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 Pathology
Posture
• 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.
10. 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
12. Effectiveness Thoracic
Manipulation
Boyles et al 2009
• Tx spine V
• 56 pts with SAIS
• SPADI, Pain Scale, Neer, Empty can,
Abd
• 48 hours all sig increase /decrease
13. Thoracic spine
Stunce 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
14. 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
15. Thoracic Manipulation
• Most studies consider combined with
other manual therapy
• But ? this makes sense……
Michener et al 2012
16. 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
17. • Long global muscles have specific fascicles of
attachment
• Oscillatory mobilisations change afferent
input
• Change muscle resting tone
20. Sympathetic System
Sympathetic 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
22. 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
23. Mechanisms
• Palpation diagnosis poor reliability
• Restoration neurophysiologic motor control due to
reduction muscle inhibition
• Increase LT and Serratus activation
• Hypo-algesic effect
• Sympathetic function
24. Finding the primary driver
• Failed load transfer
• Meaningful task
• Scapula
• Glenohumeral joint
• Kinetic Chain
25. Assessment Considerations
• Coupling patterns
during arm elevation
• Thoracic rotation
• What do the ribs do?
• Ring dysfunction
• Effect of stability
correction
26. 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
27. 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
