Awareness for Chronic Pain, Obers test, Rehab and Capacity: Article Sharing Time

Written by Kento Kamiyama PT, DPT

Hurricane Jonas has hit us like a ton of bricks.  As I shoveled a total of 4 hours of snow on Sunday (most of our neighbors did the same), I was able to manage to put this together for this week.

  1.  Quick interview between Greg Spatz and Bill Hartman
    • Any technique we use can be useful especially in the right context.  Once your form, ROM, positioning and pain is decreased maybe it is actually a capacity issue (endurance, strength, anaerobic/aerobic).  Depending on what you find, the type of intervention would differ.  Its just important to know when to apply them.  Great interview by these two. Its all a spectrum right?


2.  Mike Robertson’s quick cue on RDLs

  • I’ve been following IFAST stuff more recently.  I must say they provide some really good cues on exercises either it be external or internal cue.  Having multiple cues I believe is important since every client learns things differently.  Chest over bar….genius.


3.  Awareness as an Agent of Change by Seth Oberst

  • This is not necessarily a new article but I came across this through the Facebook newsfeed.  I’ve read some of Seth’s articles and I’m glad I read this one.  Many chronic pain patients or just chronic behaviors and patterns can be happening due to the lack of awareness.  Becoming aware is the first step.  What I tend to see is a pattern of sudden fear or denial once the individual gets to the awareness stage.  This I believe is when continued support, guidance and empathy from the clinician is crucial.  Its not always about the technique but showing them that you care and its going to be okay.

4.  Obers Test Research 

  • We are taught that Obers test measure IT Band length but its really not.  As per the research it assesses more of the proximal hip structures such as the gluteus medius/minimus.  Also it could be due to bony blocks secondary to pelvis position.


Stay Warm!



5 Simple Ways to Get More Done in Less Time

“The world is full of people who are waiting for someone to come along and motivate them to be the kind of people they wish they could be.  The problem is that no one is coming to the rescue.  These people are waiting for a bus on a street where no buses pass.” – Brian Tracy

One of my goals for this year is to become more efficient with everyday activities.  As my business is picking up and my teaching career taking off along with my 11 month old son growing, I quickly realized there were more things I had less control of and needed to learn how to become more efficient.  Hence, like the quote above instead of waiting for things to happen, I started ordering some books and observed highly organized individuals.  This is when I picked up the book “Eat that frog” by Brian Tracy.   As skeptical I was with reading this book, there were some nice key points that has helped me in the past few months.  There were many techniques I already know but here are some pointers:

  1.  “The first rule of frog eating:  If you have to eat two frogs, eat the ugliest one first.”
    • Discipline yourself to first work with the largest or most difficult task which usually are the ones you don’t want to do first.  We can all do the easy ones even when we are tired but you are more likely to not do the hardest one when you are fatigued.  Just like the 80/20 rule, 80% of your work probably comes from 20% (usually the big stuff) of the things you do.  (I.E. – Since I don’t consider myself a great writer, I tend to do this blog post first thing in the morning).
  2. Decide exactly what you want to achieve in each area of your life.
    • Gaining CLARITY is probably the most important concept in personal productivity.  If you are not clear in what you do, you are more likely not to perform the big tasks.  Write down the goals, long-term and short term goals and organize the list.  This is something I preach all the time but its always nice to repeat.
  3. Ask the right questions
    • This comes more from the book “To Sell is Human” by Daniel Pink.  I will likely do a review on this book as well since I like to review and learn.  Instead of trying to positive talk your way to performing a problem, studies have shown (according to the book) when you ask yourselves whether you can solve a problem instead of tell yourselves you can solve the problem, the self questioning group solved nearly 50 percent more puzzles.  The positive self talk may give you a short-term emotional boost however asking the right questions may inspire thoughts about autonomous or intrinsically motivated reasons to pursue a goal.  I’ve seen this in Tony Robbins book and its a helpful tool.
  4. Use the ABCDE method prioritization
    • Sometimes your to-do-list is wicked long.  Unfortunately, you won’t have the time to do everything.  This is when prioritizing your lists can be helpful.  For example,  to each to-do list, you add a A, B or C on it.  A is the most important that it needs to be done today.  B is something you ‘should’ do but only has mild consequences and C…you get the point.  Then you can prioritize the A by adding numbers after.  A-1, A-2, etc. Interesting enough, this has been the most helpful for me since it was more of a novel idea for me.
  5. Prepare before you begin
    • Sometimes its the environment that you are in or created that is making it more difficult to start.  Have everything you need before hand and that might help you do it.  This is the example of already having your work out clothes out the night before so when you wake up you are more incline to go for a run.

