreating the trapezius in this area themselves to help relieve problems that patients have with neck pain, lower back pain, everything else that goes along with this, as well as extremity problems. And levator scapula, a lot of people kind of forget with this area themselves, that also this transitions through the area, attaches to the scapula, but goes to the upper four segments of the cervical spine. So again, it's another muscle group that's very much involved with it. So in summary, looking at the functional anatomy associated with the first rib, the cervical thoracic junction, also referred to as the thoracic inlet, there's really some key things to remember. One is, we're looking at it as a functional anatomy. We're looking at the area themself that the importance of this area is because of multiple structures that come through, both vascular, neurologic, lymphatic, as well as different organ systems involved. Pulmonary, think of the trachea, GI with the esophagus itself. So these are all impacted with it. The other piece is this transition area. These are key transition areas of the spine, as in the cervical occiput, cervical thoracic, thoracolumbar, lumbosacral. What's key about this also is tied into diaphragms. The key diaphragms, you think about the thoracobdominal, urogenital, pelvic. But Simpson's fashion, the cupula of the lung, act as a functional diaphragm. So when they're working synergistically, and it's moving superiorly, the thoracobdominal diaphragm is moving inferiorly. That creates this negative endothoracic pressure, helping with low pressure systems. That's why it's a model area to describe, the benefits of the respiratory circulatory model. And treating somatic dysfunction and making this work well helps in treating problems, especially conditions of the head and neck, upper extremities. There are key muscles also, groups that are also involved in this area. One is looking at the scalene itself, attached to the first and second rib. The attached cervical spine involves accessory muscles respiration. Look at the trapezius, which superiorly is at the occiput, all the way inferior to T12, but also attached to the extremities, both anteriorly with the clavicle, posterior with the scapula. So dysfunction there, that midpoint, the trapezius, is also infected. The later scapulae attached to the medial borders superiorly above the spine of the scapula to the cervical spine, the upper segments laterally. It's a key thing that a lot of things transitioning affect neck pain, other problems with that. So if we keep those key things in mind, we can see that this has a lot of functional anatomy that's very important. So the lab that we begin with that looks at this functional anatomy associated with the first rib, the cervical thoracic area, sometimes referred to as thoracic inlet, is really a time to kind of key hit those points about functional anatomy, those theory. And also to illustrate, what are key things that we want to make sure we get across? Talked about important structure of the body, and people can see, looking at the individual, that we've got elements that go from the head and neck themselves down to the rest of the body, and can kind of mention to them. I said, you know, this does impact a lot of parts of the vascular, neurologic, lymphatic, and other areas themselves. It also helps to say that we can see with this transition area themselves that we acknowledge that this also is the area that has the diaphragm associated with that Simpsons fascia, cupular lungs. So kind of bring out those teaching points that you have with them. And this is a key transition area, as well as the cervical, kind of the occipital cervical area, cervical thoracic, as well as the thoracolumbar lumbosacral. And what you're doing is saying, well, there are some key muscle groups that are also impacted with this. And it's probably the one that's most tangible, looking at it. There were kind of three key muscle groups we kind of talked about. And one of them was the scalene. And I think people also see that. They can realize in the front, the scalene is attached to the first two ribs, but it goes anteriorly. And this is a key area that goes along with accessory muscles. So if you're dealing with a patient with any respiratory issue, you want to mention to the specialist, hey, remember that scalene that's right through here. So we're treating this area. We're impacting these scalene muscles that are impacted here on that first few ribs, and kind of seeing where they are in relation to that. Why don't you turn around and face the other way for me? Thanks so much. The other thing is describing a trapezius. You talk about the trapezius has quite a varied area with themself. But what the trap here is also pointing out to individuals that it really starts from the base of the occiput themself here down to T12. And anteriorly, it goes all the way to the clavicle. Posteriorly, this goes back here to the spine of the scapula. So that in itself is saying that this is a huge kind of a muscle group that impacts a lot. It impacts the head and neck, the upper extremities. This whole area, also a gateway to the problems of the low back can also be impacted with this. So because of the fact that cervical thoracic is right in between, it's kind of the center point of that. So for them to see that and also to touch, to feel, say, oh, yeah, yeah, I can feel that muscle. That way, that muscle is tight. That may be cause of a problem that we're getting that area themselves. So you haven't gone to a full assessment, but they start appreciating those components you're going to get later. The other kind of key muscle we talked about, which kind of transverses it themself here, is looking at levator scapula. Again, finding the scapula, the