Assessment and Treatment of the Thoracic Spine

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

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Subjective Assessment

Detailed information on 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?
  • If there is stiffness for a prolonged period in the morning?
  • Is there also a history of enthesopathies?
  • This history could indicate that the patient has a seronegative spondyloarthropathy
• What are the patient's specific 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 clues about the potential cause of pain (inflammatory, mechanical or non-mechanical):

• Nerve root or facet pain may be described as lancinating / nauseating and it may radiate and follow angulation of 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
• 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
  • 4 point
• Neurodynamic tests
  • Upper limb tension test for thoracic outlet syndrome (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 (by blocking 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
• 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. 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 look from the front if you wish to specifically assess 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 in combination with specific rehabilitation
• 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 UK 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.

Specific Exercises

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

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  Figure 3. Exercises to stretch the thoracic spine.

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  Figure 4. Stretch to address an inverted thoracic spine.

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

• Exercises to mobilise the thoracic spine.jpg

  Figure 5. Exercises to mobilise the thoracic spine.

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  Figure 6. Right side flexion, lateral translation, rotation and extension.

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  Figure 7. Thoracic rotation exercises.

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).

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  Figure 8. Thoracic motor control exercises.

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  Figure 9. Thoracic motor control exercise progressions.

• Thoracic motor control strengthening through range exercises.jpg

  Figure 10. Thoracic motor control exercises - strengthening through range.

A Lot is Unknown

• Most ‘research’ is anecdotal, or on social media, YouTube
• Information from other spinal areas has been ‘tansferred’ to the thoracic spine, not recognising the unique differences of the thorax
• 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:

• Use anatomical knowledge and biomechanical insights to look at poor motion habits
• Do not focus on tiny faults

Management:

• It can be beneficial to use specific 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 mobility (optimal range of motion), 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