The above is great in life but I’ve also realized how important this is when it comes to treating.  Be prepared, set your environment, gain clarity with the patient, ask the right questions and prioritize.  Sometimes we are problem solvers but also sometimes organizers to create more efficiency with their rehab.


– Kento Kamiyama PT, DPT

“Breathe to unleash”

“Let your breathe move you”



Moving onto 2016!Cool Things I learned in 2015

Happy New Year

2015 was quite the year for me.  I took a leap in going independent and cash based along with starting to teach seminars.  I’ve learned a ton and since this time of year is when every other blog are doing “what I’ve learned in 2015”, I’ll just ride that band wagon and write mine.


  1.  Cashed Based Practice is possible
    • Since I’ve started getting involved in the healthcare profession, I always wanted to eventually go cash based.  With insurance reimbursements getting more complicated, lengthy and decreased, I noticed many insurance based clinics starts to steer their focus to volume/numbers and eventually lose quality.  This is when quantity starts to trump quality and it should be the other way around.  Now don’t get me wrong, you still need to hustle, market, you need to give quality care and its not easy.    However, looking back last year I didn’t do so bad, earning more than last year where I was working in an insurance based company.
  2.  Surround yourself with inspiring individuals
    • I’ve surround myself with some incredible and inspiring individuals this year.  Surrounded by this motivating environment improved many things in life:  training, strength, clinical skills, movements, and business in a faster pace than before.  You are who you surround with might hold some truth.
  3. You are your own brand.
    • When starting a business, I think many are scared of their competition.  However, don’t forget that there is only one YOU.   Have a foundation, work on your strengths and weaknesses and be you.  Life is not a competition, just become a better you than yesterday and slowly your uniqueness will come out.


  1.  Teaching makes you better
  2. Be open to new ideas and different ways of thinking but…
    • We should always keep learning and embrace the new ideas that come along the way.  Nevertheless, we should still be skeptical and analyze the information secondary to how easy it is to receive information now a days.  With all the information out in the world, it is easy for us to become information ADD.  There were times where I wanted to learn SO MANY THINGS that I would try to learn 5 different things in 1 month.  The problem was, I would spread myself too thin and I don’t make much gains.   This lead to a shut gun approach and constant experimentation with different techniques without a good system in place.   I strongly believe having a good system that allows you to integrate many different modalities is key.  Learn one system well, learned the rules, master the rules first and THEN make it your own.  As John Cage once said: “Don’t try to create and analyze at the same time. They’re different processes.”
  3. Postural Restoration is a system
    • I’ve heard about PRI for years now and was always interested in taking the course.  However, claiming that everyone is a left AIC didn’t appeal to me.  As I have taken a good amount of courses and discussed with colleagues this year, I realized PRI is much more than just Left AICs but a system that makes me see things from a different lens where SFMA, NKT, FRR may not see.   And to be honest, its a damn good system.


  1.  Market to a target audience
    • I’ve followed some of Dr. Jarod Carter’s work regarding how to market for cash based practices.  I’ve consulted with him 3 times for some advice and he was very precise and informative.  As a cash based practice, you will learn how to market uniquely depending on your target audience.  I went to BNI meetings, coffee dates, visit physicians offices, social media marketing, blogs etc.   Many have worked; however, BNI meetings did not resonate with me.  I attempted for 3 months realizing later that the referral network I was trying to create was not within that group.   Instead, I started conducting more workshops to potential audience and going to health fair meetings which targeted my audience more precisely.  This is not to say BNI meetings don’t work but also showing that you will never know until you try, fail and learn from the experiences.
  2.  Balance with Family
    • Compared to some colleagues, I don’t work nearly as many hours as they do.  However, running a cash based practice, teaching for a University and teaching seminars on weekends eventually took away time from my family.  Even when I was home, I wasn’t “present”.  As a new father, I want to be more mindful and be efficient in order to spend more quality time with family.
  3.  Be good to your  current clients
    • Gaining new patients are great, but make sure you give your best to your current clients.  Gaining trust from them will eventually lead to a sustainable long term practice.