self, the spine. right above it, medially, is where it attaches. But it also goes all the way to the kind of lateral posterior aspect of the upper four cervical vertebrae. So because of that, you see a lot of patients with neck pain, it transverses through here. They're getting it because of that and other problems with the shoulders. So people kind of think of these core areas. When we go into other concepts later, like thoracic outlet syndrome, understanding the anatomy to the area that all these different muscle groups play apart, the clavicle, other things like pectoralis muscle, and muscle itself also play into this, along with the scalene, that these are key muscles understanding this area. So now we've kind of gone through the functional anatomy and key points you want to get across. So the first lab session, we're going to go to the tables now. So we're going to take a look at this area of this functional anatomy. And using it as a teaching point to go through key things with one patient or the other. So again, the model is the one fellow will be the physician, teacher. The other will be the patient, and also the learner. So Kelsey, as you remember from medical school, we have the common compensatory mechanism that we learn, approached by Dr. Zinke. And the three main areas, one being the junctions between the thoracic, cervical thoracic, tricolumbar, and pelvic area, lumbar, and pelvis area. So that focuses on the three transitions. And we're going to now focus on the cervical thoracic area. And the three main muscles are scalene, trapezius, and the middle scapula. So those are the key muscles basically driving that transition area. And that's what you just learned, and that Dr. Zinke only had a limited amount of time to teach. And I think that was genius of him to focus on these three regions and get great results without having to be taking a long time for people who had limited access to services. So we have the trapezius muscle that starts off from the cervical area and all the way down. And we have the levator scapula that would help elevate the scapula. And then the scalene are one of the main muscles that help with raising the first rib, which is one of the key factors in the thoracic inlet area, the movement of the first and second rib. So that starts from the cervical area attaches to the first and the second rib. And then we talked about those are key muscles, but also the anatomical things. You're right. You hit on the area of the transition areas themselves, the involvement of the fact that we've got the diaphragm that's associated with that, and that kind of plays into that respiratory circulatory model and going through it. So anyway, in those four transition of the occipital, cervical, cervical thoracic, thoracolumbal, lumbosacral, and doing. We're talking about the first rib, the cervical thoracic area, which is called thoracic inlet. So right away, you frame it where it's at. There are several things we're going to talk about with this. I said there's a few things is that this area is a transition area. There's a number of transition areas of the body, but this is one transition area itself. We mentioned occipital, cervical, cervical thoracic, thoracolumbal, lumbosacral. But say, look, it's one key transition area. The other thing that's unique about it is it has a diaphragm attached. So that diaphragm attached to the Simpsons fascia is a functional diaphragm, and it helps work with the thoracic cage, create this negative interthoracic pressure, helps with the low pressure system. So that's why treating the cervical thoracic area structurally helps a lot. And that's what people with conditions in the head and neck and upper extremity are doing, especially all of the immunology. Head and neck, there's a lot of things. And respiratory, a lot of things you have with that. So treating it's important. It's relevant. And above it also, I'm going to say, the other thing is there are also key muscle groups to think about in this area. And those key muscle groups that impact it, because of its location through here, is that trapezius. It's a pretty extensive muscle. The occiput, inferior to T12, anteriorly to the clavicle, posterior to the spine, the scapula. And then, also, we've got other muscles, the levator. The levator is tight to the scapula. Find the spine right above it, and that's where it attaches. And it goes all the way up to the upper floor of the cervical spine. So it's involved a lot of people with neck pain. So with that, we can see that. OK, yeah, good. In fact, you can actually turn a little bit more. There you go. So here, I'm going to show the muscles that relate to the cervical thoracic transition area. So the first one is going to be the scalene muscles. It's in the front, and I'm going to show you where it is. It's right here, and it transverses the first and the second rib. Second muscle is the levator scapula, and the muscles is right here. And what it does is it elevates, it brings up the scapula. And then, the largest one is the trapezius muscle. So it has several points of attachment. It starts in the back of your head, or the occiput, right here, and it goes around to the front and attaches to the cervical. And then, it goes to the back, across the scapula, where it ends at your T12. All those muscles are important muscles as it relates to the cervical thoracic area. It's important for breathing, for clearing the lymphatics. For example, if you have an infection, like a sinus infection, or infection, or even allergies. So these muscle groups are pretty important in this definition. Do you have any questions? Let me give you a critique here, just to help you out. I think you did a good job. You were very clear in the way you talked. You approached your patient and looked