Assessment and Treatment of the Thoracic Spine: Difference between revisions

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== Subjective Assessment ==
== Subjective Assessment ==
Further information about the assessment of the thoracic spine is available [[Thoracic Examination|here]], but specific questions to consider in the subjective assessment include:<ref name=":0">Bell-Jenje T. Assessment and Treatment of the Thoracic Spine Course. Physioplus, 2021.</ref>
Further information about the assessment of the thoracic spine is available [[Thoracic Examination|here]], but specific questions to consider in the subjective assessment include:<ref name=":0">Bell-Jenje T. Assessment and Treatment of the Thoracic Spine Course. Plus , 2021.</ref>


* How did the problem begin? How long has it been a problem?
* How did the problem begin? How long has it been a problem?
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** Is there stiffness for a prolonged period in the morning?
** Is there stiffness for a prolonged period in the morning?
** Is there also a history of enthesopathies?
** 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)<ref>Alvarez A, Tiu TK. Enthesopathies. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK559030/</nowiki></ref>
*** NB: enthesopathies are pathologies that affect the entheses (i.e. the bony insertion sites of [[Tendon Anatomy|tendon]]<nowiki/>s and [[ligament]]<nowiki/>s)<ref>Alvarez A, Tiu TK. Enthesopathies. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK559030/</nowiki></ref>
** This history could indicate that the patient has a seronegative [[Co-morbidities and Extra-articular Manifestations of Spondyloarthropathy|spondyloarthropathy]]<ref name=":0" /><ref>Martey C. Co-morbidities within Spondyloarthritis Course. Physioplus, 2020.</ref>
** This history could indicate that the patient has a seronegative [[Co-morbidities and Extra-articular Manifestations of Spondyloarthropathy|spondyloarthropathy]]<ref name=":0" /><ref>Martey C. Co-morbidities within Spondyloarthritis Course. Plus , 2020.</ref>
* What are the patient's functional impairments?  
* What are the patient's functional impairments?  
** Consider sport and activities of daily living
** Consider sport and [[Activities of Daily Living|activities of daily living]]
* What is the patient’s medical history?
* 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 [[Clinical Reasoning and Pathologies of the Thoracic Spine|masquerade]] as musculoskeletal thoracic pain  
** It is essential to have a detailed understanding of this history as there are a number of conditions that can [[Clinical Reasoning and Pathologies of the Thoracic Spine|masquerade]] as musculoskeletal thoracic pain  
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* Are there any [[An Introduction to Red Flags in Serious Pathology|red flags]]?<ref>Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL et al. [https://www.jospt.org/doi/10.2519/jospt.2020.9971?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed International framework for red flags for potential serious spinal pathologies]. J Orthop Sports Phys Ther. 2020;50(7):350-72.</ref>
* Are there any [[An Introduction to Red Flags in Serious Pathology|red flags]]?<ref>Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL et al. [https://www.jospt.org/doi/10.2519/jospt.2020.9971?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed International framework for red flags for potential serious spinal pathologies]. J Orthop Sports Phys Ther. 2020;50(7):350-72.</ref>


Subjective information can give quite specific clues about the potential cause of pain (i.e. inflammatory, mechanical or non-mechanical):<ref name=":0" />
Subjective information can give quite specific clues about the potential cause of pain (i.e. [[Inflammation Acute and Chronic|inflammatory]], mechanical or non-mechanical):<ref name=":0" />


* Nerve root or facet pain may be described as lancinating / nauseating. It may radiate and follow the angulation of the rib
* Nerve root or [[Facet Joints|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)
* [[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
* [[Rib Fracture|Rib fracture]] or [[Intercostal Muscle Strain|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
* 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)
** This could be from an [[Autoimmune Disorders|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’
* When patients have immobility, they tend to report stiffness, restricted movement, or a sense of feeling ‘stuck’


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** Consider combinations of tests
** Consider combinations of tests
* The best ‘special test’ is the one the patient demonstrates to you
* The best ‘special test’ is the one the patient demonstrates to you
* Consider the diaphragm
* Consider the [[Diaphragm Anatomy and Differential Diagnosis|diaphragm]]


