Thoracic Manual Techniques and Exercises

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Original Editor - Lucinda hampton Top Contributors - Lucinda hampton, Jonathan Wong, Kim Jackson and Khloud Shreif

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Top Contributors - Lucinda hampton, Jonathan Wong, Kim Jackson and Khloud Shreif  

Introduction

Physiotherapists often address movement disorders of the thoracic region that respond well to manual techniques and/or exercise prescription to address joint restrictions or muscle weakness.

• This page outlines some of the Manual Techniques and Exercises for the Thoracic Spine.

Range of motion (ROM) in the thoracic region is necessary for a number of daily activities and sporting tasks such as golf, throwing sports, tennis, and rowing. Dysfunction of the thoracic spine can also play a role in breathing difficulties and may be linked to postural issues in the later stages of life. Additionally getting more ROM through the thoracic spine has impact on areas upstream and downstream the body.

• Restrictions in motion have the potential to impact performance and may manifest as local or distant musculoskeletal pathology.
• Movement of the thoracic spine is coupled with movement of the adjoining ribs. Thoracic extension involves concurrent posterior rotation (external torsion) and depression of the posterior ribs with elevation of the anterior ribs. Bending to the side is a combination of spinal segments side bending, ribs on the same come together while ribs on the opposite side separate. Inability to move well in all directions predisposes people to injury and pain.
• Motion restrictions may be due to contractile or non-contractile structures, and interventions to address each specific tissue restriction can vary depending on the source of the involved tissue.

1. Contractile restrictions - eg.muscle tightness, trigger points, may be addressed via muscle stretching or manual interventions such as soft-tissue mobilization or sustained pressure.
2. Non-contractile restrictions - eg hypermobile, or hypomobile joints

Joint hypermobility is usually addressed with therapeutic exercise to improve neuromuscular control

Joint hypomobility may be addressed with manual interventions including joint mobilization and manipulation. Hypomobility of vertebral and costovertebral joints in the thoracic spine may prevent the patient from attaining full motion of the thorax. 

• Most interventions to address thoracic spine mobility are dependent on the clinician providing the intervention.
• The ability for the patient to incorporate self-mobilizations of the thoracic spine into therapeutic exercise programs may help maximize intervention outcomes.

Mobilisations

• Joint mobilisations have been defined by Maitland as an externally imposed, small amplitude passive motion that is intended to produce gliding or traction at a joint. ​
• They are often used in Physiotherapy management in order to produce mechanical and neurophysiological effects.

These videos demonstrate 3 common mobilisation styles.

This first 2 minute video shows a good upper thoracic function mobilisation for extension, and extension combined with rotation.

This 4 minute video is a demonstration of a reverse NAG for thoracic spine using the Mulligan concept (MWM).

This video is of mid thoracic Maitland PA mobilisation (5 minutes).

Manipulation

• There is no much research literature on the safety of joint manipulation when applied to the thoracic spine.
• Thrust joint manipulation should never be performed when contraindications or precautions are present.

Exercises

Exercises are beneficial in situations of hypomobility to increase movement and hypermobility and postural issues to increase strength.

• They are an essential part of physiotherapy

The first video (6 minutes) gives a good range of exercises for hypomobile joints

The next video is of exercises for eg Scheuermann's Kyphosis

Exercises for strengthening Extensors of Thoracic Region

Training of the muscles used for hyperextention - done to prevent the flexion of the thoracic spine eg due to use of tablets. poor posture, osteoporosis.

Strengthening of the thoracic extensor muscles can be achieved by following exercises:

1. Bow and arrow on the side [1]

With this exercise it is important to give the following instructions:

• The upper back and abdominal muscles should be working at all times.
• The legs should not be moving and should be in a 90° angle in the hip and in the knee to make sure that the pelvis stays in position.

