The thoracic spine

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  • 1. The Thoracic SpineA Case of stiffness of Stability?
  • 2. Why does it matter?• Important region of force transmission• Transfers load between legs and lumbo-pelvic region and arms, neck and head• Central area of myo-fascial connections• Protective unit• Closely related to autonomic nervous system Lee DG 2003, Lee LJ 2008, 2012
  • 3. Thoracic Spine• Centre of rotation for the trunk• Essential for the production and transmission rotational torques• Inter-segmental control as per other areas of the spine Hodges 2003
  • 4. Why does it matter?• Stiff pain-free thorax can create excessive loading and mobility demands in adjacent areas.• Results in excessive movement, compression, shear and or tensile forces• Addressing stiffness allows a more even distribution of load through the spine
  • 5. Evidence re role in pathology• Throwing shoulder• Swimmers• Cricketers
  • 6. Role in Shoulder Pathology• Relevance kinetic chain• Movement strategies• Functional reach• Relevance in overuse pathology Teyssedre 2000 Lin et al 2005 Roy et al 2008
  • 7. Role in Shoulder PathologyPosture• Muscle activation patterns• Increase size subacromial space Lewis et al 2009, Foster et al 2008
  • 8. Role in Shoulder Pathology• Decreased thoracic rotation• GIRD• Scapula Dyskinesis Bialowsky 2009,Lee et al 2002
  • 9. The story so far…• Techniques directed at increasing thoracic mobility• Tx Spine most frequently manipulated• Exercises designed around increasing mobility• Muscle training – dissociation and postural control
  • 10. Current Trends Treatment• Manipulation• MET• MWM - F/Rotation - Ribs
  • 11. Effectiveness Thoracic ManipulationBoyles et al 2009• Tx spine V• 56 pts with SAIS• SPADI, Pain Scale, Neer, Empty can, Abd• 48 hours all sig increase /decrease
  • 12. Thoracic spineStunce et al 2009• 21 subjects av age 47 shoulder pain• Tx F restriction 100% Tx E 7%• Unilat rib restriction 79%• All manipulated• Sh AROM imp by 38º F, 38º Abd, 30º Rot• VAS decreased by 32 mm
  • 13. Thoracic Manipulation• Manual therapy and exercises addressed to Tx and ribs• In addition to usual Rx• Improved success rates vs usual Rx alone• Maintained at 1 year• Improved patient rated outcomes Bialowsky et al 2009, Walser et al 2009
  • 14. Thoracic Manipulation• Most studies consider combined with other manual therapy• But ? this makes sense…… Michener et al 2012
  • 15. Why does manipulation work?Stiffness ? ;• Increased resting tone and dominance global muscles of the thorax• Connections to upper quadrant• Neuro-myofascial compression of joints of the thorax• Creates rotational dysfunction
  • 16. • Long global muscles have specific fascicles of attachment• Oscillatory mobilisations change afferent input• Change muscle resting tone
  • 17. Proposed Mechanism• Mechanical stimulus• Neurophysiological mechanism• Peripheral mechanism• Spinal mechanisms• Supraspinal mechanisms
  • 18. Effects of Manual Therapy
  • 19. Sympathetic SystemSympathetic system• Pain pressure thresholds• Cold hyperalgesia• Thermal pain threshold• BMD > 21%• Feature frozen shoulder Slater et al 1995, Muller et al 2000, Ge et al 2006
  • 20. Movement Re-educationMWM• Reinforce ‘normal’ pattern• Tx extension through range• F/Rotation with functional reach Mulligan et al 2006
  • 21. But is it all about stiffness?• Is stiffness the only problem?• Why do we have to keep on treating it?!• Commonly believed that thorax is inherently stable and stiff due to ribcage• Range of motion trunk rotation 6-9 ° per segment
  • 22. Mechanisms• Palpation diagnosis poor reliability• Restoration neurophysiologic motor control due to reduction muscle inhibition• Increase LT and Serratus activation• Hypo-algesic effect• Sympathetic function
  • 23. Finding the primary driver• Failed load transfer• Meaningful task• Scapula• Glenohumeral joint• Kinetic Chain
  • 24. Assessment Considerations• Coupling patterns during arm elevation• Thoracic rotation• What do the ribs do?• Ring dysfunction• Effect of stability correction
  • 25. Assessment of Dysfunction• ? Does it move when during tasks when there should be no inter- segmental movement• Clinical tests to detect loss of ring control• Altered timing between long superficial muscles thorax and deep segmental muscles
  • 26. Assessment of dysfunction• During rotation contra-lateral translation of the ribs• Palpate ribs laterally• Non-optimal strategies; - not translate ‘away’ - move excessively ‘away’ - translate ipsilaterally All = failed load transfer but is this just stiffness? Lee LJ 2008,2012
  • 27. Prone Arm Lift
  • 28. Sitting Arm Lift
  • 29. Victims & Culprits• Fascial considerations• Movement pattern/control• Segmental restriction
  • 30. Subcostal Angle• Reflects length of IAO and EAO• Ideally should be 90°
  • 31. Wide Subcostal Angle• Shortness/stiffness of IAO + RA• Lengthening of EAO• Associated with; - poor abdominal tone/sway back - too many curls!!
  • 32. Narrow Subcostal Angle• Shortness/ stiffness EAO