Download The Thoracic Spine

Chapter 25
The Thoracic Spine
Copyright 2005 Lippincott Williams & Wilkins
Review of Anatomy
Typical Thoracic Vertebrae
Copyright 2005 Lippincott Williams & Wilkins
Atypical Anatomy
Five of twelve vertebrae are considered
atypical (T1 and T9-T12).
Most apparent difference between thoracic
spine and remainder of the spine are the
twelve ribs and their articulations.
Copyright 2005 Lippincott Williams & Wilkins
Typical Thoracic Vertebrae (T2-T8)
Body and Intervertebral Joint
Ratio of disk:vertebral body height – Less in
thoracic spine than in cervical or lumbar regions.
Ratio of disk diameter:disk height – 2–3 times
higher in thoracic spine than in lumbar spine.
Acute angular orientation of lamellae of anulus
and small nucleus pulposus.
Clinical Significance
Creates stiffness and stability
Copyright 2005 Lippincott Williams & Wilkins
Spinous/Transverse Processes
Slope inferiorly and overlap spinous processes
of adjacent inferior vertebrae.
Limits extension
Facet articulates with tubercle of rib to form
costotransverse joint on ventral aspect.
Restricts motion of rib in rotation about an axis parallel to
and through neck of rib.
Copyright 2005 Lippincott Williams & Wilkins
Transverse Processes
Upper and mid thoracic spine (T1-T6) facet is
concave, corresponding to convex tubercle on
neck of rib.
Facet is planar in lower thoracic region (T7-T10).
Shape of lower thoracic costotransverse joints allows rib
more flexibility during respiration and motion of thorax.
Copyright 2005 Lippincott Williams & Wilkins
Facets
 Orientation of the zygapophyseal joints (ZJ) depends on
the region of the thorax.
ZJ orientation guides and restricts mobility.
 Posterolateral corners of superior and inferior aspects of
vertebral body contain ovoid demifacet (except T1, T11,
and T12).
Development of costovertebral joint delayed until early
adolescence, contributing to flexibility of the
young thorax.
Copyright 2005 Lippincott Williams & Wilkins
Typical Thoracic Vertebrae
Copyright 2005 Lippincott Williams & Wilkins
Atypical Vertebrae (T1, T9, T10)
T1
 Superior costal facets are
circular to articulate with
head of 1st rib.
 Spinous process is
horizontal and is long and
prominent as C7.
T9
 Inferior costal facets are
absent and there is no
direct articulation with the
10th ribs.
T10
 No inferior costal facets
and no direct articulation
with the 11th ribs.
Copyright 2005 Lippincott Williams & Wilkins
Atypical Vertebrae (T11, T12)
T11
Articulates only with
heads of 11th ribs.
Transverse processes
are small and do not
have articular facets
for tubercles of ribs.
T12
Possesses only two
costal facets for the
12th ribs.
Body, transverse
processes, and
inferior facets are
similar to lumbar
vertebrae.
Copyright 2005 Lippincott Williams & Wilkins
Ribs
 Ribs 1–7 – True ribs
 Ribs 8–10 – False ribs
 Ribs 11, 12 – Floating ribs
Rib Functions:
 Protect heart, lungs, and great vessels against trauma
 Provide attachment for skeletal and respiratory muscles
 Facilitate postural alignment and upper extremity
function
Copyright 2005 Lippincott Williams & Wilkins
Typical Rib/Costovertebral Joint
Copyright 2005 Lippincott Williams & Wilkins
Articulations of Rib Cage
Copyright 2005 Lippincott Williams & Wilkins
Kinetics
ROM
 Flexion and extension – More limited in upper
thoracic region (facets lie closer to frontal plane).
Flexion – 20–45 degrees
Extension – 20–45 degrees
 Lateral flexion increases in lower thoracic region.
Lateral flexion 20–40 degrees
Copyright 2005 Lippincott Williams & Wilkins
Kinetics (cont.)
ROM
 Rotation is more limited in lower thoracic region.
Rotation 35–50 degrees in each direction
Lee states:
If lateral flexion in frontal plane occurs first it is
accompanied by contralateral rotation BUT if rotation in
transverse plane occurs first it is accompanied by
ipsilateral rotation.
Lee DG. Manual Therapy for the Thorax – A Biomechanical
Approach. Delta, British Columbia, Canada: DOPC, 1994.
Copyright 2005 Lippincott Williams & Wilkins
Respiration
During Inhalation
Pump handle movement is result of anterior
aspect of rib moving superiorly.
Bucket handle movement is result of lateral
aspect of rib moving superiorly.
During Exhalation
Anterior and lateral aspects of ribs move
inferiorly.