  1.  Father hood is the most rewarding thing
    • Not going to lie, this has changed my outlook on life dramatically.  Crazy how one person makes a difference huh?
  2. You can still make gains in your training
    • My training volume has gone down significantly.   My overall conditioning has decreased but I was able to have strength gains.  With a help of a coach I was still able to achieve: a one arm one leg push up, be able to perform one arm push up 5 reps in a row both sides, press 1/2 body weight on one side, able to strict muscle up for the first time.  Its been a slow progress but its doable.  I’m currently in communication with my coach on how to be efficient with my workouts next year.
  3. Its when you are vulnerable is when growth happens
    • This can be translated in many ways.  When you fail, you grow.  You are at your strongest when you are at your weakness.  Sometimes during your vulnerable times, you can actually find your core strengths about yourself.  Although it doesn’t feel great while you are going through the stumbles and failures, this is when your true self sometimes come out and shine.


  1. Breathing and Gait still rules
    • Basics, basics, basics.  Many patients can benefit from breathing drills.  As I understand more of the above, its all connected and you learn how to guide your breathe so you become more aware of the imbalances.  Its not just about diaphragmatic breathing but improving awareness to your body that lacks flow.
  2. Awareness
    • Feeding from #1.  As I learn more about PRI its making me more “aware” of things which in turn helps me improve my movement variability and others.  The more I help individuals become aware parts of their body they haven’t felt, the body starts to put itself back together.  With all the technology, medication, etc are we just non-aware beings now?
  3. Take your chances
    • I took chances this year to take steps forward to my goals and dreams.  Becoming an entrepreneur is probably the best decision I have made.  If you work more off hours, study off hours, you have this burning desire to become better, this is a thought.  It is scary yet if you know you will regret if you’ve never tried, I encourage others to eventually go for it.  It doesn’t have to be now, or soon but eventually.   Be nervous yet don’t be afraid.  Once you take that jump, regardless of the outcome you will see things many others haven’t.  You got this :).


Lastly, I can’t thank enough for the groups and individuals that influenced me this year.  The team at Catalyst SPORT (Dr. Kathy Dooley, Jason Kapnick, Joe Boffi, Fabian, Jackie, Talia, Isang Smith, Anna, Jake, Paul, Flex, Long, Coach Fury), Mejor Strength (Joe Gonzalez), Michael Jocson, Elana Behar, My wife and son and friends that supported me.  I know without you all, I wouldn’t have able to do what I did this year.

Thats all folks.  I’ve never been a good writer but when I meet some of my colleagues, they talked about my blogs here and there which is an unbelievable honor.  I appreciate you all for reading and thank you for letting me share my thoughts and knowledge.

To a stronger 2016!!!



Written by: Kento Kamiyama PT, DPT

“Breathe to Unleash”

“Let your breathe move you”

To Stretch or not to stretch?: Case Study

Written by Kento Kamiyama PT, DPT

Just honoring Star Wars here

As I have yet to see the new Star Wars movie, I wanted to post a case study regarding a client (which I received consent from) in todays blog along with the idea of stretching something that is ‘tight’.

Whenever I choose a manual technique or even non-manual techniques my patient preference will matter significantly and I will try to find a mutual goal to make the healing start.  This will matter from a pain science perspective  which I highly recommend reading if you haven’t (here).

On to the case study: this is a client who came in for chronic low back pain which we are making good strides in.  Recently, one of his older injuries are coming back where he feels brachial plexus (ulnar/median) symptoms on his R upper extremity.

In the past, he has performed nerve tension stretches which has relieved some symptoms immediately, however, the symptoms have not dissappeared.   After further assessment, it became clear the symptomatic side of the neck was long and weak which for the patient ‘feels’ tight.  It became even more clear when a scapular clock type of movement was assessed.

I apologize for the bad camera work here.

For this particular client, his neck was not necessarily short and tight, but it was actually long and even inhibited.  This is where I educate and tell the client to put the brakes on stretching and perform different drills with the yoda like wisdom aura.  I will use analogies of how that muscle is like a rubber band that is being stretched.  A stretched rubber band tends to have a lot of tension within the structure and that could be what the ‘tight’ feel is.


