The thoracic spine

Chapter 7


The thoracic spine




Flexion control



Extension control



Rotation control



Thoracic/rib respiration control





Introduction


The thoracic spine has been the focus of little research or review attention compared to the lumbar and cervical spine. This may partly be due to the lower frequency of thoracic spinal pain syndrome and partly because the thoracic region is well stabilised by the rib cage and rib articulations to the thoracic vertebrae (Watkins et al 2005). Almost all of the research and review literature available that is related to the thoracic spine is based on anatomical and biomechanical analysis of osteoligamentous and myofascial influences on articular function (Edmondston & Singer 1997; Maitland et al 2005). There is a lack of research and analysis of neurophysiological motor control changes associated with pain and dysfunction in the thorax.




Diagnosis of the site and direction of UCM in the thoracic spine


The diagnosis of the site and direction of UCM in the thoracic spine can be identified in terms of the site (being thoracic spine) and the direction of flexion, extension, rotation and respiratory movement (Table 7.1).




Linking the site of UCM to symptom presentation


A diagnosis of UCM requires evaluation of its clinical priority. This is based on the relationship between the UCM and the presenting symptoms. The therapist should look for a link between the direction of UCM and the direction of symptom provocation: i) Does the site of UCM relate to the site or joint that the patient complains of as the source of symptoms? ii) Does the direction of movement or load testing relate to the direction or position of provocation of symptoms? This identifies the clinical priorities.


The site and direction of UCM at the thoracic spine can link with different clinical presentations, and postures and activities which may aggravate symptoms. The typical assessment findings in the thoracic spine are identified in Table 7.2.



The following section will demonstrate the specific procedures for testing for UCM in the thoracic spine.


THORACIC TESTS FOR UCM



Thoracic flexion control



Thoracic flexion control tests and flexion control rehabilitation


These flexion control tests assess the extent of flexion UCM in the thoracic spine and assess the ability of the dynamic stability system to adequately control flexion load or strain. It is a priority to assess for flexion UCM if the person complains of or demonstrates flexion-related symptoms or disability. The tests that identify dysfunction can also be used to guide and direct rehabilitation strategies.



Movement faults associated with thoracic flexion



Relative stiffness (restrictions)



• Lumbopelvic restriction of flexion – a lumbopelvic flexion restriction may contribute to compensatory increases in thoracic flexion range. This is confirmed with manual segmental assessment (e.g. Maitland PPIVMs or PAIVMs) of the lumbopelvic joints. There may also be a loss of lumbar-dorsal fascia extensibility if a lordotic posture is exaggerated.


• Cervical restriction of flexion – a cervical flexion restriction may contribute to compensatory increases in thoracic flexion range. This is not usually associated with articular restrictions of flexion. However, a chin poke neck posture may have an increased cervical lordosis and a loss of extensibility of the posterior cervical fascias and the ligamentum nuchae.


• Scapular restriction of protraction – recruitment overactivity or postural change may result in a loss of extensibility of the rhomboids. A subsequent myofascial restriction of scapular protraction may also contribute to compensatory increases in thoracic flexion range.





Tests of thoracic flexion control



T42 Standing: back flattening test(tests for thoracic flexion UCM)


This dissociation test assesses the ability to actively dissociate and control thoracic flexion then reverse the lumbar lordosis to the back flat position (i.e. flex the lumbar spine and posterior tilt the pelvis) while standing against a wall.



Test procedure


The person stands with the back of the pelvis, the upper thoracic spine and the back of the head resting against a wall with the shoulders and arms relaxed. The heels are positioned about 20 cm in front of the wall with the feet at least shoulder width apart and with the knees slightly flexed (hip flexors unloaded and wide base of support) (Figure 7.1). Then, keeping the thoracic spine and head stationary on the wall, the person is instructed to roll the pelvis backwards into posterior tilt to flatten the lumbar spine against the wall. The lumbar lordosis should reverse so that the whole lumbar spine is in full contact with the wall (Figure 7.2). There should be no flexion of the thorax, head or shoulders off the wall.




This test should be performed without any extra feedback (self-palpation, vision, etc.) or cueing for correction. When feedback is removed for testing, the therapist should use visual observation of the head and thorax relative to the wall to determine whether the control of thoracic flexion is adequate.



