Thoracic Manual Techniques and Exercises

Original Editor - Lucinda hampton Top Contributors - Lucinda hampton and Kim Jackson

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.

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  • 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.[1]
  • 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. Thoracic manip.JPG
    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.[2]

Range of Options - Manual Therapy Thoracic Spine

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As therapists we are trained in a multitude of techniques - chooseing the appropriate ones are usually to do with your expertise and choice. The following have great site links for detailed information.

  • Joint Manipulation: A passive, high velocity, low amplitude thrust applied to a joint complex within its anatomical limit* with the intent to restore optimal motion, function, and/ or to reduce pain.[4]
  • Joint Mobilisation: A manual therapy technique comprising a continuum of skilled passive movements to the joint complex that are applied at varying speeds and amplitudes, that may include a small-amplitude/ high velocity therapeutic movement (manipulation) with the intent to restore optimal motion, function, and/ or to reduce pain.[4]

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[5]. ​
  • They are often used in Physiotherapy management in order to produce mechanical and neurophysiological effects[5].

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.
[6] This 4 minute video is a demonstration of a reverse NAG for thoracic spine using the Mulligan concept (MWM).
[7] This video is of mid thoracic Maitland PA mobilisation (5 minutes).
[8]

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.[9]
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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

[10]

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

Exercises - home exercise program

A good way to help clients to combat a painful/stiff upper back is to make an appropriate home exercise program (HEP) ie the right stretching and strengthening routine. Be sure to read this link to help get better adherence to a HEP

Scheuermann's Kyphosis Pectoral Stretch.jpg

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

Cow -Cat stretch

To perform: Begin in quadruped (hands and knees) with knees under hips and hands under shoulders. Inhale as you move your sit bones up towards the ceiling, arching the back and pressing the chest towards the floor as you lift the head up. Relaxing the shoulder blades behind you. From there, inhale as you move from this “cow” position to an angry “cat” position, rounding out your back and pushing shoulder blades away from you as your spine forms a “C” curve in the opposite direction. Go through this cycle 10 times.

Open Book

This stretch is a great way to improve rotation in the thoracic spine.

Begin by lying on your left side with knees bent and arms straight out in front of you, palms touching. Gently lift your right hand straight up off of the left hand, opening up the arm like it’s a book or door while following the top hand with your head and eyes until your right hand is on the other side of your body, palm up, with your head and eyes turned towards the right. Hold this stretch for a few breaths before returning to the starting position with palms facing each other. Repeat up to 10 times on each side.

Thoracic extension over Foam Roller

If using a foam roller, place the foam roller perpendicular to torso. Sit in front of the foam roller, and gently hammock the head with your hands, interlocking the fingers and supporting the weight of your head without pulling it.

Lean backwards so that your upper back is reaching backwards over the foam roller. Gently allow your shoulders to reach towards the floor while the foam roller supports your upper back. Carefully lift the hips to roll up and down the muscles of the upper back or move the foam roller up and inch after each stretch, leaning backwards over the roller until a gentle stretch is felt. Repeat several times, without forcing your body into discomfort. This stretch can be very intense, so start with small movement and don’t spend more than a couple minutes in this position.

Doorway Stretch (Pec stretch)

Use the walls of a standard doorway to stretch out the pecs.

Bring each forearm up against one side of the doorway. Gently lean forward through the doorway keeping the arms on one side to stretch out the chest. Hold for 30 seconds.[11]

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]

Education - Postural training and Body mechanics

  • Kyphosis Degenerative.png
    The complications of poor posture include back pain, spinal dysfunction, joint degeneration and rounded shoulders.
  • Suggestions to improve posture include regular exercise and stretching, ergonomic furniture and paying attention to the way the body feels.
  • It is is important that the patient understands his problem and the cause of his problem. Postural education and training is an important aspect of treatment.

Postural awareness training steps:

  • Explaining the patient what the problematic posture is
  • Demonstrating correct posture, explaining every motion that should be made:
  • Belly button in & down (soft contraction)
  • Knees slightly bent
  • Shoulders back ie scapular retraction, it can help to do external rotation in the shoulder to accompany this motion
  • Chest up
  • Chin slightly tucked in
  • Have the patient try this him/herself, the first time still going over every cue. Once the patient has practiced the posture a sufficient amount of times to immediately be able to resume good posture on command, taping and random reminders (timer) can be used to ensure the posture is kept during the day.

The training of all the postural muscles is important to assure the stability of the spine.  Training of the postural muscles can be achieved by eg.balance training

  • a balance exercise example, Single leg stance - 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)

see also: Thoracic Hyperkyphosis, Sway Back Posture, Posture; Forward Head Posture.

Concluding Remarks

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Because pain in the thoracic region is often caused by muscle tension and poor posture, initial treatment efforts focus on relieving the tension with

  1. Physical therapy - using some of the techniques given above eg. home exercises that stretch and strengthen the back, shoulder and stomach muscles, massage, postural education, joint mobilisations, heat and/or ice therapy etc.

2. Over-the-counter medications such as acetaminophen or ibuprofen.

The majority of clients usually will improve with these measures

References

  1. Lifecare North sports Clinic Thoracic spine Available from: https://www.lifecare.com.au/clinic/northern-sports-physiotherapy-clinic/news/thoracic-spine/ (last accessed 16.4.2020)
  2. Johnson KD, Grindstaff TL. Thoracic region self-mobilization: a clinical suggestion. International journal of sports physical therapy. 2012 Apr;7(2):252.Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3325630/ (last accessed 16.4.2020)
  3. George, J.W., Tunstall, A.C., Tepe, R.E. and Skaggs, C.D., 2006. The effects of active release technique on hamstring flexibility: a pilot study. Journal of manipulative and physiological therapeutics29(3), pp.224-227. Available from: https://www.sciencedirect.com/science/article/pii/S0161475406000376
  4. 4.0 4.1 Mintken PE, et al. A Model for Standardizing Manipulation Terminology in Physical Therapy Practice. J Orthop Sports Phys Ther 2008;38(3):A1-A6.
  5. 5.0 5.1 Edmond S. Joint Mobilization/Manipulation - E-Book. 3rd ed. Elsevier Health Sciences.​; 2016.
  6. Upper thoracic functional mobilization. Available from: https://www.youtube.com/watch?v=ZMThXJf6mrE
  7. Thoracic Spine mobilization. Reverse Nag. Mulligan Mobilization with movement Technique MWM. Available from: https://www.youtube.com/watch?v=A8juGfCJOcc
  8. Mid Thoracic Spine PA Manipulation. Available from: https://www.youtube.com/watch?v=PpsxLSn3sQo
  9. Puentedura EJ, O'Grady WH. Safety of thrust joint manipulation in the thoracic spine: a systematic review. J Man Manip Ther 2015;23:154-161.
  10. Thoracic Spine Mobility Exercises with Dr. Steven Horwitz, Dallas, Texas Available from:https://www.youtube.com/watch?v=GlU_o5zWd8Q (last accessed 16.4.2020)
  11. Mens Health Stretches to relieve back pain Available from: https://www.menshealth.com/fitness/a25616194/upper-back-stretches/ (last accessed 17.4.2020)