chapter 25 the thoracic spine

Copyright 2005 Lippincott Williams & Wilkins

Chapter 25The Thoracic Spine


Review of AnatomyTypical Thoracic Vertebrae


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.


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


Spinous/Transverse ProcessesSlope 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.


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.


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.


Typical Thoracic Vertebrae


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.


Atypical Vertebrae (T11, T12)

T11Articulates only with

heads of 11th ribs. Transverse processes

are small and do not have articular facets for tubercles of ribs.

T12Possesses only two

costal facets for the 12th ribs.

Body, transverse processes, and inferior facets are similar to lumbar vertebrae.


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


Typical Rib/Costovertebral Joint


Articulations of Rib Cage


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


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.


Respiration

During InhalationPump handle movement is result of anterior

aspect of rib moving superiorly.Bucket handle movement is result of lateral

aspect of rib moving superiorly.

During ExhalationAnterior and lateral aspects of ribs move

inferiorly.


Pump and Bucket Handle Motions


Myology of Thoracic Spine

ExtensionSpinalis capitis,

cervicis, thoracisLongissimus thoracisSemispinalis thoracisRotatores thoracisMultifidusInterspinales

FlexionLevatores costarumRectus abdominisInternal obliquesExternal obliques


Myology of Thoracic Spine (cont.)

Lateral FlexionLongissimus thoracisIliocostali thoracisSemispinalis thoracisMultifidusIntertransversariiLevatores costarum

RotationIliocostalis thoracisSemispinalis thoracisRotatores thoracisMultifidusIntertransversariiInternal obliquesExternal obliquesLevatores costarum


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)


Accessory Muscles of RespirationInspiration

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


Anatomic ImpairmentsKyphosis

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.


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.


Scheuermann’s DiseaseAt 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.


Scoliosis – 3 Types

Lateral curvature of the spine, involving lateral flexion and rotation of the

involved region(s).

3 Types:1. Nonstructural scoliosis2. Transient structural scoliosis3. Structural scoliosis (idiopathic accounts for

70–80% of cases of scoliosis)


Patterns of Scoliosis


Vertebrae and Ribs – Thoracic Scoliosis


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!


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.


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


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.


Stretch Lateral Trunk and Intercostal Muscles


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.


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.


Length-Associated Changes

Subtle imbalances in muscle length lead to length-associated 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.


Supportive Taping for Thoracic Spine


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.


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.


Establish Neutral Spine


Establish Improved Movement Patterns


Establish Improved Movement Patterns (cont.)


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.


Segmental/Regional Mobilization


Muscle/Myofascial Length

TreatmentSpecific 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.


Impaired Posture and Motor FunctionKyphosis

Manual and soft tissue mobilizationSelf-mobilizationManual stretching of pectoralis

major/minor, intercostals, lumbar spine extensors, shoulder adductors

Tape thoracic spine for feedbackStrengthen thoracic extensors and

cervical spine flexors


Self-Mobilization


Scoliosis Correction of asymmetrical postural habits

(prevention during childhood)


ScoliosisUse asymmetric exercises to promote symmetry.


Lordosis

TreatmentImprove impairments of shoulder girdle.Modify traditional exercises to prevent

thoracic extension.Self-mobilization techniques (promoting

thoracic flexion and rotation).


Modified Middle and Lower Trapezius Strengthening for Individuals with Thoracic

Lordosis


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).


Exercise to Promote Thoracic Extension


Management of Scoliosis

In immature spine with curve of 25-40°, use of brace 16+ hours a day.

Immature spines with curves 40° + require spinal fusion.

In the case of brace management, promote aerobic fitness.


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.


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 kyphosisneeds to go well beyond strengthening of thoracic

erector spinae!!


Thoracic Outlet Syndrome

3 SubsetsType 1: Etiology of compression onlyType 2: Etiology of stretch onlyType 3: Etiology of compression and stretch


Thoracic Outlet SyndromeTreatment – 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


Thoracic Outlet SyndromeType 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


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.


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.


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 non-structural scoliosis if treated through asymmetric exercises and movement training.


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.

chapter 25 the thoracic spine

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