Thoracic flexion UCM


The person complains of flexion-related symptoms in the thoracic spine. The thorax has UCM into flexion relative to the lumbar spine under flexion load. The head and thoracic spine start to flex off the wall before full back flattening and posterior tilt is achieved. During the attempt to dissociate the thoracic flexion from independent posterior pelvic tilt and lumbar flexion, the person either cannot control the UCM or has to concentrate and try hard to control the thoracic flexion.



Clinical assessment note for direction-specific motor control testing


If some other movement (e.g. a small amount of thoracic rotation) is observed during a motor control (dissociation) test of thoracic flexion, do not score this as uncontrolled thoracic flexion. The thoracic rotation motor control tests will identify if the observed unrelated movement is uncontrolled. A test for thoracic flexion UCM is only positive if uncontrolled thoracic flexion is demonstrated.



Rating and diagnosis of thoracic flexion UCM


(T42.1 and T42.2)





Correction

If control is poor, retraining is best started by allowing both the lumbar and thoracic spines to start in flexion, and then reverse the dysfunction by unrolling the thoracic spine back up the wall into extension. The person stands with the heels at least shoulder width apart and about 20 cm in front of a wall with the knees slightly flexed (hip flexors unloaded and wide base of support). Rest the pelvis against the wall and allow the whole spine to slump forwards into flexion, but roll the pelvis backwards into posterior tilt and flatten the lumbar spine against the wall (Figure 7.3). Once the pelvis and lumbar spine are in contact with the wall, slowly lift the head and chest to unroll the thoracic spine back up the wall (Figure 7.4). Only move as far as the thoracic extensor muscles can extend the thoracic spine while holding the lumbopelvic region flat on the wall.




The person should self-monitor the control of thoracic flexion UCM with a variety of feedback options (T42.3). There should be no provocation of any symptoms within the range that the flexion UCM can be controlled.



Once segmental unrolling and control of the thoracic flexion improves, the exercise can return to the original start position. The person stands with the back of the pelvis, the upper thoracic spine and the back of the head resting against a wall. Then, keeping the thoracic spine and head stationary on the wall, the person rolls the pelvis into posterior tilt to flatten the lumbar spine against the wall. They should only roll the pelvis into posterior tilt as far as the head and thoracic spine can stay on the wall (Figure 7.5). At the point in range that the head and thoracic spine begin to flex off the wall, the movement should stop.




T43 Sitting: head hang test(tests for thoracic flexion UCM)


This dissociation test assesses the ability to actively dissociate and control thoracic flexion then lower the head towards the chest to hang forwards (i.e. flex the cervical spine) while sitting upright and unsupported.



Test procedure


The person should have the ability to actively hang the head forwards towards the sternum (flexing the cervical spine) while controlling the thoracic spine and preventing thoracic flexion. The person sits tall with the feet off the floor and with the spine and head positioned in the neutral. Position the head directly over the shoulders without chin poke (Figure 7.6). Without letting the thoracic spine or shoulders move, lower the head forwards towards the sternum. Do not allow the sternum or shoulders to drop forwards. This is independent cervical flexion. Ideally, the person should have the ability to keep the thoracic spine neutral and prevent thoracic flexion while independently flexing the cervical spine region through full flexion so that the chin is within 2–3 cm of the upper sternum (Figure 7.7).




This test should be performed without any extra feedback (self-palpation, vision, etc.) or cueing for correction. The therapist should use visual observation of the head and thorax relative to the wall to determine whether the control of thoracic flexion is adequate when feedback is removed for testing.



Thoracic flexion UCM


The person complains of flexion-related symptoms in the thoracic spine. The thorax has UCM into flexion relative to the cervical spine under flexion load. The thoracic spine starts to flex before full cervical flexion (head hanging forwards and chin within 2–3 cm of the sternum) is achieved. During the attempt to dissociate the thoracic flexion from independent cervical flexion, the person either cannot control the UCM or has to concentrate and try hard to control the thoracic flexion.



Clinical assessment note for direction-specific motor control testing


If some other movement (e.g. a small amount of thoracic rotation) is observed during a motor control (dissociation) test of thoracic flexion, do not score this as uncontrolled thoracic flexion. The thoracic rotation motor control tests will identify if the observed unrelated movement is uncontrolled. A test for thoracic flexion UCM is only positive if uncontrolled thoracic flexion is demonstrated.



Rating and diagnosis of thoracic flexion UCM


(T43.1 and T43.2)





Correction

If control is poor, retraining is best started by supporting the thoracic spine against a wall and flexing the cervical spine through reduced range. The person stands with the heels at least shoulder width apart and about 20 cm in front of a wall with the knees slightly flexed.


