Anatomy, Biomechanics and Regional Interdependence of the Thorax: Difference between revisions

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Because of the strong anatomical connections between the ribs and the thoracic spine, mobilising the rib laterally will cause motion at the vertebral segments of that thoracic ring, as well as the ribs on the opposite side of the body.<ref name=":0" />
Because of the strong anatomical connections between the ribs and the thoracic spine, mobilising the rib laterally will cause motion at the vertebral segments of that thoracic ring, as well as the ribs on the opposite side of the body.<ref name=":0" />


=== Thoracic Function ===
== Thoracic Function ==
Lee has described the thoracic spine as a “‘slinky’ or a shock-absorbing spring”.<ref name=":1" /> It consists of a dynamic stack of 10 thoracic rings<ref name=":1" /> and has the following functions:<ref name=":0" />
Lee has described the thoracic spine as a “‘slinky’ or a shock-absorbing spring”.<ref name=":1" /> It consists of a dynamic stack of 10 thoracic rings<ref name=":1" /> and has the following functions:<ref name=":0" />


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* Aids optimal respiratory function
* Aids optimal respiratory function
* Houses the autonomic nervous system
* Houses the autonomic nervous system
== Thoracic Asymmetry ==
It is normal for there to be thoracic asymmetry of the facet orientation in the thoracic spine.<ref>Masharawi Y, Rothschild B, Dar G, Peleg S, Robinson D, Been E et al. Facet orientation in the thoracolumbar spine: three-dimensional anatomic and biomechanical analysis. Spine (Phila Pa 1976). 2004;29(16):1755-63.</ref> Asymmetric anatomy may cause changes in the coupled motion at a segment.<ref>Andriacchi T, Schultz A, Belytschko T, Galante J. A model for studies of mechanical interactions between the human spine and rib cage. J Biomech. 1974;7(6):497–507.</ref>
== Regional Interdependence ==
The concept of [[Regional Interdependence|regional interdependence]] is when: “seemingly unrelated impairments in remote anatomical regions of the body may contribute to and be associated with a patient’s primary report of symptoms.”<ref>Sueki DG, Cleland JA, Wainner RS. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3649356/ A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications]. ''J Man Manip Ther''. 2013;21(2):90-102.</ref>
Examples of interdependency in the thoracic spine include the following.<ref name=":0" />
=== Cervical spine ===
Tsang and colleagues found that during all cervical movements, there is associated movement at T1, T6 and T 12. In particular, the upper thorax contributes:<ref name=":2">Tsang SM, Szeto GP, Lee RY. Normal kinematics of the neck: the interplay between the cervical and thoracic spines. Man Ther. 2013;18(5):431-7. </ref>
* 25 percent to cervical flexion and extension
* 10 percent to cervical rotation
Thoracic spine changes are, therefore, implicated in a loss of cervical range of motion, so this area should always be assessed in patients with neck dysfunction.<ref name=":2" />
=== Shoulder ===
The scapula is a sesamoid bone, which rests upon the thorax. It is influenced by the position of the thoracic spinal elements and the ribs. Positions such as a thoracic kyphosis, a thoracic scoliosis or a flattened / inverted thoracic spine, can change the resting position of the scapula.<ref name=":0" />
* Treating the thoracic spine has been shown to alter shoulder symptoms<ref>Strunce JB, Walker MJ, Boyles RE, Young BA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813499/ The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain]. J Man Manip Ther. 2009;17(4):230-6.</ref><ref>Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moore JH et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther. 2009;14(4):375-80.</ref> <ref>Haider R, Bashir MS, Adeel M, Ijaz MJ, Ayub A. [https://jpma.org.pk/article-details/8600?article_id=8600 Comparison of conservative exercise therapy with and without Maitland Thoracic Manipulative therapy in patients with subacromial pain: Clinical trial]. J Pak Med Assoc. 2018 Mar;68(3):381-7. </ref>
* Thoracic kyphosis is associated with a loss of glenohumeral range of motion and impingement symptoms<ref>Barrett E, O'Keeffe M, O'Sullivan K, Lewis J, McCreesh K. Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Man Ther. 2016;26:38-46. </ref>
Other relationships include:
* Sympathetic nerve blocks at the thoracic spine can improve chronic upper extremity neuropathic pain<ref>Yoo HS, Nahm FS, Lee PB, Lee CJ. Early thoracic sympathetic block improves the treatment effect for upper extremity neuropathic pain. Anesth Analg. 2011;113(3):605-9. </ref>
* 70 percent of patients with lateral elbow pain have co-existing thoracic pain (compared to 16 percent of the control group)<ref>Berglund KM, Persson BH, Denison E. Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain. Man Ther. 2008;13(4):295-9.</ref>


== References ==
== References ==

Revision as of 03:07, 28 August 2021

Original Editor - Jess Bell based on the course by Tanja Bell-Jenje
Top Contributors - Jess Bell, Lucinda hampton, Kim Jackson, Olajumoke Ogunleye, Merinda Rodseth and Robin Tacchetti
This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (28/08/2021)

Introduction[edit | edit source]

The thorax is an area of the spine that has, historically, been under-explored. It can, however, be a silent contributor to many presentations in clinical practice.