Copyright 2005 Lippincott Williams & Wilkins
Pump and Bucket Handle Motions
Copyright 2005 Lippincott Williams & Wilkins
Myology of Thoracic Spine
Extension
Spinalis capitis,
cervicis, thoracis
Longissimus thoracis
Semispinalis thoracis
Rotatores thoracis
Multifidus
Interspinales
Flexion
Levatores costarum
Rectus abdominis
Internal obliques
External obliques
Copyright 2005 Lippincott Williams & Wilkins
Myology of Thoracic Spine (cont.)
Lateral Flexion
Longissimus thoracis
Iliocostali thoracis
Semispinalis thoracis
Multifidus
Intertransversarii
Levatores costarum
Rotation
Iliocostalis thoracis
Semispinalis thoracis
Rotatores thoracis
Multifidus
Intertransversarii
Internal obliques
External obliques
Levatores costarum
Copyright 2005 Lippincott Williams & Wilkins
Myology of Thoracic Spine (cont.)
Rib Depression
 Longissimus thoracis
 Iliocostalis lumborum
Rib Elevation
 Iliocostalis cervicis
Viscera compression
 Transversus abdominis
Respiration
 Diaphragm (inspiration)
 Intercostals
(inspiration/expiration)
 Rectus abdominis
(expiration)
 Internal/external obliques
(expiration)
 Transversus abdominis
(expiration)
Copyright 2005 Lippincott Williams & Wilkins
Accessory Muscles of Respiration








Inspiration
Levatores costarum
Pectoralis major/minor
Rhomboids
Anterior/medial/posterior
scalenes
Serratus anterior and posterior
superior
Subclavius, SCM
Thoracic erector spinae
Trapezius
Expiration
 Iliocostalis lumborum
 Transversus thoracis
Inspiration/Expiration
 Latissimus dorsi
 Quadratus lumborum
 Serratus posterior inferior
Maintenance of rib cage shape
 Intercostals
Copyright 2005 Lippincott Williams & Wilkins
Anatomic Impairments
Kyphosis
An exaggeration of the normal posterior curve of the
spine.
 Results from change in structure and shape in spine
or posture.
 Fracture of anterior aspect of vertebral body –
Osteoporosis (OP).
 Scheuermann’s disease – Hereditary disorder that
results in kyphosis.
Copyright 2005 Lippincott Williams & Wilkins
Osteoporosis
Low bone density, skeletal fragility, and fracture.
Intervention
 Consult with referring provider to determine if fracture
is stable.
 Pain control – Medications, back braces, and
physical therapy modalities.
 Moderate weight-bearing exercise (e.g., walking).
 Resisted upper extremity exercise.
 Balance training exercises.
Copyright 2005 Lippincott Williams & Wilkins
Scheuermann’s Disease
At least three wedged adjacent vertebral
bodies of five degrees or more.
Intervention
 Usually limited to patients with painful deformity,
painful progression, and at least two years of
growth remaining.
 Manage with bracing until skeletal maturity.
 Strengthen spinal extensors.
 Stretch hamstrings, pectoralis major, superior
rectus abdominus, and anterior longitudinal
ligament.
Copyright 2005 Lippincott Williams & Wilkins
Scoliosis – 3 Types
Lateral curvature of the spine, involving
lateral flexion and rotation of the
involved region(s).
1.
2.
3.
3 Types:
Nonstructural scoliosis
Transient structural scoliosis
Structural scoliosis (idiopathic accounts for
70–80% of cases of scoliosis)
Copyright 2005 Lippincott Williams & Wilkins
Patterns of Scoliosis
Copyright 2005 Lippincott Williams & Wilkins
Vertebrae and Ribs –
Thoracic Scoliosis
Copyright 2005 Lippincott Williams & Wilkins
Examination and Evaluation
 History
 Systems review
 Disorders of other systems can mimic thoracic
pain (i.e., cancer, vascular disease, etc.).
 Skeletal systems review – Scan examination of
both upper and lower quadrants.
 Elderly females with kyphosis screened for OP.
 Individuals with exaggerated thoracic stiffness
screened for ankylosing spondylitis.
Refer to appropriate healthcare
provider when indicated!
Copyright 2005 Lippincott Williams & Wilkins
Tests and Measures
 Aerobic capacity
 Ergonomics and body
mechanics
 Gait, locomotion, balance
 Joint mobility, integrity
 Motor function
 Muscle performance
 Pain tests and disability
measures
 Posture
 ROM and muscle length
 Sensory integrity
 Ventilation, respiration, and
circulation
 Additional medical screening
(radiographs, etc.)
Choice of tests depends
on results of history
and systems review.