The thoracic spine and the back of the head are supported upright against a wall (Figure 7.8). The person should monitor the control of thoracic flexion by palpating the sternum or clavicles. Any forward or lowering movement of the sternum or clavicles indicates uncontrolled thoracic flexion. The person is instructed to slowly allow the head to flex forwards off the wall. Only allow the head to hang forwards as far as there is no thoracic flexion (monitored by the hand palpating the sternum). Using feedback from palpating the sternum, the person is trained to control and prevent thoracic flexion and perform independent lower cervical flexion (Figure 7.9).




The person should self-monitor the control of thoracic flexion UCM with a variety of feedback options (T43.3). There should be no provocation of any symptoms within the range that the flexion UCM can be controlled.



Once control of the thoracic flexion improves, the person should move away from the wall and the exercise can be performed with self-monitoring of thoracic flexion control by palpating the sternum, with the thoracic spine unsupported (no wall support).



t44 Sitting: pelvic tail tuck test(tests for thoracic flexion UCM)


This dissociation test assesses the ability to actively dissociate and control thoracic flexion then roll the pelvis backwards (i.e. ‘tail tuck’ or posterior pelvic tilt) while sitting upright and unsupported.



Test procedure


The person should have the ability to actively roll the pelvis backwards into posterior pelvic tilt while controlling and preventing thoracic flexion. The person sits tall with the feet off the floor and with the lumbar spine and pelvis positioned in the neutral. The therapist should passively support the thoracic spine and passively roll the pelvis backwards to assess the available range of posterior pelvic tilt that is independent of thoracic flexion. This also allows the person to experience and learn the movement pattern that will be tested.


The person is then instructed to make the spine as tall or as long as possible to position the normal curves in an elongated ‘S’. Position the head directly over the shoulders without chin poke (Figure 7.10). Then, without letting the thoracic spine flex (sternum does not lower or move forwards), actively roll the pelvis backwards (tuck the tail under the pelvis) into full available posterior pelvic tilt. The person is required to produce the same range of posterior pelvic tilt that the therapist identified with passive assessment.



Ideally, the person should have the ability to dissociate the thoracic spine from posterior pelvic tilt as evidenced by the ability to prevent thoracic flexion while independently rolling the pelvis backwards (Figure 7.11). There must be no movement into thoracic flexion. There should be no provocation of any symptoms under posterior tilt (flexion) load, so long as the thoracic flexion UCM can be controlled.



This test should be performed without any extra feedback (self-palpation, vision, etc.) or cueing for correction. When feedback is removed for testing the therapist should use visual observation of the thorax relative to the pelvis to determine whether the control of thoracic flexion is adequate.



Thoracic flexion UCM


The person complains of flexion-related symptoms in the thoracic spine. The thorax has UCM into flexion relative to posterior pelvic tilt under flexion load. The thoracic spine starts to flex before full independent posterior pelvic tilt (’tail tuck’) is achieved. During the attempt to dissociate the thoracic flexion from independent posterior pelvic tilt, the person either cannot control the UCM or has to concentrate and try hard to control the thoracic flexion.



Clinical assessment note for direction-specific motor control testing


If some other movement (e.g. a small amount of thoracic rotation) is observed during a motor control (dissociation) test of thoracic flexion, do not score this as uncontrolled thoracic flexion. The thoracic rotation motor control tests will identify if the observed unrelated movement is uncontrolled. A test for thoracic flexion UCM is only positive if uncontrolled thoracic flexion is demonstrated.



Rating and diagnosis of thoracic flexion UCM


(T44.1 and T44.2)





Correction

Retraining is best started by supporting the thoracic spine against a wall for increased thoracic support and feedback and posterior tilting the pelvis through reduced range. The person stands with the back of the pelvis, the upper thoracic spine and the back of the head resting against a wall with the shoulders and arms relaxed. The pelvis is positioned in anterior tilt to start the training. This can also be performed with the person sitting on a low stool with the feet on the floor and the thoracic spine and head resting against a wall. Then, keeping the thoracic spine and head stationary on the wall, the person is instructed to roll the pelvis backwards into posterior pelvic tilt (Figure 7.12). It may be useful to visualise tucking an imaginary tail under the pelvis. Another visualisation cue is to visualise the pelvis as a bucket full of water and the thorax as the handle of the bucket. The aim is to visualise the ability to tip water out the back of the bucket but not allow the handle to swing forwards into thoracic flexion.