One cross-sectional survey in Denmark looked at the prevalence of spinal pain. It found that in one year:[1]

  • 13 percent of respondents had thoracic pain
  • 43 percent had low back pain
  • 44 percent had neck pain

However, 36 to 41 percent of individuals have thoracic pain which co-exists with neck or back pain.[2] Thus, four in ten patients will have an associated thoracic spine condition. This is, therefore, a region that should not be ignored in physiotherapy practice.[3]

Anatomy[edit | edit source]

The thoracic spine includes 136 joints and 112 muscle attachments. The orientation of the thoracic joints and ribs limit flexion, extension and lateral flexion, but facilitate rotation.[3]

Range of Motion[edit | edit source]

The total rotation available in the thoracic spine is 85 degrees (+/- 14.8 degrees).[4] It contributes 80 percent of the total range of axial trunk rotation.[5] Each thoracic segment rotates between 6 and 8 degrees. This is significantly more than each lumbar segment, which only has 2 to 3 degrees of rotation.[3]

Thoracic movement is critical for optimal performance in rotational sports and kinematically links the upper and lower quarters.[6][7] It also contributes 55 percent to total force during a throw.[8]

Regions of the Thorax[edit | edit source]

  • Verebromanubrial:
    • Includes: T1 and T2, ribs 1 and 2, the manubrium and clavicle
  • Vertebrosternal
    • Includes: T3 to T7, true ribs 3 to 7 and sternum
  • Vertebrochondral:
    • Includes: T8 to 10 and false ribs 8 to 10
  • Thoracolumbar
    • Includes: T11 and T12, floating ribs 11 and 12[3]

Ribs[edit | edit source]

  • Ribs 1, 11 and 12 articulate with the named vertebra (i.e. rib 1 articulates with T1)
  • Ribs 2 to 10 articulate with the named vertebra, as well as the body above, the intervertebral disc and the anterior surface of the transverse process of the named vertebra
  • More information on the ribs is available here

The Thoracic Ring (T3-T9)[edit | edit source]

“The “thoracic ring” consists of two adjacent vertebrae and the related intervertebral disc, the right and left ribs (attached to the vertebra-disc-vertebra complex at the costovertebral joints), and the anterior attachments to the sternum/ manubrium and related cartilages.”[9]

There are 13 articulations per thoracic ring:[3][9]

  • Zygapophyseal / facet = 2
  • Costovertebral = 4
  • Intervertebral = 1
  • Costotransverse = 2
  • Costochondral = 2
  • Sternocostal = 2

Because of the strong anatomical connections between the ribs and the thoracic spine, mobilising the rib laterally will cause motion at the vertebral segments of that thoracic ring, as well as the ribs on the opposite side of the body.[3]

Thoracic Function[edit | edit source]

Lee has described the thoracic spine as a “‘slinky’ or a shock-absorbing spring”.[9] It consists of a dynamic stack of 10 thoracic rings[9] and has the following functions:[3]

  • Force transmission
    • NB: many patients with chronic low back pain or cervical pain have a stiff thoracic spine
    • Increasing thoracic mobility allows more even distribution of load through the spine with movement[10] [11][12]
  • Central area for myofascial attachments
  • Protects of heart, lungs, vessels, digestive tract[13]
  • Aids optimal respiratory function
  • Houses the autonomic nervous system

Thoracic Asymmetry[edit | edit source]

It is normal for there to be thoracic asymmetry of the facet orientation in the thoracic spine.[14] Asymmetric anatomy may cause changes in the coupled motion at a segment.[15]

Regional Interdependence[edit | edit source]

The concept of regional interdependence is when: “seemingly unrelated impairments in remote anatomical regions of the body may contribute to and be associated with a patient’s primary report of symptoms.”[16]

Examples of interdependency in the thoracic spine include the following.[3]

Cervical spine[edit | edit source]

Tsang and colleagues found that during all cervical movements, there is associated movement at T1, T6 and T 12. In particular, the upper thorax contributes:[17]

  • 25 percent to cervical flexion and extension
  • 10 percent to cervical rotation

Thoracic spine changes are, therefore, implicated in a loss of cervical range of motion, so this area should always be assessed in patients with neck dysfunction.[17]

Shoulder[edit | edit source]

The scapula is a sesamoid bone, which rests upon the thorax. It is influenced by the position of the thoracic spinal elements and the ribs. Positions such as a thoracic kyphosis, a thoracic scoliosis or a flattened / inverted thoracic spine, can change the resting position of the scapula.[3]

  • Treating the thoracic spine has been shown to alter shoulder symptoms[18][19] [20]
  • Thoracic kyphosis is associated with a loss of glenohumeral range of motion and impingement symptoms[21]

Other relationships include:

