thoracic pain

Simply the Thorax Article

Tanya Bell-Jenje

Better known as the big bit above the abdomen in a beetle, good quality research pertaining to the thoracic spine is in short supply, with most proposed managements and exercises being more prevalent on various social media platforms than in randomized controlled trials. Often described as a ‘Cinderella’ region (Heneghan et al, 2018) due to the sparsity of research compared to other regions of the spine, astute clinicians are realizing that this area has been under-explored and may be a silent contributor to various clinical presentations, both proximal and distal as well as visceral and neural.

13 joints per thoracic ring, 136 joints overall and 112 muscle attachments demand the Physiotherapists attention. Stiffness of the thorax restricts rotation, respiration, cervical and shoulder motion and so is implicated in injuries or dysfunctions elsewhere in the system. This ‘slinky shock absorber’ (LJ Lee, 2008) is integral in the transference of forces & loads to & from the limbs & pelvis. The thoracic spine is closely related to the autonomic nervous system which can present with various complex symptoms related to sympathetic deregulation.  The thorax also houses the lungs, pericardium and mediastinum and the intercostal nerves supply many of these regions as well as pass into the abdominal cavity, resulting in pain in the thoracic spine sometimes masquerading as local musculo-skeletal pathology when in fact the pain is referred from a visceral or more sinister source.

Various studies propose that approximately 13% of your patients with spinal pain will be of thoracic origin & 40% of your patients presenting with either neck or low back pain will have an associated thoracic pathology (Roquelaure et al, 2014), justifying more attention from the treating clinician.

Nonetheless, understanding, managing, and treating the thorax should not be hard or complicated, but rather simply integrated into your overall assessment of the system. A knowledge of the surface anatomy, especially the anatomy of the ribs and their underlying structures is very helpful in both diagnosing as well as specifically treating. Using rib angles to specifically mobilise other areas of a thoracic ring can be very relieving. Using asymmetrical exercises can be effective in improving overall thoracic mobility which can improve both load transference to the limbs as well as respiration and optimal use of the diaphragm. Best treatment outcomes are from a combination of manual therapy with prescriptive rehabilitation & exercise that either stretches, mobilises, stabilises, or strengthens the thoracic unit. The thorax should not simply be considered as ‘stiff’, but similar to all other regions in the kinetic chain, can be dysfunctional due to a hypermobility (‘Give’) in a certain direction, or a lack of intersegmental motor control. This is logical as the muscles that provide intersegmental control of the neutral zone in the lumbar and cervical spines also traverse the thorax.

The 2 hour online webinar that accompanies this blog, aims, simply, to review the thoracic pathologies as well as functional biomechanics of the thorax in a clinically applied manner. Assessment tips, treatment options & rehabilitation will also be covered. Videos of myself exploring the surface anatomy, assessing, and treating the thorax are included to help you learn effectively.  I look forward to exploring this under-described, yet crucial anatomical region with you.

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