Copyright 2005 Lippincott Williams & Wilkins
Therapeutic Exercise for Common
Physiologic Impairments
Impaired Muscle Performance
Sources:
 Neurologic impairment or pathology
 Muscle strain or injury
 Disuse resulting in atrophy and general
deconditioning
 Length-associated changes resulting in
altered length-tension properties
Copyright 2005 Lippincott Williams & Wilkins
Neurologic Impairment or Pathology
Treatment
 Neural input must be restored for muscle performance
to improve.
 Protect weakened muscles from overstretch with
proper support.
 Stretch short muscles to maintain extensibility and
prevent contracture.
 For example: Impaired respiration – Stretch short
muscles and apply manual or elastic band resistance to
facilitate strength.
Copyright 2005 Lippincott Williams & Wilkins
Stretch Lateral Trunk and
Intercostal Muscles
Copyright 2005 Lippincott Williams & Wilkins
Muscle Strain or Injury
Address posture and movement patterns.
Improve performance of underused synergists.
For example, in the case of overuse of anterior
scalene during breathing, reduce anterior
scalene use by improving performance of deep
anterior cervical flexors and instruct in proper
pump and bucket handle diaphragmatic
breathing.
Copyright 2005 Lippincott Williams & Wilkins
Disuse Resulting in Atrophy and
General Deconditioning
Caused by illness, immobilization, sedentary
lifestyle, subtle shifts in muscle balance.
 Progressive resistive exercises for the upper body.
 Initially, weight of limb is ample stimulus.
 Progress in small increments.
 Address balance between abdominal and spinal
extensors as well as thoracic multifidii.
Copyright 2005 Lippincott Williams & Wilkins
Length-Associated Changes
Subtle imbalances in muscle length lead to lengthassociated strength changes and positional weakness of
one synergist compared with agonist or antagonist.
 Strengthen weak overstretched muscle groups in
shortened range.
 Stretch adaptively shortened muscles.
 Supportive taping adjunctive.
 Correction of posture and movement patterns.
Copyright 2005 Lippincott Williams & Wilkins
Supportive Taping for Thoracic Spine
Copyright 2005 Lippincott Williams & Wilkins
Impaired ROM, Muscle Length, and
Joint Mobility/Integrity
Optimal function of the thoracic region requires
full symmetrical cardinal plane motion and full
rib motion.
Consider symmetrical breathing patterns.
Diagnose restrictions that are joint versus soft
tissue origin.
Copyright 2005 Lippincott Williams & Wilkins
Hypermobility
 First, determine contributing impairments.
 Improve muscle balance and stability of trunk musculature (i.e.,
superficial vs. deep, anterior vs. posterior).
 Consider effect of kinematic chain from ground upward (i.e., foot,
ankle, knee, hip, pelvis).
 Improve motor control (e.g., hold spine in ideal alignment during
movements of extremities).
 Improve mobility of adjacent hypomobile segments/regions.
 Prevent thoracic flexion through use of bracing or taping.
Copyright 2005 Lippincott Williams & Wilkins
Establish Neutral Spine
Copyright 2005 Lippincott Williams & Wilkins
Establish Improved Movement Patterns
Copyright 2005 Lippincott Williams & Wilkins
Establish Improved Movement Patterns
(cont.)
Copyright 2005 Lippincott Williams & Wilkins
Hypomobility
First, establish contributing impairments to
hypomobility.
Establish need for joint and/or soft tissue
mobilization.
Include passive stretching, AROM exercise.
Stabilize mobile segments while stretching
hypomobile segments.
Copyright 2005 Lippincott Williams & Wilkins
Segmental/Regional Mobilization
Copyright 2005 Lippincott Williams & Wilkins
Muscle/Myofascial Length
Treatment
Specific soft-tissue mobilization followed by
exercises to maintain new mobility.
Passive stretch with diaphragmatic breathing for
restrictions in oblique abdominal length.
As stability/mobility progresses – Progress to full
arcs of motion.
Copyright 2005 Lippincott Williams & Wilkins
Impaired Posture and Motor Function
Kyphosis
Manual and soft tissue mobilization
Self-mobilization
Manual stretching of pectoralis
major/minor, intercostals, lumbar spine
extensors, shoulder adductors
Tape thoracic spine for feedback
Strengthen thoracic extensors and
cervical spine flexors
Copyright 2005 Lippincott Williams & Wilkins
Self-Mobilization
Copyright 2005 Lippincott Williams & Wilkins
Scoliosis
Correction of asymmetrical postural habits
(prevention during childhood)
Copyright 2005 Lippincott Williams & Wilkins
Scoliosis
Use asymmetric exercises to promote symmetry.
Copyright 2005 Lippincott Williams & Wilkins
Lordosis
Treatment
Improve impairments of shoulder girdle.