at her when you were going through, to make sure that you had that contact. Initially, some areas that you can improve a little bit, it's a little artificial, because we have a camera. But if the camera was watching you, you made an introduction to the camera, and then you ignored the camera for the rest of the session. And a way to improve would be to say, okay, here's the scaling muscle that goes here to here. Now I'm gonna talk to the levator scapulae. Then you go back and do this, so that the camera is de facto another student. Everyone that's watching you, you gotta point your comments to that particular place. I like the way you also asked for questions, so that you knew whether or not the student was understanding what you were doing. So overall, very good. Couple little things to think about the next time. Hi, I'm going to be showing my student the cervical thoracic region of the neck, specifically transition areas. So we'll be talking about the scalenes, trapezius muscle, and the levator scapulae. So I'm going to start with discussing the scalene muscle. So the scalene muscle is in the anterior part of the neck over here, and it helps with flexing your neck and rotating your head. The second muscle is the trapezius muscle, and the trapezius muscle has multiple points of attachment. The trapezius muscle is connected here, superiorly at the occiput, and anteriorly, it connects to the clavicle. Posteriorly, it connects to the spine of the scapula, and it ends at T12. And this muscle is really important in, it acts as an accessory muscle for respiration. In addition, the levator scapulae is the last muscle I wanted to discuss, and the levator scapulae will help elevate the scapula, which is this bone in the back, and it also will help with respiration. So the levator scapulae is pretty much connecting here. Okay? Do you have any questions? No, I don't think so. Okay. Let's give a little bit of a critique. I think you did a very good job. You did something which is very important, and that is you smiled. I think that's good, and if you smile, the student tends to return your smile with another smile, and now you have a little bond there with your learner, so I think that's good. You addressed the camera a little bit artificial at this point in time, because that's not usually how you teach in the clinic or in the hospital or whatever, but it's okay. You had a nice, simple summary. You went through and did everything you did, then you went back to say, okay, now I'm gonna switch and do something else. Then you went to your student and your patient and said that, and then you did that again, and then finally, you did a summary of saying, this is what we did, this is why it's important, and then you asked for feedback with questions to say, did you understand, did you learn what I was trying to teach you? So all of those things were good. You followed all the principles. It was very, very good. Good job. Thank you. So basically, what you wanna do when you're teaching somebody, you wanna come up and really emphasize the transition points. There's the occipital cervical, cervical thoracic, thoracic thoracolumbar, and then thoracosacral, or I'm sorry, lumbosacral at the bottom. But today, what we're gonna really be concentrating on is the thoracocervical, cervical thoraco, and the transition point. And with that, there are three major muscle groups that you wanna point out to somebody. You wanna point out posteriorly, the biggest one is the trapezius. And it's such a large muscle group, it will attach to the anterior portion onto the clavicle. It attaches to the scapula, all the way down at the bottom to like T12, and all the way up to the occiput. So it has this huge net that it covers. And then also, you have the levator scapula that can cause a lot of issues as well. That one attaches to, its origin is the spine of the scapula, and then it attaches up onto the cervical, cervical, the second, third, fourth cervical scapular processes, yeah. And then the third one we're gonna concentrate on today is scalenes in the front, because those can become hypertonic and cause issues with the thoracic outlet. So, and those are attached, for scalene is on the first rib, and the second one is on the second rib. And those attach to the anterior portions of the transverse processes. So, you can get any combination of dysfunction with any of those muscle groups all together, one just specifically. And so that's what you wanna point out to someone. So I'll go ahead and have you show me what kind of what I just showed you. So the transition points between the occipital, cervical, like cervicothoracic, thoracolumbar, and lumbosacral areas have a lot of dysfunction. Then in the cervicothoracic area, the three muscle groups that we're focusing on are the trapezius, which is kind of like a big giant diamond in this area. And then, so that's like all of this. And then the levator scapulae, which are occipital cervical junction, cervicothoracic, the thoracolumbar, and then the lumbosacral. Perfect. And then sort of focusing on the muscles mainly at the cervicothoracic junction. So one of the main ones is the trapezius. So that's gonna start up here at the occiput, come down to the spines of the scapula, and then kind of come down to a point at T12. Exactly. And it's also, yeah, this is attaching all along here as well. The spinous processes, yeah. So that's one of the muscle groups. The second one would be levator scapulae that we're gonna talk about. So the levator scapulae, you're gonna find the medial part of the scapula, come up to like the superior angle, and then follow that up to the cervical transverse.

cervical thoracic junction

Dr. G. Gordon Zink

transition areas

thoracic inlet

respiratory function

common compensatory pattern