Once the client understood that the scapula needed to learn how to upwardly rotate or elevate, the symptoms has been getting better progressively.  The client is learning how to utilize the scapula while keeping a good rib position through breathing drills.

In the past, I used to give stretching to clients without thinking of it whenever the patient complaint of ‘feeling tight’.   Then I realized, the ‘feeling of tight’ can mean many different things: a tissue that is short OR long, stress, poor rib position, lack of hydration, lack of sleep, etc.  Similar to the mechanism of ‘pain’, the ‘feeling of tight’ is also a signal from our system sending communication signals that there might be something going on in that area.  After that signal, the individual will communicate to the therapist through their perception what may be going on.  I acknowledge their complaints and make sure to assess to double check.  This has helped me improve my outcomes in the long run.

Acknowledge the symptoms, become aware, get assessed and implement the intervention.

Have a great week guys!!



Several honorable mention articles:

Dr. Kathy Dooley’s blog about the The Stretching Instinct.

An article through the PRI lens on how a scapular position can alter neck muscle length by Mike Cantrell.  His explanation on the elevator scapula was on point.  An excellent piece.

Stretching has been one of the more controversial topics.  Greg Lehman does a great job with his blogs which I posted before.


Just had to put this in here.


To Teach is to learn among other things

By Kento Kamiyama PT, DPT

Teaching in Japanese? Ya I was nervous and I’m lateralized here (oops wrong seminar)

Couple weekends ago, I hit a milestone in my career teaching the first Neurokinetic Therapy seminar in Tokyo, Japan to well respected athletic trainers, chiropractors, physical therapist, massage therapists and acupuncturist.

Although I was born and raised in the US, teaching in Japan has been a long term goal of mine.  Teaching in Japan…check!

As I teach more and more, I come to realize several things:  teaching is still learning, don’t throw out what you know and preparation is key for traveling.

Teaching is still learning

When one thinks of teaching, many don’t think they learn as much.  However, I find it quite the contrary.  Although I may know the material a little more in detail than attendees, you are teaching to 20-30 different (or less/more) brains and perspectives.  This often leads to similar yet vastly different point of views and questions depending on the background.  These different point of views can broaden your horizon.

When I teach, I tend to openly encourage my students to ask questions.  I’ll also set expectations that I’ll do my best to answer but if I don’t have the answer, I apologize and research it later.  This allows the walls to break down and creative juices start flowing.

While I usually can answer most of the questions, there are times the questions are dense or just a different perspective that I learn that there is another way of thinking!  Or they find details that I haven’t found which leads to other possibilities.

This allows you to see the material from different perspectives; furthermore, solidify your material and see minutiae that you haven’t seen before.  I always notice, the more I teach the more I learn AND even become better as a clinician.

Dalai Lama
Thank you oh wise one

Don’t Throw Out What You Know

Just because you had a paradigm shift in how you treat, do not chuck the information or training you had before.  The techniques or system you had before worked for a reason.  Practice the new techniques or systems, find the connection and make it your own.

I will have to warn you.  Before you make it your own, make sure to practice and fail/succeed the material you have learned.  As Dalai Lama would say (did I just quote two in a row?  yes I did):

“Know the rules well, so you can break them effectively”- Dalai Lama


Dr. Kawai a well respect chiro in Japan.  If it wasn’t for him, NKT Japan wouldn’t have happened

Preparation is key for your health when traveling

Since I started teaching, I’ve done fairly well and had good/great feedback.  However, my body took quite the toll with traveling.   Why?  I always prepared for my lectures but I did not prepare for traveling well.  Poor preparation lead me to poor execution on training, eating healthy and sleeping.  Hence, this time (since time difference is 14 hours), I made sure I prepared.  This lead to less procrastination and better execution. Dr. Dooley’s post on jet lag was exceptionally helpful.  Here were some points:

  • Sleep on their world clock.
  • Short naps if needed
  • Hydrate…. ALOT
  • Get some organic green powder to keep your immune system in check
  • Do light training/movement drills
  • Have supplemental herbs for sleeping (I.E. – ZMA, valerian root)

By sticking to these, I had minimal jet lag and was able to get back to work immediately without feeling as much jet lag.

One studious group here


If you want to know your material, start teaching yet listen.  Don’t worry about being perfect because you will never be.  Making the mistakes and continuing is what makes the process perfect :).

Happy Teachings.



