Thoracic Treatment

Have you ever felt that as a massage therapist you are delivering the same form of back treatments over and over again? You may be treating your clients individually and acknowledging their subjective feedback, yet the hands-on treatment you provide varies little among clients. Many therapists report to me that over the years they have begun to feel a little “stale,” wanting to vary their treatments but at the same time being cautious as to whether other techniques will be as effective.

Provided here are a large selection of tips, techniques which I have found helpful in breaking up the monotony of a regular thoracic massage treatment. Of course, they should be used with a specific purpose in mind. This might be to relax a client, to reduce stiffness globally or locally, to stretch muscles, or to lengthen soft tissues. As with all the tips in this book, it is useful to experiment, not only in trialing the techniques, but also in receiving them. So much can be learned from experiencing how a technique feels, so I encourage you to be the “client” for one of your colleagues and to work together to explore these suggestions.

There are a few clients for whom the tips provided here are contraindicated. You may already know that unexplained pain in a localized area of the thorax is a warning sign, so clients presenting in this way should be referred to a doctor. Most of the tips provided here can be applied to most clients. There are some that are for specific client groups, such as those with “flat back,” in the thoracic region, or an exaggerated kyphosis. When working with clients, ask yourself what is it that you are hoping to achieve, and then whether the suggested tip fits that purpose. After practicing with a colleague, ask which of these treatments you enjoyed receiving yourself.

Have you ever used stretching or massage to reduce the tone in muscles? Unless you are using tapotement techniques, massage is most often used to relax soft tissues and bring about a decrease in their tone. It is therefore important to find ways to facilitate this and to avoid situations during the treatment where tone may become elevated. There are two interesting experiments you can do to demonstrate how thought affects muscle tone.

Experiment 1

With your subject in the prone position, feel for the rhomboid muscles. Ask your subject to contract their rhomboids, drawing their scapulae toward the spine. Both you and your subject can feel these muscles contracting and you will observe the scapulae change position. Now that your subject knows which muscles you want them to focus on, ask them to see if they can contract these muscles without moving their scapulae. As you continue to palpate, you will feel the muscles contract simply as a result of the client thinking about drawing their scapulae back toward their spine.

Experiment 2

A second experiment you can try works best if you use someone who engages regularly in a sporting activity, especially if this involves a lot of upper limb action such as racket sports, throwing, rowing, or climbing. With your subject lying comfortably in the prone position, place your hands gently on the muscles of their thorax. Ask your subject not to talk to you. Once you feel that your client is comfortable and has relaxed, ask them to think about performing their particular sport in a way that makes them feel energized and excited. Perhaps they might envisage reaching to hit or to shoot a ball, swimming extra fast, or pulling themselves up a rock face. As your client engages in thinking about their activity, you will notice an increase in tone in the muscles beneath your hands.

These two simple experiments have been included as a treatment tip—rather than as an assessment tip—because they demonstrate that it can be disadvantageous to engage a client in conversation if your purpose is to decrease tone, perhaps through massage or stretching. This is especially true if your conversation involves them thinking about their own particular physical activity.

You may wish to encourage thoracic expansion:

• When treating a client in the post-acute stage following intercostal strain or a rib fracture, where they are likely to have maintained a hunched, protective posture.

• When working with asthmatic clients.

• When trying to encourage clients to have a greater awareness of their bodies for the purposes of postural correction.

• When working with a client who is prone to maintaining a hunched posture at work or when engaged in a hobby.

• To facilitate an initial stretch in soft tissues of the thorax when treating clients in the post-acute stages following operations such as mastectomy.

• To help calm those clients prone to anxiety.

Yes, with your client in the prone position, stand at the head of the couch and reach over to place your hands on the lower ribs. Notice that you cannot apply pressure in quite the same way in this position as when you treat a seated client. With the client supine or in a semi-reclined position you can access the inferior ribs, but notice that to do so you need to maintain a position in which you are flexed at the waist, and this could harm your own back.

During different sessions, you could compare the difference between the following:

• Different treatment positions.

• The same position but different hand placements.

• Performing this technique with or without a verbal prompt.

An example of a prompt is, “Try to keep your chest wall touching my hands as you breathe in.”

Question: How many times can this technique be performed?

This technique is particularly useful:

• When working with clients with a reduced range of movement in the thorax.

