The Thoracic Spine

A Case of stiffness of Stability?

Why does it matter?

• Important region of force transmission

• Transfers load between legs and lumbo-pelvic region and arms, neck and head

• Central area of myo-fascial connections

• Protective unit

• Closely related to autonomic nervous system

Lee DG 2003, Lee LJ 2008, 2012

Thoracic Spine

• Centre of rotation for the trunk

• Essential for the production and transmission rotational torques

• Inter-segmental control as per other areas of the spine

Hodges 2003

Why does it matter?

• Stiff pain-free thorax can create excessive loading and mobility demands in adjacent areas.

• Results in excessive movement, compression, shear and or tensile forces

• Addressing stiffness allows a more even distribution of load through the spine

Evidence re role in pathology

• Throwing shoulder

• Swimmers

• Cricketers

Role in Shoulder Pathology

• Relevance kinetic

chain

• Movement

strategies

• Functional reach

• Relevance in

overuse pathology

Teyssedre 2000

Lin et al 2005

Roy et al 2008

Role in Shoulder Pathology

Posture

• Muscle activation

patterns

• Increase size

subacromial space

Lewis et al 2009, Foster et al 2008

Role in Shoulder Pathology

• Decreased thoracic rotation

• GIRD

• Scapula Dyskinesis

Bialowsky 2009,Lee et al 2002

The story so far…

• Techniques directed at increasing thoracic mobility

• Tx Spine most frequently manipulated

• Exercises designed around increasing mobility

• Muscle training – dissociation and postural control

Current Trends Treatment

• Manipulation

• MET

• MWM

- F/Rotation

- Ribs

Effectiveness Thoracic

Manipulation

Boyles et al 2009

• Tx spine V

• 56 pts with SAIS

• SPADI, Pain Scale, Neer, Empty can,

Abd

• 48 hours all sig increase /decrease

Thoracic spine

Stunce et al 2009

• 21 subjects av age 47 shoulder pain

• Tx F restriction 100% Tx E 7%

• Unilat rib restriction 79%

• All manipulated

• Sh AROM imp by 38º F, 38º Abd, 30º Rot

• VAS decreased by 32 mm

Thoracic Manipulation

• Manual therapy and

exercises addressed to Tx

and ribs

• In addition to usual Rx

• Improved success rates vs

usual Rx alone

• Maintained at 1 year

• Improved patient rated

outcomes Bialowsky et al 2009, Walser et al 2009

Thoracic Manipulation

• Most studies consider combined with

other manual therapy

• But ? this makes sense……

Michener et al 2012

Why does manipulation work?

Stiffness ? ;

• Increased resting tone and dominance global muscles of the thorax

• Connections to upper quadrant

• Neuro-myofascial compression of joints of the thorax

• Creates rotational dysfunction

• Long global muscles have specific fascicles of attachment

• Oscillatory mobilisations change afferent input

• Change muscle resting tone

Proposed Mechanism

• Mechanical stimulus

• Neurophysiological mechanism

• Peripheral mechanism

• Spinal mechanisms

• Supraspinal mechanisms

Effects of Manual Therapy

Sympathetic System

Sympathetic system

• Pain pressure thresholds

• Cold hyperalgesia

• Thermal pain threshold

• BMD > 21%

• Feature frozen shoulder

Slater et al 1995, Muller et al 2000, Ge et al 2006

Movement Re-education

MWM

• Reinforce ‘normal’ pattern

• Tx extension through range

• F/Rotation with functional reach

Mulligan et al 2006

But is it all about stiffness?

• Is stiffness the only problem?

• Why do we have to keep on treating it?!

• Commonly believed that thorax is inherently stable and stiff due to ribcage

• Range of motion trunk rotation 6-9 ° per segment

Mechanisms

• Palpation diagnosis poor reliability

• Restoration neurophysiologic motor control due to reduction muscle inhibition

• Increase LT and Serratus activation

• Hypo-algesic effect

• Sympathetic function

Finding the primary driver

• Failed load transfer

• Meaningful task

• Scapula

• Glenohumeral joint

• Kinetic Chain

• Coupling patterns

during arm elevation

• Thoracic rotation

• What do the ribs do?

• Ring dysfunction

• Effect of stability

correction

Assessment Considerations

Assessment of Dysfunction

• ? Does it move when during tasks when there should be no inter-segmental movement

• Clinical tests to detect loss of ring control

• Altered timing between long superficial muscles thorax and deep segmental muscles

Assessment of dysfunction

• During rotation contra-lateral translation of the ribs

• Palpate ribs laterally

• Non-optimal strategies;

- not translate ‘away’

- move excessively ‘away’

- translate ipsilaterally

All = failed load transfer but is this just stiffness?

Lee LJ 2008,2012

Prone Arm Lift

Sitting Arm Lift

Victims & Culprits

• Fascial considerations

• Movement pattern/control

• Segmental restriction

Subcostal Angle

• Reflects length of IAO and EAO

• Ideally should be 90°

Wide Subcostal Angle

• Shortness/stiffness of IAO + RA

• Lengthening of EAO

• Associated with;

- poor abdominal tone/sway back

- too many curls!!

Narrow Subcostal Angle

• Shortness/ stiffness EAO