Monday Funday Reads: Updates on stretching, posture and IT Band

Written by Kento Kamiyama PT, DPT

stretching everywhere

There has been a ton of good material online recently thanks to the experts in the field out there trying to relay good information.  Hence, it must be spread and shared.  As we progress in our careers it is important to update our information and fine tune our thoughts on certain things.  You ready for the challenge?  Without further ado, here are some good reads:


  1.  What does stretching do to a joint? Part 1.  A post from Greg Lehman on challenging his own biases to see if the joint can actually loosen or stays stiff.  I also was more on the stretch tolerance camp but I like how he becomes more specific.  Must read to update your thoughts.
  2. Stretching tendons: What can we do and why we should challenge our biases: Part 2 Part 2 of the article above from Greg Lehman.  The result of this may surprise you.
  3. Posture Matters:  Does posture matter?  Through research, there is poor correlation between posture and pain.  According to my experiences this is true.  I’ve worked with many individuals who have less than optimal postural positioning with no pain.  However, like anything else as I progress into my career: IT DEPENDS.  Bill Hartman, PT from IFAST Physical Therapy with a nice video clip on the idea.


Honorable Mention:  The mechanical case against foam rolling the IT Band.  It can not lengthen and it is NOT tight.   One of the things I teach in my seminars to challenge our current thoughts.  The Obers test is one of the ways we learned how to test IT Band tightness.  However, I’ve seen and improved Obers test without even touching or stretching the IT band.  Great read by Greg Lehman yet again.


Have a great week everyone!

Let’s talk about Ribs

Written by Kento Kamiyama PT, DPT

no no not these ribs!
no no not these ribs!

In today’s post, lets talk about the ribs in relation with other areas of the body.  When we look at the thorax, as a physical therapist we commonly think about the thoracic spine and not the ribs.  We are almost taught to look at those as separate entities which I believe is not a great way to think considering the amount of articulation involved with the thoracic spine and ribs.

thoracic cavityHowever, if you look at the close relationship the ribs have on the thorax along with other areas in the body, it is hard to ignore them.

Once I had a better understanding about the roles of the ribs on our cardiovascular, neurological and musculoskeletal system, I realized I was missing something pretty significant in the early parts of my PT career.

The 12 ribs (1-7 true, 8-10 false, 11-12 floating) protect the lungs and heart from external forces and have a role in respiration.  Due to its role in respiration many muscles have attachments to the ribs:

Example Muscles include:

Inspiratory:  scalenes, sternocleidomastoid, pectorals minor/major, serratus anterior, serratus posterior superior, external intercostals, iliocostalis, longissimus, diaphragm, etc.

Expiratory:  Rectus abdominus, Internal/External Oblique, Tranversus Abdominis, Quadratus lumborum, serratus posterior inferior, tranversus thoracic, etc

inspiratory and expiratory muscles

I’m sure I’m missing some here but this is a good majority of it.

Whenever a muscle is connected to the ribs it is considered either a primary breathing muscle or a accessory breathing muscle.  Both primary and accessory muscles have important function during breathing.  During relaxed breathing it is recommended to utilize the primary breathing muscles (i.e.- diaphragm) instead of the accessory breathing muscles (ie- pec minor, SCM, scalenes).  The accessory muscles are their for ‘accessory’ reasons such as helping the individual get more air in during activities that need more oxygen.  However, in the clinic, I often see strategies where we use our accessory muscles more than the primary breathing muscles even during a relaxed state.

Rib Mechanics 101 

During inspiration, with good mechanics the diaphragm descends from its dome shape and the lower rib go through a bucket handle effect in a more transverse dimension and the upper ribs expand more in a anterior posterior dimension.   During expiration, the ribs go down back to its original position and allowing the diaphragm to dome back up.

rib movements

Unfortunately, what I tend to see a lot is more of a pump handle effect on all the ribs for many of the clients which can lead to rib flares.  This leads to increased externally rotated and protracted ribs which can decrease its ability to depress the ribs during expiration and to expand laterally and posteriorly during inspiration.

