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Thorax

The lord of the rings

Introduction

The ribcage makes up a disproportionately large area of the spine, is responsible for the majority of the rotation in the spine, houses the lymphatics, sympathetic nervous system and diaphragm. As well as protecting important organs, it is also covered by many layers of muscles, myofascia, visceral membranes and pleura, and has the shoulder blades and neck stabilising upon it. The abdominal muscles and diaphragm cross the lower 6 ribs, as do the erector spinae lumborum. Additionally, the latissimus dorsi spans the shoulder, thorax and continues onto the pelvis, as do the previously mentioned muscle slings. The upper half of the thorax has a similar complexity of muscle slings, crossing the neck, up to the head. Hence, large expanses of the body are muscularly and neurophysiologically linked to the thorax. Many traditional exercise therapies, such as Yoga, pay a significant amount of emphasis on thoracic movement.

stack-dinner-plates 

The thoracic rings can be likened to 'dinner plates'. When they are stacked on top of one another the plates are stable and each 'plate' can be turned without affecting the stability. However, when the 'plates' are slightly malaligned the stack comes crashing down. With thoracic rings, when they become malaligned, the muscles around the trunk tighten up to prevent further movement. This in turn affects diaphragmatic movement and the normal 'ebb and flow' of the breath of life. The reduced 'ebb and flow' as well as the sideways shifts of the ribs reduces the normal pressure movements within the sympathetic ganglia during breathing, resulting in potential sympathetic nervous system dysfunctions. This can lead to heightened background muscle tension and vasoconstriction of the blood vessels as well as potential changes in sudomotor (sweating) function. Additionally, shallowness of breath can lead to hyperventilation (high respiratory rate, low tidal volume) resulting in respiratory alkalosis and metabolic acidosis. Metabolic acidosis leads to further sympathetic nervous system hypersensitivity. It is important to recognise that hypermobility can lead to ring shifts which then, paradoxically, lead to muscle tension and increased stiffness.

stackPlatessquewwif

Besides looking upon the ribcage as a stack of dinner plates, another analogy would be to consider the 'rings' as a spring, much like a 'slinky'. Importantly, examining the rings as springs means that they hold an important shock absorbing function with 'damping' and oscillating properties.

slinky dog 

Assessment

Assessment involves identification of the thoracic ring shifts and examination of the thoracic range of movement. An attempt should be made to correct the ring shifts and assess the effects on the range of movement. Lateral diaphragmatic breathing, active straight leg raise and active leg extension should also be assessed before and after ring shift corrections. Once the rings are 'racked and stacked' an exercise regime can be commenced to maintain the ring positions.

Patients frequently seek treatment for pain in various parts of the body, but infrequently present for treatment of thoracic pain. Yet, simple, quick assessment and correction of the thoracic rings frequently demonstrates a link to the pain and musculoskeletal dysfunction in areas some distance away. Wainner et al (J orthop Sports Phys Ther, 2007; 37, 658-660) describe regional interdependence as “the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint.” This perception suggests that interventions targeting adjacent anatomical areas may directly affect the outcomes of the involved joint. Boyles et al (Manual Therapy, 2009 Aug;14(4):375-80) and Strunce et al (J Man Manip Ther, 2009, 17(4): 230-236) have demonstrated the immediate effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. The latter describing  a 51% reduction in shoulder pain, 30-38 degree increase in range of motion (ROM), and a mean patient perceived global rating change of 4.2 in 21 subjects. McCormack (J Man Manip Ther., 2012 Feb;20(1):28-34) showed a 25 degree improvement in shoulder ROM when using thoracic spine manipulation in the treatment of adhesive capsulitis. Brian Mulligan described 'mobilisation with movement' (MWM) techniques on the first rib which have dramatic effects on the cervical ROM for contralateral lateral flexion and ipsilateral rotation. Canadian physiotherapist Linda Joy Lee has advocated ring shift corrections for low back pain, pelvic girdle pain and hip problems, as well as shoulder and neck issues.