If control is poor, it is also recommended that the person use self-palpation to monitor the correct performance of the exercise. Monitor the control of thoracic flexion by placing one hand on the sternum or clavicles. Monitor lumbopelvic motion by placing the other hand on the sacrum (Figure 7.13). Without letting the thoracic spine flex (sternum does not lower or move forwards) actively roll the pelvis backwards (tuck the tail under the pelvis) into full available posterior pelvic tilt. Using feedback from palpating the sternum, the person is trained to control and prevent thoracic flexion and perform independent posterior pelvic tilt. Only allow posterior pelvic tilt (tail tuck) as far as there is no thoracic flexion (monitored by the hand palpating the sternum). There must be no UCM into thoracic flexion. There should be no provocation of any symptoms under flexion load, so long as the thoracic flexion UCM can be controlled.



The person should self-monitor the control of thoracic flexion UCM with a variety of feedback options (T44.3). There should be no provocation of any symptoms within the range that the flexion UCM can be controlled.



If control is very poor, rather than specific dissociation, for some patients it is easier to initially use a recruitment reversal exercise. The upper body and trunk weight can be supported on hands and knees. Position the pelvis in neutral pelvic tilt and the lumbar spine, the thoracic spine and head in neutral alignment (the back of the head touches an imaginary line connecting the sacrum and mid-thoracic spine). There are two recruitment reversal strategies that are appropriate:



When the pattern of this recruitment reversal feels easy to perform, the person can progress back to the sitting dissociation exercise.



t45 Sitting: bilateral forward reach test(tests for thoracic flexion UCM)


This dissociation test assesses the ability to actively dissociate and control thoracic flexion then reach forwards in front of the body with both arms (i.e. bilateral scapular protraction) while sitting upright and unsupported.



Test procedure


The person should have the ability to actively reach forwards with both arms into full scapular protraction while controlling and preventing thoracic flexion. The person sits tall with the feet off the floor. The person is then instructed to sit upright with the spine in its neutral normal curves and the head directly over the shoulders without chin poke. Both arms are held at 90° of shoulder flexion, with the scapulae relaxed in a neutral mid-position (Figure 7.16). Then, without letting the thoracic spine flex (sternum does not lower or move forwards) or the head to move forwards, actively reach forwards with both hands into full available scapular protraction.



Ideally, the person should have the ability to dissociate the thoracic spine from scapular protraction as evidenced by the ability to prevent thoracic flexion while independently reaching forwards (Figure 7.17). There must be no movement into thoracic flexion. There should be no provocation of any symptoms under flexion load, so long as the thoracic flexion UCM can be controlled.



This test should be performed without any extra feedback (self-palpation, vision, etc.) or cueing for correction. When feedback is removed for testing the therapist should use visual observation of the head and thorax relative to the shoulders to determine whether the control of thoracic flexion is adequate.



Thoracic flexion UCM


The person complains of flexion-related symptoms in the thoracic spine. The thorax has UCM into flexion relative to scapular protraction. The thoracic spine starts to flex before full independent scapular protraction (forward reach) is achieved. During the attempt to dissociate the thoracic flexion from independent scapular protraction, the person either cannot control the UCM or has to concentrate and try hard to control the thoracic flexion.



Clinical assessment note for direction-specific motor control testing


If some other movement (e.g. a small amount of thoracic rotation) is observed during a motor control (dissociation) test of thoracic flexion, do not score this as uncontrolled thoracic flexion. The thoracic rotation motor control tests will identify if the observed unrelated movement is uncontrolled. A test for thoracic flexion UCM is only positive if uncontrolled thoracic flexion is demonstrated.



Rating and diagnosis of thoracic flexion uncontrolled movement


(T45.1 and T45.2)



Correction

If control is poor, retraining is best started by supporting the thoracic spine against a wall and reaching forwards (scapular protraction) through reduced range. The person stands with the heels at least shoulder width apart and about 20 cm in front of a wall with the knees slightly flexed.




The thoracic spine and the back of the head are supported upright against a wall. The person should monitor the control of thoracic flexion by palpating the sternum or clavicles with one hand. Any forward of lowering movement of the sternum or clavicles indicates uncontrolled thoracic flexion. The person is instructed to slowly reach forwards with the other arm. Only reach forwards as far as there is no thoracic flexion (monitored by the hand palpating the sternum) (Figure 7.18). Using feedback from palpating the sternum, the person is trained to control and prevent thoracic flexion and perform independent scapular protraction.