• When treating clients who report their upper back feeling “stiff.”

• Where you feel thoracic segments are palpably “stuck.”

• When treating hypermobile clients who may have tension in localized segments of the thorax.

This technique affects the joints of the thorax by bringing about a minor stretch in the soft tissues associated with these joints—including costovertebral joints—as each individual thoracic vertebra is rotated to a minor degree. It is not appropriate for clients with osteoporosis or fused joints, and would be unhelpful if applied to segments of the spine that are hypermobile. Obviously it should not be used in acute conditions of any kind, including herniations. Given the gentle nature of the technique, it is unlikely to be harmful if used when treating clients with scoliosis. However, given the complex nature of the scoliotic spine, it would be unwise to use the technique with the intention of bringing about anatomical change. It could, however, be beneficial in treating clients with scoliosis, where your goal is a decrease in muscle tone, or when treating clients with thoracic pain that you believe is of muscular origin.

STEP 1 With your client in the prone position, stand to one side of the treatment couch. Locate the spinous processes of the thoracic spine and position your thumbs, reinforced as shown, against the side of one of the processes. Keep the flat pad of your thumb against the process rather than the tip of your thumb. You would not usually be encouraged to press through a thumb joint in this way, but this pressure is very slight, and reinforcing your thumbs as pictured reduces the likelihood of injury to your own joints.

STEP 2 Using gentle pressure, push the spinous process away from you using a gentle rocking motion, one, two, or three times. Work your way down the spine and then move to the opposite side of the couch and repeat on the other side of the spine.

The purpose of your “rocking” is to help relax soft tissues and decrease pressure on joints. Do not force any vertebrae which feel stuck: this is not a manipulative technique. If one segment feels less mobile than the others, leave it and return to it later. You may have already discovered that the body sometimes responds better to gentle, subtle techniques than to forcible ones.

TIP: One way to think of this technique is to imagine the spinous processes are like a sail on a sailboat and you are facilitating a tilting motion. Of course, the spinous processes in the thoracic region are not as prominent as a sail on a sailboat, as they lie flatter to the spine.

When you have finished your treatment, it is important to do two things:

• First, reassess your client. Is there an increase in thoracic range of motion? Is there a decrease in symptoms?

• Second, document how many times you “rocked” the spinous processes, and which part of the spine you worked on.

In later treatments, you could experiment with rocking only one side of the spine and retesting to see if this alone has made a positive difference.

The thoracic spine may be exaggerated in three ways:

• When the natural outward curvature—the kyphosis—of the thoracic spine is exaggerated, a person is said to have a kyphotic spine. There are various types of kyphotic spine.

• When the natural kyphosis is diminished, and the back becomes more flat in appearance, this is described as a flat back. The term is usually used with reference to a reduced lumbar lordosis.

• Lateral, C-shaped or S-shaped curvatures combining an exaggeration in the normal kyphosis of the thorax (and an exaggeration of the normal lordosis of the lumbar region) are described as scoliotic.

In general terms, treatments for clients with increased kyphosis, flat back, or scoliosis involve the shortening of lengthened muscles and the lengthening of shortened muscles in order to achieve balance in soft tissues and a realignment of joints. This will help both soft tissues and joints to function more optimally. There are many different ways to achieve these, some of which are listed in the following tables.

A kyphotic posture is one in which the normal kyphotic curve is exaggerated. There are good reasons for wanting to correct excessively kyphotic postures, some of which are the following:

• The imbalance that results can be painful, not only in the upper back, but also in the cervical and lumbar regions, which usually compensate for the kyphosis with an increase in the lordotic curve in these regions.

• The imbalance that results affects the correct functioning of the shoulder because scapulae are usually protracted. Problems such as anterior impingement syndromes in the shoulder and thoracic outlet syndrome are likely to be more common in clients with protracted shoulders. In kyphotic postures, the ability of the trapezius to stabilize the scapulae is compromised.

• The rib cage is depressed, and altered rib function can impair the mechanics of breathing. Abdominal organs are squashed, and this could impair their functioning too.

Much can be done to correct a kyphotic posture when, for example, it is the result of habitual hunching over a desk, steering wheel, or laptop, or prolonged hunching to perform a hobby. Over the next few pages, you will find information on what you can do for a client with a kyphotic posture and what a client might do for themselves.