=== Objective Testing ===
=== Objective Testing ===
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** Watch how the patient moves / drifts / hinges
** Watch how the patient moves / drifts / hinges
** Consider different [[Postural Changes Affecting Voice Production|types of postural dysfunctions]]<ref>Czaprowski D, Stoliński Ł, Tyrakowski M, Kozinoga M, Kotwicki T. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5836359/ Non-structural misalignments of body posture in the sagittal plane]. Scoliosis Spinal Disord. 2018;13:6. </ref> (see Figure 1)
** Consider different [[Postural Changes Affecting Voice Production|types of postural dysfunctions]]<ref>Czaprowski D, Stoliński Ł, Tyrakowski M, Kozinoga M, Kotwicki T. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5836359/ Non-structural misalignments of body posture in the sagittal plane]. Scoliosis Spinal Disord. 2018;13:6. </ref> (see Figure 1)
** Is the postural change a primary or secondary problem (e.g. lumbopelvic dysfunction)
** Is the [[Posture|postural]] change a primary or secondary problem (e.g. lumbopelvic dysfunction)
* [[Assessment of Breathing Pattern Disorders|Breathing mechanics]]
* [[Assessment of Breathing Pattern Disorders|Breathing mechanics]]
* [[File:Dermatomes for Thoracic Spine Course.jpg|alt=|thumb|Figure 2. Dermatomes.]]ROM tests from neutral
[[File:Dermatomes for Thoracic Spine Course.jpg|alt=|thumb|Figure 2. Dermatomes.]][[Range of Motion|ROM]] tests from neutral
** Look for intersegmental restrictions
* Look for intersegmental restrictions
** Assess from behind
* Assess from behind
 
* Inter-ring and articular palpation during motion
* Inter-ring and articular palpation during motion
* Motor control and strength tests  
* Motor control and strength tests  
** Sitting
** Sitting
** Puppy lie
** Puppy lie (i.e. prone extension propped on forearms)
** 4 point
** 4 point
* Neurodynamic tests
* [[Neurodynamic Assessment|Neurodynamic tests]]
** Upper limb tension test for [[Clinical Reasoning and Pathologies of the Thoracic Spine|thoracic outlet syndrome (TOS)]] (see videos below)<ref>Jones MR, Prabhakar A, Viswanath O, Urits I, Green JB, Kendrick JB et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6514035/ Thoracic outlet syndrome: a comprehensive review of pathophysiology, diagnosis, and treatment]. Pain Ther. 2019;8(1):5-18.</ref><ref>Li N, Dierks G, Vervaeke HE, Jumonville A, Kaye AD, Myrcik D et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957681/ Thoracic outlet syndrome: a narrative review]. J Clin Med. 2021;10(5):962.</ref> - NB this test may not always be positive in TOS patients, but it needs to be assessed in detail<ref name=":0" />
** Upper limb tension test for [[Clinical Reasoning and Pathologies of the Thoracic Spine|thoracic outlet syndrome (TOS)]] (see videos below)<ref>Jones MR, Prabhakar A, Viswanath O, Urits I, Green JB, Kendrick JB et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6514035/ Thoracic outlet syndrome: a comprehensive review of pathophysiology, diagnosis, and treatment]. Pain Ther. 2019;8(1):5-18.</ref><ref>Li N, Dierks G, Vervaeke HE, Jumonville A, Kaye AD, Myrcik D et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957681/ Thoracic outlet syndrome: a narrative review]. J Clin Med. 2021;10(5):962.</ref> - NB this test may not always be positive in TOS patients, but it needs to be assessed in detail<ref name=":0" />
* Neurological  
* Neurological  
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==== Thoracic Flexion and Extension ====
==== Thoracic Flexion and Extension ====


* Flexion: feel for anterior tilt of the ribs
* Flexion: feel for anterior tilt of the [[ribs]]
* Extension: feel for posterior tilt of the ribs
* Extension: feel for posterior tilt of the ribs
* NB extension is the most limited movement in the thoracic spine<ref>Wilke HJ, Herkommer A, Werner K, Liebsch C. [https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0177823 In vitro analysis of the segmental flexibility of the thoracic spine]. PLoS One. 2017;12(5):e0177823. </ref>
* NB extension is the most limited movement in the thoracic spine<ref>Wilke HJ, Herkommer A, Werner K, Liebsch C. [https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0177823 In vitro analysis of the segmental flexibility of the thoracic spine]. PLoS One. 2017;12(5):e0177823. </ref>
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=== Sleep ===
=== Sleep ===
Sleep is the most powerful antioxidant.<ref name=":0" /> It is recognised that there is a bi-directional relationship between pain and sleep.<ref>Haack M, Simpson N, Sethna N, Kaur S, Mullington J. [https://www.nature.com/articles/s41386-019-0439-z Sleep deficiency and chronic pain: potential underlying mechanisms and clinical implications]. Neuropsychopharmacology. 2020;45(1):205-16. </ref>
[[Sleep: Theory, Function and Physiology|Sleep]] is the most powerful antioxidant.<ref name=":0" /> It is recognised that there is a bi-directional relationship between pain and sleep.<ref>Haack M, Simpson N, Sethna N, Kaur S, Mullington J. [https://www.nature.com/articles/s41386-019-0439-z Sleep deficiency and chronic pain: potential underlying mechanisms and clinical implications]. Neuropsychopharmacology. 2020;45(1):205-16. </ref>