  • Sympathetic nerve blocks at the thoracic spine can improve chronic upper extremity neuropathic pain[22]
  • 70 percent of patients with lateral elbow pain have co-existing thoracic pain (compared to 16 percent of the control group)[23]

References[edit | edit source]

  1. ↑ Leboeuf-Yde C, Nielsen J, Kyvik KO, Fejer R, Hartvigsen J. Pain in the lumbar, thoracic or cervical regions: do age and gender matter? A population-based study of 34,902 Danish twins 20–71 years of age. BMC Musculoskelet Disord. 2009;10(39).
  2. ↑ Roquelaure Y, Bodin J, Ha C, Le Marec F, Fouquet N, Ramond-Roquin A et al. Incidence and risk factors for thoracic spine pain in the working population: the French Pays de la Loire study. Arthritis Care Res (Hoboken). 2014;66(11):1695-702.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Bell-Jenje T. The Thorax Simplified - Anatomy, Biomechanics and Regional Interdependence Course. Physioplus, 2021.
  4. ↑ Heneghan NR, Hall A, Hollands M, Balanos GM. Stability and intra-tester reliability of an in vivo measurement of thoracic axial rotation using an innovative methodology. Manual Therapy. 2009; 14(4):452-5.
  5. ↑ Fujii R, Sakaura H, Mukai Y, Hosono N, Ishii T, Iwasaki M et al. Kinematics of the lumbar spine in trunk rotation: in vivo three-dimensional analysis using magnetic resonance imaging. Eur Spine J. 2007;16(11):1867-74.
  6. ↑ Heneghan NR, Lokhaug SM, Tyros I, Longvastøl S, Rushton A. Clinical reasoning framework for thoracic spine exercise prescription in sport: a systematic review and narrative synthesis. BMJ Open Sport Exerc Med. 2020;6(1):e000713.
  7. ↑ Heneghan NR. Webb K, Mahoney T, Rushton A.  Thoracic spine mobility, an essential link in upper limb kinetic chains in athletes: A systematic review. Transl Sports Med.  2019;2:301-15.
  8. ↑ Kaczmarek PK, Lubiatowski P, Cisowski P, Grygorowicz M, Łepski M, Długosz J et al. Shoulder problems in overhead sports. Part I - biomechanics of throwing. Pol Orthop Traumatol. 2014;79:50-8.
  9. ↑ 9.0 9.1 9.2 9.3 Lee LJ. Thoracic ring approach. Available from: https://ljlee.ca/teaching-models/the-thoracic-ring-approach/ (accessed 28 August 2021).
  10. ↑ McConnell J. Recalcitrant chronic low back and leg pain--a new theory and different approach to management. Man Ther. 2002;7(4):183-92.
  11. ↑ Mohanty PP, Pattnaik M. Mobilisation of the thoracic spine in the management of spondylolisthesis. J Bodyw Mov Ther. 2016;20(3):598-603.
  12. ↑ Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Man Ther. 2005;10(2):127-35.
  13. ↑ Edmondston SJ, Singer KP. Thoracic spine: anatomical and biomechanical considerations for manual therapy. Man Ther. 1997;2(3):132-43.
  14. ↑ Masharawi Y, Rothschild B, Dar G, Peleg S, Robinson D, Been E et al. Facet orientation in the thoracolumbar spine: three-dimensional anatomic and biomechanical analysis. Spine (Phila Pa 1976). 2004;29(16):1755-63.
  15. ↑ Andriacchi T, Schultz A, Belytschko T, Galante J. A model for studies of mechanical interactions between the human spine and rib cage. J Biomech. 1974;7(6):497–507.
  16. ↑ Sueki DG, Cleland JA, Wainner RS. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. J Man Manip Ther. 2013;21(2):90-102.
  17. ↑ 17.0 17.1 Tsang SM, Szeto GP, Lee RY. Normal kinematics of the neck: the interplay between the cervical and thoracic spines. Man Ther. 2013;18(5):431-7.
  18. ↑ Strunce JB, Walker MJ, Boyles RE, Young BA. The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. J Man Manip Ther. 2009;17(4):230-6.
  19. ↑ Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moore JH et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther. 2009;14(4):375-80.
  20. ↑ Haider R, Bashir MS, Adeel M, Ijaz MJ, Ayub A. Comparison of conservative exercise therapy with and without Maitland Thoracic Manipulative therapy in patients with subacromial pain: Clinical trial. J Pak Med Assoc. 2018 Mar;68(3):381-7.
  21. ↑ Barrett E, O'Keeffe M, O'Sullivan K, Lewis J, McCreesh K. Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Man Ther. 2016;26:38-46.
  22. ↑ Yoo HS, Nahm FS, Lee PB, Lee CJ. Early thoracic sympathetic block improves the treatment effect for upper extremity neuropathic pain. Anesth Analg. 2011;113(3):605-9.
  23. ↑ Berglund KM, Persson BH, Denison E. Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain. Man Ther. 2008;13(4):295-9.
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