Assessment and Treatment of the Thoracic Spine
Top Contributors - Jess Bell, Kirenga Bamurange Liliane, Kim Jackson, Tarina van der Stockt and Merinda Rodseth
Subjective Assessment[edit | edit source]
- 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[edit | edit source]
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[edit | edit source]
The following tests should be included in an objective examination of the thoracic spine:
- Static and dynamic postural assessment:
- Breathing mechanics
- Look for intersegmental restrictions
- Assess from behind
- Inter-ring and articular palpation during motion
- Motor control and strength tests
- Puppy lie
- 4 point
- Neurodynamic tests
- Thoracic dermatome testing (see Figure 2)
- Palpation, including the clavicle and first rib
Active Thoracic Movement Tests[edit | edit source]
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[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
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:
- 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:
- Ipsilateral approximation of the ribs
- Contralateral separation of the ribs
- Contralateral rib translation
Treatment[edit | edit source]
Sleep[edit | edit source]
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.
- 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[edit | edit source]
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[edit | edit source]
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[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.
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[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. 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[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.
Figures 5 and 6 show exercises to mobilise the thoracic spine, while Figure 7 focuses specifically on exercises that rotate the thoracic spine.
- Exercises to mobilise the thoracic spine.jpg
Figure 5. Exercises to mobilise the thoracic spine.
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).
- Thoracic motor control strengthening through range exercises.jpg
Figure 10. Thoracic motor control exercises - strengthening through range.
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]
- It is beneficial to use anatomical knowledge and biomechanical insights to look at poor motion habits
- Do not focus on tiny faults
- 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]
- Bell-Jenje T. Assessment and Treatment of the Thoracic Spine Course. Physioplus, 2021.
- 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/
- Martey C. Co-morbidities within Spondyloarthritis Course. Physioplus, 2020.
- 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.
- 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.
- 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.
- 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.
- John Gibbons. Upper Limb Tension Test (ULTT) for the Median Nerve (C5-T1 Brachial plexus). Available from: https://www.youtube.com/watch?v=fhsrNKWVh0s [last accessed 4/9/2021]
- John Gibbons. Upper Limb Tension Test - Radial Nerve (C5-T1 Brachial Plexus). Available from: https://www.youtube.com/watch?v=VngRTMhAlGE [last accessed 4/9/2021]
- Wilke HJ, Herkommer A, Werner K, Liebsch C. In vitro analysis of the segmental flexibility of the thoracic spine. PLoS One. 2017;12(5):e0177823.
- Haack M, Simpson N, Sethna N, Kaur S, Mullington J. Sleep deficiency and chronic pain: potential underlying mechanisms and clinical implications. Neuropsychopharmacology. 2020;45(1):205-16.
- Takatalo J, Leinonen T, Rytkönen M, Häkkinen A, Ylinen J. The effect of thoracic spine manipulation on thoracic spine pain and mobility – Preliminary results of RCT. Manual Therapy. 2016;25:e161.
- Henson B, Kadiyala B, Edens MA. Anatomy, Back, Muscles. [Updated 2021 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537074/
- 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.