Thoracic Treatment

Chapter V


Thoracic Treatment




Chapter 5 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.


Tip 1: How Thought Affects Muscle Tone


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.


Tip 2: Encouraging Thoracic Expansion


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.


This tip explains how a therapist can facilitate thoracic expansion in a safe manner. You may wish to assess thoracic expansion before and after this technique, using either Tip 14 (pp. 255258) or Tip 15 (pp. 259261) in Chapter 4.


STEP 1 Position your client so that they are comfortably seated, straddling a chair, perhaps with a pillow against their chest and stomach, or in the prone position. They may be fully clothed as long as they are comfortable. Sit or kneel behind them and place your hands on their back, spreading your fingers to “cup” the posterolateral ribs, and with your palms flat against your client’s body. Apply firm but gentle pressure through your palms. Encourage your client to breathe normally. Feel the movement as their rib cage expands and contracts with inhalation.


STEP 2 As your client inhales, ever so slightly decrease your hand pressure. With their next inspiration, your subject will increase their inspiration, expanding their rib cage as they naturally try to breathe “into” your palms.



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Question: Can this technique be performed with my client on a couch?



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.



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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?



Once your client is relaxed, avoid asking them to inhale more than three times in order to prevent hyperventilation.


There are many exercises that a client may do for themselves to help expand their rib cage, some of which are described in Chapter 6, Tip 5: Breathing Exercises (pp. 306309).


Tip 3: Rocking Spinous Processes


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.



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Question: Does it matter where I start the rocking, at the superior or inferior thoracic region?



No, you can start wherever it feels appropriate. It is good to be consistent, however, because you will need to document your findings: does the client report discomfort when you “rock” a particular vertebra or does a particular section of the thorax feel less able (or more able) to rock than other areas? Such findings indicate hypomobility or hypermobility of that segment.


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.



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Question: Does it matter how many times I “rock” each vertebra or how quickly?



There is no data to help answer this question. It is important not to overwork any segments of the spine, so rocking each spinous process one to three times seems like an appropriate starting point. The technique should feel soothing to receive, which could equate to about one “rock” per second. This is a good example of where it is useful to receive a technique yourself in order to both appreciate its benefits and experience how it feels to have it applied to your own body.


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.


Tip 4: Treating Exaggerated Postures of the Thoracic Spine – An Overview


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.


Before reading about some of the treatments, you might employ as a therapist to help a client with an exaggerated kyphosis (Tip 5, pp. 228229), a flattened thoracic spine (Tip 6, p. 229), or scoliosis (Tip 7, p. 231), it is important to consider three things.


First, ask yourself “What is the rationale for my intervention?”


It may be to address symptoms you believe are the result of the spinal shape, such as pain, feelings of stiffness, or reduced function.


It may be purely esthetic, based on the wishes of your client.


It may be prophylactic, because you believe that with time, the shape of the spine could lead to problems. For example, as we age, the kyphotic curve becomes more pronounced, the thorax is squashed anteriorly, and our breathing function is impaired due to altered rib mechanics.


Second, although a subject may have a spine with exaggerated curves, this does not necessarily mean that their spine is abnormal. Brunnstrom (1972) notes that the erect, perpendicular posture described by Braune and Fischer (1889) as “Normalstellung” has been incorrectly translated to describe “normal posture,” when in fact Braune and Fischer used this term to describe the anatomical relationship of body parts when making measurements. It is interesting that what was an anatomical description of a very erect posture has filtered down through the last century to become a standard for body alignment: the erect posture is now commonly believed to be normal. Therapeutically, postural correction is about alleviating existing symptoms and preventing the likelihood of symptoms occurring in the future without feeling obliged to strive for an esthetic ideal.


Third, the most significant factor in bringing about postural change is what a subject does for themselves on a daily basis. A single, one-off intervention provided by a therapist may be effective but is unlikely to have lasting effect if the change this has facilitated is not maintained by the subject. Chapter 6 provides ideas you can pass on to your clients to help them maintain and improve their posture.


Overview of Treatments


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.