=== Thoracic Manipulation ===
=== Thoracic Manipulation ===
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Correcting a patient’s posture can also have a positive impact on a patient’s pain.<ref name=":0" />
Correcting a patient’s posture can also have a positive impact on a patient’s pain.<ref name=":0" />


* Consider the centre of gravity
* Consider the [[Centre of Gravity|centre of gravity]]
* Look for areas of muscle spasm or hyperactivity (e.g. of iliocostalis)
* Look for areas of muscle spasm or hyperactivity (e.g. of [[Iliocostalis Lumborum|iliocostalis]])


=== Iliocostalis Release ===
=== Iliocostalis Release ===
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=== Posterior-Anterior Glides ===
=== 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.<ref name=":0" />
Patients with inverted thoracic spines, rotated spines and / or [[Thoracic Hyperkyphosis|increased kyphosis]] will likely find posterior-anterior (PA) glides of the spinous processes uncomfortable as they are highly nociceptive.<ref name=":0" />


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.<ref name=":0" /> 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.<ref name=":0" />
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.<ref name=":0" /> 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.<ref name=":0" />


=== Exercise Therapy ===
=== 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.<ref>Heneghan NR, Gormley S, Hallam C, Rushton A. Management of thoracic spine pain and dysfunction: A survey of clinical practice in the UK. Musculoskelet Sci Pract. 2019;39:58-66. </ref> 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.<ref name=":0" />
A survey of thoracic spine management trends in the United Kingdom found that [[Therapeutic Exercise|exercise]] is used widely as a treatment modality despite limited supporting evidence.<ref>Heneghan NR, Gormley S, Hallam C, Rushton A. Management of thoracic spine pain and dysfunction: A survey of clinical practice in the UK. Musculoskelet Sci Pract. 2019;39:58-66. </ref> Speed, starting positions, dosage and load progression have not been investigated, but exercises which aim to [[Stretching|stretch]], mobilise and stabilise the thoracic spine can be beneficial in clinical practice.<ref name=":0" />


==== Types of Exercises ====
==== 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.
Stretches for the thoracic spine are shown in Figure 3. Figure 4 shows stretches that can specifically address an inverted thoracic spine.
[[File:Thorax exercises stretch.png|alt=|center|thumb|785x785px|Figure 3. Thoracic spine stretches. (Courtesy of Grooviphysiosoftware)]]
[[File:Thoracic_stretch_out_of_inverted_position.jpg|alt=|center|thumb|785x785px|Figure 4. Thoracic stretches out of an inverted position. (Courtesy of Grooviphysiosoftware)]]


[[File:Stretches_for_the_thoracic_spine.jpg|alt=|frameless|785x785px]][[File:Thoracic_stretch_out_of_inverted_position.jpg|alt=|frameless|785x785px]]
[[File:Stretches for the thoracic spine.jpg|Figure 3. Exercises to stretch the thoracic spine|777x777px]].
[[File:Thoracic stretch out of inverted position.jpg|Figure 4. Stretch to address an inverted thoracic spine.|770x770px]]


 
Figures 5 and 6 show exercises to mobilise the thoracic spine, while Figure 7 focuses specifically on exercises that rotate the thoracic spine.
 
[[File:Thoracic spine exercises - mobilise.png|alt=|center|thumb|895x895px|Figure 5. Exercises to mobilise the thoracic spine. (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.  
[[File:Right_side_flexion_rotation_translation_extension.jpg|alt=|center|thumb|825x825px|Figure 6. Exercises to mobilise the thoracic spine - right side flexion, right lateral translation, right rotation and extension. (Courtesy of Grooviphysiosoftware)]]
 
[[File:Exercises_to_enhance_thoracic_rotation.jpg|alt=|center|thumb|830x830px|Figure 7. Thoracic rotation exercises. (Courtesy of Grooviphysiosoftware)]]
[[File:Exercises_to_mobilise_the_thoracic_spine.jpg|alt=|frameless|895x895px]][[File:Right_side_flexion_rotation_translation_extension.jpg|alt=|frameless|825x825px]][[File:Exercises_to_enhance_thoracic_rotation.jpg|alt=|frameless|830x830px]]


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).
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).
 