The normal lumbar lordosis is sometimes flattened, giving rise to the term “flat back.” However, you may have come across clients who appear to have a flatter than usual thoracic spine. Such clients may have prominent scapulae and a low body mass index. Such scapulae are sometimes described as “winged” when in fact they simply appear more prominent because the thoracic curve is diminished. These clients often complain of mid-back pain, especially on standing erect or leaning backward. In fact, they may adopt a slight rounding of the shoulders as this alleviates their pain. However, such a posture creates excessive strain on other segments of the spine, such as the C7/T1 region, as posterior neck muscles work to control the forward head position—consequently, therapeutic intervention is often welcomed.

Pain experienced by subjects with thoracic flat back postures may arise because, when standing erect or extending the spine, the spinous processes in this region approximate one another, and soft tissues are squashed.

Whether a person has a C-shaped or an S-shaped scoliosis, there are physiological (as opposed to esthetic) reasons for correction of an excessively scoliotic posture. In such postures:

• Internal organs become displaced and their function may be compromised.

• Spinal nerves may be pinched where they exit the vertebral canal.

• The spine’s ability to support bodyweight is reduced by lateral curvature.

When treating a client with a flattened thoracic curve, the erector spinae muscles are shortened compared to those of a client with a normal thoracic curve. The purpose of this technique is to stretch out these shortened tissues, focusing on the midline region and the spinalis thoracic muscle.

STEP 1 Select the side-lying or the prone position. If using the side-lying position, your client needs to flex at both the hips and knees by about 90 degrees; if using the prone position, they need to tuck their chin toward their chest.

STEP 2 Place one hand on the base of the skull and one on the sacrum and apply gentle traction. Your aim is to gently traction the skin, fascia, and maybe even underlying muscle. Patience is required as you settle into a comfortable hand position and wait for tissues to yield.

Alternatives are to get the client to turn their head to one side (a), to apply a diagonal stretch (b), or to apply the stretch with your arms crossed (c).

This soft tissue technique is also particularly useful for clients with tension in the midline, such as clients with a flattened kyphotic curve. It is soothing to receive and may therefore be incorporated into a general back massage routine.

With your client prone, and without using any medium (such as wax or oil), gently stretch the tissues on either side of the spinous processes by using your fingers to create S shapes as you push the skin upward (cephalad) on one side and downward (caudal) on the other.

Question: Do I need to start at the top of the thoracic spine and work down, or at the bottom of the thorax and work up?

Erector spinae are spinal extensors as you know. They are active all of the time we are sitting, standing, walking, or engaged in sport or physical activity. Observing that a client has enlarged erector spinae muscles does not mean that there is anything wrong with these muscles. We would not attempt to dampen down the tone in the muscles of a client who had, for example, nicely developed biceps, would we? So it is strange that many therapists feel they need to reduce the size of a client’s erector spinae muscles by “working” them, rubbing the muscles, “twanging” them like guitar strings, or circling them with friction type movements in an attempt to flatten them out.

However, it would be appropriate to try and reduce tone in erector spinae where the increase in tone is the source of pain. Often this occurs where tone is localized to a short segment of muscle. It would also be appropriate to try and decrease tone where you believe hypertrophy of the muscle is contributing to muscle imbalance.

As with all manual techniques, if you don’t find the routine here helpful, then simply don’t use it; if you like it, practice with it for several sessions, with several different clients or work with a colleague and receive the routine yourself.

Suggested Routine to Decrease Tone in Erector Spinae

With your client in the prone position, covered with a towel, you can perform the following routine:

• Work through the towel:

3. Compression Gently lean onto your client, transferring your weight through either your hands (a), reinforced palms (b), or forearm (c), and then lean off your client. Repeat this several times, without moving your hands. This gentle compression–release–compression–release is calming. Move your hands (or forearms) to two different positions on the back and repeat the technique.

4. Massage Using effleurage only, massage the back. As you massage, notice which parts of the erector spinae seem to have an increase in tone or which parts the client reports are uncomfortable. Continue with this routine.

• Replace the towel:

Now that a massage medium is on the skin, it will “grip” the towel and provide a greater degree of traction. This will enable you to compress and stretch tissues using less pressure than usual.