Examples of ways to shorten lengthened muscles


Active correction of posture by the client where possible


Active strengthening using techniques such as:


– bodyweight against gravity


– exercise bands such as therabands (The Hygenic Corporation)


– hand weights


– multigym equipment


Isometric strengthening using techniques such as muscle energy technique, provided that joints are in fairly optimal alignment


















Examples of ways to lengthen shortened muscles


The client adopting resting positions to affect stretch and relaxation of soft tissues


Passive stretching using techniques such as:


– Simple passive stretches


– Soft tissue release


– Muscle energy technique


Active stretching of specific body parts, using common stretches or specific techniques such as active soft tissue release


Correction of posture by the client where this is possible


Release of trigger points either passively or actively to decrease tone in muscles and facilitate lengthening


Myofascial release to bring about a relaxation in fascia


Tip 5: Kyphotic Postures


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.












Muscle Imbalance in Kyphotic Postures


Shortened muscles


Lengthened muscles


Pectoralis major
Pectoralis minor
Rectus abdominis (upper)
Posterior neck (where there is associated lordosis in this region)


Rhomboids
Middle fibers of trapezius


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 following table provides an overview of treatments for this particular posture. By using the page references in the table, you will be able to locate where particular techniques are described in detail. You will see that most of the suggested techniques for treating people with a kyphotic posture are included in Section 2 of this book as separate tips. This is because they can also be helpful for treating other conditions.











































Twelve things you can do for your client with a kyphotic posture


Pages


1. Teach your client the “dart” exercise to strengthen the lower fibers of trapezius and help realign the scapulae


314


2. Teach your client chest stretches


292295


3. Teach your client thoracic mobility stretches


302304


4. Teach your client breathing exercises to increase inspiration and improve thoracic mobility


306309


5. Provide passive chest stretches:


– Simple, passive pectoral stretching or


– Muscle energy technique stretches to the pectoral muscles (supine or seated) or


– Soft tissue release stretches to pectoral muscles (unilaterally and at the sternum)


255258
259261
251253


6. Help relax anterior chest wall muscles using myofascial release


245246


7. Provide massage with the aim of stretching pectorals


 


8. Address trigger points in pectorals


 


9. Release tension in upper abdominals


 


10. Mobilize the rib cage to encourage improved respiration. This means facilitating correct functioning of the sternocostal and costovertebral joints


269271


11. Tape the thorax


 


12. Refer your client to a fitness professional for strengthening middle and lower fibers of the trapezius and spinal extensors


278280


Remember that the client is likely to have a lordotic neck and internally rotated shoulders, and these areas also should be addressed. This section of the book focuses on the thorax.




























Seven things a client with a kyphotic posture can do for themselves


Pages


1. Strengthen opposing muscle groups with exercises such as the dart. This helps strengthen the lower fibers of trapezius and helps realign the scapulae


314


2. Perform active chest stretches


292295


3. Perform thoracic mobility stretches


302304


4. Practice breathing exercises to increase the range of respiration


306309


5. Alter habits: avoid prolonged kyphotic postures at work or when performing hobbies


310311


6. Perform exercises to regain correct pelvic alignment: prevent excessive anterior or posterior tilt. The spine is attached to the pelvis by way of the sacrum and the sacroiliac joints, so poor positioning of the pelvis can adversely affect the shape, and therefore the function, of the spine


331


7. Deactivate trigger points in muscles of the anterior thorax


299301


Tip 6: Flat Back Postures – in the Thoracic Region


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.






















Five things you can do for a client with a thoracic flat back


Pages


1. Provide general back massage to soothe tensioned muscles, including S bends to release tension


234235


2. Rock spinous processes to decrease muscle spasm and alleviate pain


223225


3. Address trigger points in erector spinae, rhomboids, or middle fibers of trapezius


 


4. Passively stretch the latissimus dorsi


 


5. Perform longitudinal stretches to ease tension in soft tissues of the posterior spine


232233
















Three things a client with a thoracic flat back can do for themselves


Pages


1. Avoid extending their spine


 


2. Active stretches for erector spinae, rhomboids, and middle fibers of trapezius


296298


3. Self-trigger of the posterior thorax


299301


Tip 7: Scoliotic Postures


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.


