Assessment and Treatment of the Thoracic Spine

Original Editor - Jess Bell based on the course by Tanya Bell-Jenje
Top Contributors - Jess Bell, Kim Jackson, Kirenga Bamurange Liliane, Tarina van der Stockt, Ewa Jaraczewska, Lucinda hampton, Olajumoke Ogunleye, Aminat Abolade and Merinda Rodseth

Subjective Assessment

Further information about the assessment of the thoracic spine is available here, but specific questions to consider in the subjective assessment include:

• How did the problem begin? How long has it been a problem?
• How has the pain progressed over time?
• Is there a history of overload or trauma?
• Does the patient have pain with breathing? And if so, during which part of the breath does this occur?
• What effect does coughing and / or sneezing have?
• Can the patient lie on the affected side at night?
• How is the pain behaving and what is the level of irritability?
  • Is there stiffness for a prolonged period in the morning?
  • Is there also a history of enthesopathies?
    • NB: enthesopathies are pathologies that affect the entheses (i.e. the bony insertion sites of tendons and ligaments)
  • This history could indicate that the patient has a seronegative spondyloarthropathy
• What are the patient's functional impairments?
  • Consider sport and activities of daily living
• What is the patient’s medical history?
  • It is essential to have a detailed understanding of this history as there are a number of conditions that can masquerade as musculoskeletal thoracic pain
• Are there any psychosocial factors contributing to the pain?
• Are there any red flags?

Subjective information can give quite specific clues about the potential cause of pain (i.e. inflammatory, mechanical or non-mechanical):

• Nerve root or facet pain may be described as lancinating / nauseating. It may radiate and follow the angulation of the rib
• Costochondritis tends to be described as a deep, boring, aching pain in the chest wall that may radiate (often posteriorly or to the neck)
• Rib fracture or intercostal strain is typically described as a sudden, sharp / piercing pain, which is then aggravated by laughing, sneezing, coughing, deep breaths or any type of straining manoeuvre
• Constant, burning pain can be a sign of inflammation
  • This could be from an auto-immune disorder, a severely effected joint, or referred from another structure (e.g. a duodenal ulcer might cause a constant burning pain in the thoracic region)
• When patients have immobility, they tend to report stiffness, restricted movement, or a sense of feeling ‘stuck’

Objective Assessment

The objective examination is guided by findings in the subjective interview. Remember:

• It is essential to understand which structures are loaded during each test
• Keep tests to a minimum
  • “Less is more” to avoid flaring up the patient
  • Consider combinations of tests
• The best ‘special test’ is the one the patient demonstrates to you
• Consider the diaphragm

Objective Testing

Figure 1. Common postural dysfunctions.

The following tests should be included in an objective examination of the thoracic spine:

• Static and dynamic postural assessment:
  • Watch how the patient moves / drifts / hinges
  • Consider different types of postural dysfunctions (see Figure 1)
  • Is the postural change a primary or secondary problem (e.g. lumbopelvic dysfunction)
• Breathing mechanics

Figure 2. Dermatomes.

ROM tests from neutral

• Look for intersegmental restrictions
• Assess from behind

• Inter-ring and articular palpation during motion
• Motor control and strength tests
  • Sitting
  • Puppy lie (i.e. prone extension propped on forearms)
  • 4 point
• Neurodynamic tests
  • Upper limb tension test for thoracic outlet syndrome (TOS) (see videos below) - NB this test may not always be positive in TOS patients, but it needs to be assessed in detail
• Neurological
  • Thoracic dermatome testing (see Figure 2)
• Palpation, including the clavicle and first rib

Active Thoracic Movement Tests

During the active movement tests:

• Assess the patient in sitting in order to isolate the thoracic spine (this position blocks the lumbar spine)
• Assess for asymmetry of movement and any segmental restriction
  • Remember that motor control is also important in the thoracic region, not just stiffness

Thoracic Flexion and Extension

• Flexion: feel for anterior tilt of the ribs
• Extension: feel for posterior tilt of the ribs
• Flexion and extension can be measured using the Schober test with a tape measure. Normal thoracic mobility is defined as a gain of at least 5 cm on the tape measure
• NB extension is the most limited movement in the thoracic spine

Thoracic Rotation

Rotation is one of the most useful tests for the thoracic spine. Lumbar-locked rotation test is a test of choice when assessing thoracic spine rotation. During rotation movements, it is possible to identify:

• Stiffness
• Sequencing issues

Thoracic Side Bend / Lateral Shift

Assess the patient from behind - it is only necessary to assess the patient from the front if you wish to specifically examine the ribs from this position. During thoracic side bend there is:

• Ipsilateral approximation of the ribs
• Contralateral separation of the ribs
• Contralateral rib translation

Treatment

Sleep

Sleep is the most powerful antioxidant. It is recognised that there is a bi-directional relationship between pain and sleep.