Foto 6: bow and arrow exercise nicksportphysio.com

2. Pointer dog [1]

• With this exercise it is important to give the following instructions:
• The upper back and abdominal muscles should be working at all times as well as the pelvic floor.
• Don’t raise your leg and arms to high (max horizontal)

Foto 7: 3 Bird-Dog Exercise Variations www.builtlean.com

Superman[1]

• With this exercise it is important to give the following instructions:
• The upper back and abdominal muscles should be working at all times
• Start with lifting your legs slightly of the floor than lift your torso of the floor

Foto 8: (Katzman WB, Vittinghoff E, Kado DM, Schafer AL, Wong SS, Gladin A, Lane NE.

Study of Hyperkyphosis, Exercise and Function (SHEAF) Protocol of a Randomized

Controlled Trial of Multimodal Spine-Strengthening Exercise in Older Adults With

Hyperkyphosis. Phys Ther. 2016 Mar;96(3):371-81 - LoE 1B)

Occiput to wall [4]

Stretching the Extensor Muscles and strengthening the Anterior Neck Flexors: The patient stands with his back against the wall and retracts the chin. There will be an upper cervical spine flexion and lower cervical spine extension. Hold this position for 15 seconds. [4]

Postural training

The training of all the postural muscles is important to assure the stability of the spine, the muscles should be trained for long periods of time to simulate the use in the daily life activities such as standing for a long period of time. ([5] [1])

Training of the postural muscles can be achieved by following exercise:

Single leg stance [1]

With this exercise it is important to give the following instructions:

• The upper back and abdominal muscles should be working at all times as well as the pelvic floor.
• Roll shoulder blades backwards

“Lengthen” your neck

Don’t raise your leg to high (+- 10cm of the floor)

Foto 9: ( Katzman WB, Vittinghoff E, Kado DM, Schafer AL, Wong SS, Gladin A, Lane NE.

Study of Hyperkyphosis, Exercise and Function (SHEAF) Protocol of a Randomized

Controlled Trial of Multimodal Spine-Strengthening Exercise in Older Adults With

Hyperkyphosis. Phys Ther. 2016 Mar;96(3):371-81 - LoE 1B)

Body mechanics education

It is is important that the patiënt understands his problem and the cause of his problem. In the particular case of thoracic disc herniation it is important that the patiënt realises that being in a position of hyperkyphosis will increase his symptoms. [5]

Foto 3 (41) Encyclopedia of Sportsmedicine p257 Lyle J., Micheli M.D. (LoE: 5)

https://www.ugbodybuilding.com/threads/3572-Lumbar-Disc-Herniation

Disk bulging, difference between the bend forward position and the bend backward position. (This is a photo of what goes on in the lumbar spine but the same occurs in the thoracic spine) [5]

McKenzie technique

This technique is used to re centralise the bulging disc. But also to ‘centralise’ complaints from peripheral (first days) to thoracic region (after 10 days) [3]

Foto 4 (42) Athletic Training and Sports Medicine; Schrijver: Robert C. Schenck; Editor: Jones & Bartlett Learning, 1999 (LoE: 5)

Maitland technique

The maitland technique uses specific methods of oscillation or sustained holds to eliminate reproducible signs of pain. [3]

Foto 5 [3]

Athletic Training and Sports Medicine; Schrijver: Robert C. Schenck; Editor: Jones & Bartlett Learning, 1999 (LoE: 5)

Stretching M. pectoralis major and M. latissimus dorsi

Manual therapy and exercise therapy program improving postural hyperkyphosis:

Stretching the Pectoralis Major Muscle: While facing a corner, the patient places his hands on the wall at shoulder level. Than the patient moves forward, closer to the wall, to stretch the anterior chest. Hold this position for 15 seconds. [4]

Stretching the Latissimus Dorsi Muscle: Patient lay in supine position with knees and hips flexed. Arms are in 90-90 position. Then the patient performs a posterior pelvic tilt while raising the arms overhead as far as possible without losing floor contact. Hold this position for 15 seconds. [3]

Massage

Massage: wringing and skin rolling massage to the back extensor muscles for 10 minutes

Passive mobilisation

Apply downward pressure toward thoracic extension. [3]

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