Hartvig Nissen was a firm believer in the use of exercise to help correct scoliosis, and in his book, Practical Massage and Corrective Exercises (1905), he provides examples of the assessments he made of children with scoliosis “before” and “after” his treatment using specific sets of exercises. The black and white photographs of Nissen demonstrating his “corrective” exercises, with his beard and bow tie and high-waisted trousers, are amusing to the modern eye. But Nissen was a massage therapist also and is to be applauded for being brave enough to publish what he claimed were his findings based on 30 years’ experience. Solberg (2008) notes that in 1941 the American Orthopaedic Association concluded exercises should not be used in the treatment of scoliosis, on the basis that studies showed exercise failed to halt the progress of the condition. However, Solberg does a good job in clarifying some of the research on this topic. She notes that when methodological flaws were eliminated and the studies were repeated, exercise did have a positive effect on scoliotic postures, arguing (on p. 107) that, “Therapeutic exercise may actually produce improvement in the scoliosis and engender significant change both in body posture and in general functioning of the spinal column.” Perhaps Nissen was right all along.


It is hardly surprising that there are conflicting views regarding the use of exercise to correct scoliosis. Flaws in exercise programs, whether for the treatment of scoliosis or other conditions, are common. For example, incorrect exercises may be prescribed in the first place; the exercise may be correct, but the intensity or duration wrong; the subject may perform the prescribed exercises incorrectly or they may forget to perform them at all. Notably, as a client’s condition changes, exercises need to be modified. Therapeutic exercises for scoliosis are not included in this section because there is more than one type of scoliosis, and “corrective” exercise programs need to be individually tailored and delivered by professionals specialized in this field.


















Things you can do for a client with scoliotic posture


Massage and stretching of shortened tissues


 


Referral to a specialist practitioner for corrective exercise


For more information, contact:
The British Orthopaedic Association, www.boa.ac.uk/
The American Orthopaedic Association, www.aoassn.org/


Things the client can do for themself


Page


Practice corrective postures


313


Tip 8: Longitudinal Stretches for Flat Back


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.



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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.



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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.



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Question: Is this the same as the dural tube stretch used in myofascial release?



No. Although the subtle stretch described here utilizes the same position as a myofascial release dural tube stretch, they are not the same. The aim here is not to release the dural tube but the spinal extensor muscles in the midline region.


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).



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TIP: Lower your treatment couch for this technique or practice it on the floor. Experiment to see which position is most comfortable to receive.


Tip 9: “S” Strokes


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.



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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?



It does not matter where you start.


Question: Do I alternate the S shapes so that I am pushing up on one side of the spine and then pushing down on that same side?



You could perform the same stroke from one end of the spine to the other and then reverse. So, for example, if you start by pushing up on the left of the spine and down on the right from the lumbar spine to the neck (a), when you reach the neck, change your position and push the tissues down on the left and up on the right (b), as shown in the figures below.



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Tip 10: Addressing Tension in Erector Spinae


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:


1. Rocking With a towel draped over your client, without touching the back itself, place your hands on the sides of the thorax, arms, hips, or legs and gently rock your subject for about a minute, working down one side of the body and up the other side. Use gentle, rhythmic rocking of low amplitude. For more information on rocking, see Tip 22: Rocking (p. 281).



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2. Stillness Place your hands on the thorax and wait. Have you noticed how, when you are in an environment that is very still, such as a monastery, empty beach, or in the countryside, the stillness of the moment is transmitted to you? After gentle rocking, allow your client to sense the stillness within you.



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TIP: It is useful to practice visualizing your own favorite still place as you perform this technique.


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.



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Remove the towel and apply a massage medium such as oil or wax:


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.



TIP: Compare how it feels both to give and to receive the next technique first through a towel after oil has been applied, and then on skin after oil has been applied.

Aug 25, 2019 | Posted by in MANUAL THERAPIST | Comments Off on Thoracic Treatment
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