Thoracic Manipulation

It is still not known if / why thoracic manipulation works, but it has been found that thoracic manipulation can decrease pain, improve mobility and enhance a patient’s feeling of health.

• There is, however, no evidence that one manipulation is better than another
• There is no evidence that thoracic manipulation has a long-term effect, so if it is used, it should be used in combination with specific rehabilitation exercises
• Joint position, direction, velocity and force are all variables that should be considered

Postural Correction and Motor Control

Correcting a patient’s posture can also have a positive impact on a patient’s pain.

• Consider the centre of gravity
• Look for areas of muscle spasm or hyperactivity (e.g. of iliocostalis)

Iliocostalis Release

Iliocostalis is the most lateral of the erector spinae. Patients with significant thoracic kyphosis and lumbar lordosis may have increased activity of iliocostalis. This muscle can be released under the 10th and 11th ribs.

Posterior-Anterior Glides

Patients with inverted thoracic spines, rotated spines and / or increased kyphosis will likely find posterior-anterior (PA) glides of the spinous processes uncomfortable as they are highly nociceptive.

Instead, it can be beneficial to perform a PA glide on the rib angle (which results in a mobilisation of 13 articulations for each thoracic ring). For individuals with inverted spines, this will create an anterior-posterior (AP) movement on the spinous process. For patients with increased kyphosis, a PA glide on the rib angle while performing an AP glide on the anterior shoulder / coracoid can be effective. A rotatory technique for patients with kyphosis can be effective.

Exercise Therapy

A survey of thoracic spine management trends in the United Kingdom found that exercise is used widely as a treatment modality despite limited supporting evidence. Speed, starting positions, dosage and load progression have not been investigated, but exercises which aim to stretch, mobilise and stabilise the thoracic spine can be beneficial in clinical practice.

Types of Exercises

Stretches for the thoracic spine are shown in Figure 3. Figure 4 shows stretches that can specifically address an inverted thoracic spine.

Figure 3. Thoracic spine stretches. (Courtesy of Grooviphysiosoftware)

Figure 4. Thoracic stretches out of an inverted position. (Courtesy of Grooviphysiosoftware)

Figures 5 and 6 show exercises to mobilise the thoracic spine, while Figure 7 focuses specifically on exercises that rotate the thoracic spine.

Figure 5. Exercises to mobilise the thoracic spine. (Courtesy of Grooviphysiosoftware)

Figure 6. Exercises to mobilise the thoracic spine - right side flexion, right lateral translation, right rotation and extension. (Courtesy of Grooviphysiosoftware)

Figure 7. Thoracic rotation exercises. (Courtesy of Grooviphysiosoftware)

Exercises to stabilise the thoracic spine are shown in figures 8, 9 and 10. Initially it is beneficial to use closed kinetic chain exercises (Figures 8 and 9) before aiming to increase strength through range (Figure 10).

Figure 8. Motor control exercises. (Courtesy of Grooviphysiosoftware)

Figure 9. Motor control exercises. (Courtesy of Grooviphysiosoftware)

Figure 10. Strengthening through range exercises. (Courtesy of Grooviphysiosoftware)

A Lot is Unknown

• Most ‘research’ is anecdotal, or found on social media / YouTube
• Information from other regions of the spine has been ‘transferred’ to the thoracic spine
  • The unique features of the thoracic spine are often not recognised
• There are many deep thoracic muscles whose contribution to motor control in the thorax is unknown, such as semispinalis thoracic and rotatores
• It is also not known what role the thoracic spine has in proprioception

Summary

Assessment:

• It is beneficial to use anatomical knowledge and biomechanical insights to look at poor motion habits
• Do not focus on tiny faults

Management:

• It can be helpful to use specific manual techniques to mobilise restricted areas, but this will not result in macro changes
• Postural adjustments can, however, be used to change systems and make macro changes
• Thoracic rotation is essential for movement, sports and performance
  • Utilise exercises that promote rotation, stability (motor control) and strength
• Exercise therapy should be used in conjunction with manual therapy to achieve an optimal outcome
• Management should not just focus on thoracic stiffness - it is perhaps more important to address thoracic motor control and segmental stability