Modify traditional exercises to prevent
thoracic extension.
Self-mobilization techniques (promoting
thoracic flexion and rotation).
Copyright 2005 Lippincott Williams & Wilkins
Modified Middle and Lower Trapezius
Strengthening for Individuals with Thoracic
Lordosis
Copyright 2005 Lippincott Williams & Wilkins
Therapeutic Exercise Interventions for
Common Diagnoses
Parkinson’s Disease
Combination of drug therapy and exercise.
Help of caregiver or family member is crucial!
Simple exercises promoting spinal extension
(e.g., forward weight shifting using a ball or
stick).
Copyright 2005 Lippincott Williams & Wilkins
Exercise to Promote Thoracic Extension
Copyright 2005 Lippincott Williams & Wilkins
Management of Scoliosis
In immature spine with curve of 2540°, use of brace 16+ hours a day.
Immature spines with curves 40° +
require spinal fusion.
In the case of brace management,
promote aerobic fitness.
Copyright 2005 Lippincott Williams & Wilkins
Exercise Management of Scoliosis
 Avoid symmetrical and spine flexibility exercises.
 Strengthen overstretched antagonist/synergist in
shortened range.
 Promote strength of the relatively weak muscle or groups
of muscles in the anterior thoracolumbar region and the
pelvic-hip complex.
 Trunk curl exercises or sit-ups are not indicated methods
of strengthening anterior thoracolumbar muscles.
Copyright 2005 Lippincott Williams & Wilkins
Exercise Management of Kyphosis
Consider anatomic impairment and pathology in
addition to related physiologic impairments.
Patient-related instruction is indicated to improve
alignment and avoid positions that contribute to
kyphosis.
Exercise prescription for treatment of kyphosis
needs to go well beyond strengthening of thoracic
erector spinae!!
Copyright 2005 Lippincott Williams & Wilkins
Thoracic Outlet Syndrome
3 Subsets
Type 1: Etiology of compression only
Type 2: Etiology of stretch only
Type 3: Etiology of compression and stretch
Copyright 2005 Lippincott Williams & Wilkins
Thoracic Outlet Syndrome
Treatment – Types 1 & 2
 Correct posture and movement relative to
neurovascular compression or stretching (i.e.,
depressed or anterior tilt scapula)
 Tape scapula into elevation to relieve compression
 Alter sleeping habits
 Improve diaphragmatic breathing
 Address associated physiologic/psychological
impairments
Copyright 2005 Lippincott Williams & Wilkins
Thoracic Outlet Syndrome
Type 3
 Characteristically young, slender women with drooping
shoulders and poor posture
 Treatment aimed at improving muscle performance and
reducing stretch to upper and middle trapezius
 Supportive taping to elevate scapula
 Surgical management may not be effective in patients
whose major symptoms are due to stretching of the
brachial plexus
Copyright 2005 Lippincott Williams & Wilkins
Summary
 Stiffness and stability of thoracic spine is facilitated
by rib cage, disk height, vertebral body height,
orientation of lamellae of anulus, relatively small
nucleus pulposus, and orientation of zygapophyseal
joints.
 Many muscles about the thoracic spine produce
primary movements. Imbalances contribute to
impairments in mobility, posture, and movement.
 Extension is limited in T1-T6 region and increases
inferiorly. Rotation is free in upper thoracic region and
decreases caudally.
Copyright 2005 Lippincott Williams & Wilkins
Summary (cont.)
 During inhalation and exhalation, primary rib
movement is called pump and bucket handle. Both
motions should occur during inhalation and exhalation.
 A comprehensive examination of all patients (history,
systems review, tests, and measures) must be
performed to enable therapist to determine an accurate
diagnosis, prognosis, and interventions.
 When considering therapeutic exercises for thoracic
region, the therapist must consider how neighboring
regions/kinetic chain can affect physiologic function of
the thoracic spine.
Copyright 2005 Lippincott Williams & Wilkins
Summary (cont.)
 Exercises that address respiration, mobility, and
performance of trunk, shoulder girdle, and cervical
muscles are important for optimal thoracic function.
 Thoracic spine function can be improved by treating
the cervical and lumbar spine, shoulder, pelvic-hip
complexes, and foot and ankle.
 Therapeutic exercise may affect the course of nonstructural scoliosis if treated through asymmetric
exercises and movement training.
Copyright 2005 Lippincott Williams & Wilkins
Summary (cont.)
 There are many causes of kyphosis. If
disease is cause, exercise cannot reverse
pathology but may prevent further
exaggeration of kyphosis.
 Exercises may play an important role in
management of Parkinson’s disease.
 Exercise is an important intervention in
the treatment of thoracic outlet syndrome.
Copyright 2005 Lippincott Williams & Wilkins