[[File:Thoracic_motor_control.jpg|alt=|center|thumb|593x593px|Figure 8. Motor control exercises. (Courtesy of Grooviphysiosoftware)]]
[[File:Thoracic_motor_control.jpg|alt=|frameless|593x593px]][[File:Thoracic_motor_control_2.jpg|alt=|frameless|711x711px]][[File:Thoracic_motor_control_strengthening_through_range_exercises.jpg|alt=|frameless|734x734px]]
[[File:Thoracic_motor_control_2.jpg|alt=|center|thumb|711x711px|Figure 9. Motor control exercises. (Courtesy of Grooviphysiosoftware)]]
[[File:Thorax exercises strengthen through range2.png|alt=|center|thumb|734x734px|Figure 10. Strengthening through range exercises. (Courtesy of Grooviphysiosoftware)]]


== A Lot is Unknown ==
== A Lot is Unknown ==
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** The unique features of the thoracic spine are often not recognised
** 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
* 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  
* It is also not known what role the thoracic spine has in [[proprioception]]


== Summary ==
== Summary ==
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== References ==
== References ==
[[Category:Physioplus Content]]
[[Category:Plus Content]]
[[Category:Course Pages]]
[[Category:Course Pages]]
[[Category:Thoracic Spine]]
[[Category:Thoracic Spine]]

Latest revision as of 10:47, 28 March 2024

Subjective Assessment[edit | edit source]

Further information about the assessment of the thoracic spine is available here, but specific questions to consider in the subjective assessment include:[1]

  • 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)[2]
    • This history could indicate that the patient has a seronegative spondyloarthropathy[1][3]
  • What are the patient's functional impairments?
  • 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?[4]

Subjective information can give quite specific clues about the potential cause of pain (i.e. inflammatory, mechanical or non-mechanical):[1]

  • 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[edit | edit source]

The objective examination is guided by findings in the subjective interview. Remember:[1]

  • 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[edit | edit source]

Figure 1. Common postural dysfunctions.

The following tests should be included in an objective examination of the thoracic spine:[1]

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
  • Neurological
  • Palpation, including the clavicle and first rib

Active Thoracic Movement Tests[edit | edit source]

During the active movement tests:[1]

  • 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[edit | edit source]

  • Flexion: feel for anterior tilt of the ribs
  • Extension: feel for posterior tilt of the ribs
  • NB extension is the most limited movement in the thoracic spine[10]

Thoracic Rotation[edit | edit source]

Rotation is one of the most useful tests for the thoracic spine. During rotation movements, it is possible to identify:[1]

  • Stiffness
  • Sequencing issues

Thoracic Side Bend / Lateral Shift[edit | edit source]

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:[1]

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

Treatment[edit | edit source]

Sleep[edit | edit source]

Sleep is the most powerful antioxidant.[1] It is recognised that there is a bi-directional relationship between pain and sleep.[11]

Thoracic Manipulation[edit | edit source]

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.[12]

  • 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[1]

Postural Correction and Motor Control[edit | edit source]

Correcting a patient’s posture can also have a positive impact on a patient’s pain.[1]

Iliocostalis Release[edit | edit source]

Iliocostalis is the most lateral of the erector spinae.[13] 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.[1]

Posterior-Anterior Glides[edit | edit source]

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.[1]

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.[1] 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.[1]

Exercise Therapy[edit | edit source]

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.[14] 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.[1]

Types of Exercises[edit | edit source]

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[edit | edit source]

  • 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[edit | edit source]

Assessment:[1]

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

Management:[1]

  • 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

References[edit | edit source]

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 Bell-Jenje T. Assessment and Treatment of the Thoracic Spine Course. Plus , 2021.
  2. Alvarez A, Tiu TK. Enthesopathies. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559030/
  3. Martey C. Co-morbidities within Spondyloarthritis Course. Plus , 2020.
  4. Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL et al. International framework for red flags for potential serious spinal pathologies. J Orthop Sports Phys Ther. 2020;50(7):350-72.
  5. Czaprowski D, Stoliński Ł, Tyrakowski M, Kozinoga M, Kotwicki T. Non-structural misalignments of body posture in the sagittal plane. Scoliosis Spinal Disord. 2018;13:6. 
  6. Jones MR, Prabhakar A, Viswanath O, Urits I, Green JB, Kendrick JB et al. Thoracic outlet syndrome: a comprehensive review of pathophysiology, diagnosis, and treatment. Pain Ther. 2019;8(1):5-18.
  7. Li N, Dierks G, Vervaeke HE, Jumonville A, Kaye AD, Myrcik D et al. Thoracic outlet syndrome: a narrative review. J Clin Med. 2021;10(5):962.
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