The thoracic spine

1. The Thoracic Spine
A Case of stiffness of Stability?

2. 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

3. 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

4. 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

5. Evidence re role in pathology
•Throwing shoulder
•Swimmers
•Cricketers

6. 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

7. Role in Shoulder Pathology
Posture
•Muscle activation
patterns
•Increase size
subacromial space

Lewis et al 2009, Foster et al 2008

8. Role in Shoulder Pathology
•Decreased thoracic rotation
•GIRD
•Scapula Dyskinesis
Bialowsky 2009,Lee et al 2002

10. 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

11. Current Trends Treatment
•Manipulation
•MET
•MWM
- F/Rotation
- Ribs

12. 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

13. 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

14. 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

15. Thoracic Manipulation
•Most studies consider combined with
other manual therapy
•But ? this makes sense……
Michener et al 2012

16. 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

17. •Long global muscles have specific fascicles of
attachment
•Oscillatory mobilisations change afferent
input
•Change muscle resting tone

18. Proposed Mechanism
•Mechanical stimulus
•Neurophysiological mechanism
•Peripheral mechanism
•Spinal mechanisms
•Supraspinal mechanisms

19. Effects of Manual Therapy

20. 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

21. Movement Re-education
MWM
•Reinforce ‘normal’ pattern
•Tx extension through range
•F/Rotation with functional reach
Mulligan et al 2006

22. 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

23. Mechanisms
•Palpation diagnosis poor reliability
•Restoration neurophysiologic motor control due to
reduction muscle inhibition
•Increase LT and Serratus activation
•Hypo-algesic effect
•Sympathetic function

24. Finding the primary driver
•Failed load transfer
•Meaningful task
•Scapula
•Glenohumeral joint
•Kinetic Chain

25. •Coupling patterns
during arm elevation
•Thoracic rotation
•What do the ribs do?
•Ring dysfunction
•Effect of stability
correction
Assessment Considerations

26. 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

27. 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

29. Prone Arm Lift

30. Sitting Arm Lift

31. Victims & Culprits
•Fascial considerations
•Movement pattern/control
•Segmental restriction

34. Subcostal Angle
•Reflects length of IAO and EAO
•Ideally should be 90°

35. Wide Subcostal Angle

• Shortness/stiffness of IAO + RA
•Lengthening of EAO
•Associated with;
- poor abdominal tone/sway back
- too many curls!!

36. Narrow Subcostal Angle

•Shortness/ stiffness EAO