The person should self-monitor the control of thoracic flexion UCM with a variety of feedback options (T45.3). There should be no provocation of any symptoms within the range that the flexion UCM can be controlled.



Once control of the thoracic flexion improves, the person should reach forwards with both arms while using the wall for feedback and support of the thoracic spine (Figure 7.19). Eventually, they can move away from the wall and the exercise can be performed with the thoracic spine unsupported (no wall support).





Thoracic extension control



Extension control tests and extension control rehabilitation


These extension control tests assess the extent of extension UCM in the thoracic spine and assess the ability of the dynamic stability system to adequately control extension load or strain. It is a priority to assess for extension UCM if the person complains of or demonstrates extension-related symptoms or disability. The tests that identify dysfunction can also be used to guide and direct rehabilitation strategies.




Tests of thoracic extension control



T46 Standing: bilateral overhead reach test(tests for thoracic extension UCM)


This dissociation test assesses the ability to actively dissociate and control thoracic extension then reach overhead with both arms (i.e. bilateral shoulder flexion) while standing upright and unsupported.



Test procedure


The subject stands upright with the spine in its neutral normal curves, the head directly over the shoulders without chin poke and with the arms resting by the side with the shoulders in a neutral position (Figure 7.20). The person is then instructed to slowly lift both arms into flexion. Without letting the thoracic spine extend (sternum does not lift or move backwards) or the head move backwards, the person should be able to actively reach overhead with both hands into end-range shoulder flexion.



Ideally, the person should have the ability to dissociate the thoracic spine from overhead shoulder flexion as evidenced by the ability to prevent thoracic extension while independently reaching overhead to at least 160° bilateral shoulder flexion (Figure 7.21). There must be no movement into thoracic extension. There should be no provocation of any symptoms under overhead load, so long as the thoracic extension UCM can be controlled.



This test should be performed without any extra feedback (self-palpation, vision, etc.) or cueing for correction. When feedback is removed for testing the therapist should use visual observation of the head and thorax relative to the shoulders to determine whether the control of thoracic extension is adequate.



Thoracic extension UCM


The person complains of extension-related symptoms in the thoracic spine. The thorax has UCM into extension relative to overhead shoulder flexion. The thoracic spine starts to extend before 1600 of independent shoulder flexion (overhead reach) is achieved. During the attempt to dissociate the thoracic extension from independent overhead reach, the person either cannot control the UCM or has to concentrate and try hard to control the thoracic extension.



Clinical assessment note for direction-specific motor control testing


If some other movement (e.g. a small amount of thoracic rotation) is observed during a motor control (dissociation) test of thoracic extension, do not score this as uncontrolled thoracic extension. The thoracic rotation motor control tests will identify if the observed unrelated movement is uncontrolled. A test for thoracic extension UCM is only positive if uncontrolled thoracic extension is demonstrated.



Rating and diagnosis of thoracic extension UCM


(T46.1 and T46.2)





Correction

If control is poor, retraining is best started by supporting the thoracic spine against a wall and reaching overhead (shoulder flexion) with unilateral arm movement and through reduced range. The person stands with the thoracic spine and the back of the head supported upright against a wall. The person should flatten the lumbar spine against the wall to give additional feedback and support to the ability to prevent thoracic extension. If uncontrolled thoracic extension occurs the person will be aware of the thoracolumbar spine losing contact with the wall (arching into extension). Alternatively, the person may monitor the control of thoracic extension by palpating the sternum or clavicles with one hand. Any lifting movement of the sternum or clavicles also indicates uncontrolled thoracic extension.


The person is instructed to slowly flex one arm through range to reach overhead. Only reach overhead as far as there is no thoracic extension (Figure 7.22). Using feedback from the back on the wall (or palpating the sternum), the person is trained to control and prevent thoracic extension and perform independent overhead shoulder flexion.



The person should self-monitor the control of thoracic extension UCM with a variety of feedback options (T46.3). There should be no provocation of any symptoms within the range that the extension UCM can be controlled.



Once control of the thoracic extension improves, the person should reach overhead with both arms while using the wall for feedback and support of the thoracic spine. Eventually, they can move away from the wall and the exercise can be performed with the thoracic spine unsupported (no wall support).

Related posts:

Retraining strategies for uncontrolled movement Assessment and classification of uncontrolled movement The hip The cervical spine The lumbopelvic region Muscle function and physiology

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Sep 29, 2016 | Posted by in MANUAL THERAPIST | Comments Off on The thoracic spine

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