This is not bad if you can bring the rib back down and back. When you can' can pose a problem

This, unfortunately leads to poor diaphragm efficiency secondary to poor rib positioning.  The postural restoration institute will call this having a poor zone of apposition.  As shown below, if you keep this up, the rib will continue to flare and when you attempt to perform diaphragmatic breathing you might just be using accessory muscles since the diaphragm is already in a disadvantaged length/position.   Not only can this lead to inefficient diaphragmatic breathing, it can consistently lengthen the abdominals leading to inefficient abdominal strength.  This is when one might be chest breathing OR abdominal breathing with a strong rib flare.  This, unfortunately will not be good diaphragmatic breathing.  (I was going to find one in youtube but I’m not here to call anyone out here).


When this happens a myriad of things can happen where it can affect:

  • Poor scapular/shoulder movements – Eric Cressey has a nice example of rib flare with shoulder movements here
  • Back pain or poor intrinsic core function – Kolars has a nice article about back pain and diaphragmatic breathing.
  • Neck/Hip/Foot/Thoracic Spine dysfunction –  Linda Joys Lee’s work is nice example
  • Hip dysfunction – A nice article from PRI.
  • Pelvic Floor Dysfunction- a quick clip from Dr. Kathy Dooley on diaphragm and pelvic floor function along with exercises to release it.

From a movement standpoint, when a thorax is protracted and externally rotated, it could loose its mobility in all three planes.  When a thorax is intact, the movements primarily allow transverse plane followed by lateral bending with significantly less flexion/extension moments (Watkins et al 2005, Willems et al 1996).  To repeat, when your ribs are flared, the diaphragm tends to flatten and you lose your ability to inhale through your diaphragm efficiently.  To use the diaphragm efficiently it is essential to have good rib positioning along with abdominal opposition to maintain good diaphragm dome shape (Postural Respiration Manual) .

Hence, just because an individual is abdominal breathing, it does not necessarily mean one is utilizing the diaphragm well to inhale.  If you see a rib flare and lack of rib movement laterally and posteriorly during inhale and poor rib internal rotation and depression during exhale, they still might be inefficiently utilizing the diaphragm and utilize the accessory muscles to breathe.

So….how do we improve good rib movement?  Here are some points (but not comprehensive) that I’ve learned that has helped:

  •  Exhale long.  Either utilize a balloon, straw to get the exhale going to allow the ribs to go down and back.  Remember, you want to see some rib movements here.
  • For those that can’t shut their back/rectus abdominis during exhale, utilize a ‘sigh’ type of breathe to shut down first
  • After the exhale, hold your breathe for a couple seconds to allow the diaphragm to dome a little more
  • When inhaling, try not to force the inhale and inhale silently.  Let the air in naturally.  When you force the inhale that tends to tap into the sympathetic system and the ribs tends to have a harder time expanding the way it needs to.
  • Imagine your inhale or ‘air’ going into your mid/low back (or feel it expanding) while your abdominal muscles are opposing
  • Alternate the ribs opening/closing.  Meaning learn how to bring one rib down while the other opens.  This happens with transverse and frontal plane motion such as gait.  Use alternating arm reaches as an example.  I just found a gem of Connor Ryan doing a demonstration of alternating arm reach.

Once the breathing mechanics are improved, now the questions are how are their ribs positioned or moving during:

  • Neck movements?
  • Scapular/Shoulder movements?
  • T/S mobilization exercises?
  • Core exercises?
  • Hip movements?
  • Gait?

Once you realized a certain area of the ribs not moving, it could have affects to all the movements above.

Hope this helps stir up some ideas.  Happy Holidays!!

Supplementary Videos:

Bill Hartman on thorax/rib position for scapular stability

Bill Hartman on an example of good rib position for scapular exercises

Zac Cupples talks about pelvis movement on how it can shortened certain areas of the pelvis tissues.  This is important when you can see how the ribs have an affect on pelvis positioning

Dr Kathy Dooley showing the immense connections of the diaphragm to organs


Lee LJ.  The Thoracic Ring Approach- A New View of the Thorax.  N0. 145, Winter 2013, In Touch Journal, an official publication of Physic First, the Journal for Physiotherapists in Private Practice (UK).

Liebenson, C. Rehabilitation of the Spine: A Practitioners Manual (2007).

Postural Respiration Manual Notes from Postural Restoration Institute

Watkins R 4th, Watkins R 3rd, Williams L, Ahlbrand S, Garcia R, Karamanian A, Sharp L, Vo C, Hedman T. Stability provided by the sternum and rib cage in the thoracic spine.  Spine (Phila Pa 1976) 2005; 30(11):1283-1286