Lateral diaphragmatic breathing

Assessment of breathing patterns are vital in establishing the nature of dysfunction. Are they shallow breathers tending to hyperventilation and metabolic acidosis? Where in their chest do they breath? Do they feel that their stomach always sticks out and they find that it is very difficult to develop muscle tone in the abdominal muscles? Remember all the abdominal muscles attach to the lower 6 ribs. Conscious amelioration of breathing patterns has the benefit of creating an exercise every 12-20 breaths when it becomes 'habit forming' and residing in the subconscious.


lateral diaphragmatic breathing

Assessment of leg muscle strength with ring relocations

Active Straight Leg Raising (ASLR) with and without thoracic ring relocations can provide invaluable information on the effect of the thorax on the engagement of the muscles in the lower limb and the transfer of forces across the pelvis. Ideally, the strength improves and the pelvis doesn't rotate when the ring shifts are corrected

 Active Leg Extension (ALE) can also be tested through thoracic ring relocations and retesting the ROM and strength of the subsequent ALE. Guteal and hamstring activation should occur at the same time or the gluteals come on a little earlier. Furthermore, ideally the lumber spine doesn't hyperextend or go into excessive rotation.

Hip stabilisation and thoracic mobilisation

 

Several exercises exist which stabilise the hip and shoulders whilst mobilising the thorax.

 

Swiss Ball exercises can also be used to improve thoracic ring stability

Thoracic strengthening

Thoracic stregthening regimes should be instigated to maintain the ring alignment

Stretching regimes

iliopsoasQLhamstringstretch

Many people stretch their limb muscles. However, if the thorax is the 'driver' of limb muscle tension, then the thorax needs to be nullified beforehand and/or involved in the process of stretching. For example both hamstrings and quadriceps can be stretched with lateral flexion and lateral breathing of the diaphragm. Classic moves out of yoga such as the 'down dog -> warrior pose -> triangle' can involve rib cage movements.

yoga-triangle-pose

Conclusion

At Back in Business Physiotherapy we routinely examine the thorax and devise exericise regimes involving the thorax for almost any condition in the body. Regardless whether the thorax is symptomatic or not, we should always consider the beneficial effects of thoracic movement for the organs, lungs, and sympathetic nervous system. Hands on treatment should include soft tissue techniques such as myofascial releases, dry needling, joint mobilisations and manipulations, taping, muscle energy techniques, specific 'hands on' biofeedback for movement and specific muscle activation.

Martin Krause

Uploaded : 2 March 2014


 

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    Ehlers Danlos Syndrome

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Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducable; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized liagmentous laxity by exhibiting hyperextension of both elbows > 10o, genu recurvatum of both knees > 19o, and the ability to touch his thumbto his forearm Headaches Jacome (1999, Cephalagia, 19, 791-796) reported that migraine headaches occured in 11/18 patients with EDS. Hakim et al (2004, Rheumatology, 43, 1194-1195) found 40% of 170 patients with EDS-HT/JHS had previously been diagnosed with migraine compared with 20% of the control population. in addition, the frequency of migraine attacks was 1.7 times increased and the headache related disability was 3.0 times greater in migraineurs with EDS-HT/JHS as compared to controls with migraine (Bendick et al 2011, Cephalgia, 31, 603-613). People suffering from soft tissue hypermobility, connective tissue disorder, Marfans Syndrome, and Ehler Danlos syndrome may be predisposed to upper cervical spine instability. Dural laxity, vascular irregularities and ligamentous laxity with or without Arnold Chiari Malformations may be accompanied by symptoms of intracranial hypotension, POTS (postural orthostatic tachycardia syndrome), dysautonomia, suboccipital "Coat Hanger" headaches (Martin & Neilson 2014 Headaches, September, 1403-1411). Scoliosis and spondylolisthesis occurs in 63% and 6-15% of patients with Marfans syndrome repsectively (Sponseller et al 1995, JBJS Am, 77, 867-876). These manifestations need to be borne in mind as not all upper cervical spine instabilities are the result of trauma. Clinically, serious neurological complications can arise in the presence of upper cervical spine instability, including a stroke or even death. 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Updated : 10 May 2014

No responsibility is assumed by Back in Business Physiotherapy for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material in this and it's related websites. Because of rapid advances in the medical sciences, the author recommends that there should be independent verification of diagnoses and exercise prescription. The information provided on Back in Business Physiotherapy is designed to support, not replace, the relationship that exists between a patient/site visitor and their treating health professional.

Copyright Martin Krause 1999 - material is presented as a free educational resource however all intellectual property rights should be acknowledged and respected