1. Copyright 2005 Lippincott Williams & Wilkins Chapter 25 The Thoracic Spine

2. Copyright 2005 Lippincott Williams & Wilkins Review of Anatomy Typical Thoracic Vertebrae

3. 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.

4. 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

5. 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.

6. 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.

7. 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.

8. Copyright 2005 Lippincott Williams & Wilkins Typical Thoracic Vertebrae

9. Copyright 2005 Lippincott Williams & Wilkins Atypical Vertebrae (T1, T9, T10) T1  Superior costal facets are circular to articulate with head of 1 st 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 10 th ribs. T10  No inferior costal facets and no direct articulation with the 11 th ribs.

10. Copyright 2005 Lippincott Williams & Wilkins Atypical Vertebrae (T11, T12) T11  Articulates only with heads of 11 th ribs.  Transverse processes are small and do not have articular facets for tubercles of ribs. T12  Possesses only two costal facets for the 12 th ribs.  Body, transverse processes, and inferior facets are similar to lumbar vertebrae.

11. 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

12. Copyright 2005 Lippincott Williams & Wilkins Typical Rib/Costovertebral Joint

13. Copyright 2005 Lippincott Williams & Wilkins Articulations of Rib Cage

14. 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

15. 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.

16. 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.

17. Copyright 2005 Lippincott Williams & Wilkins Pump and Bucket Handle Motions

18. 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

19. 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

20. 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)

21. 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

22. 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.

23. 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.

24. 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.

25. Copyright 2005 Lippincott Williams & Wilkins Scoliosis – 3 Types Lateral curvature of the spine, involving lateral flexion and rotation of the involved region(s). 3 Types: 1.Nonstructural scoliosis 2.Transient structural scoliosis 3.Structural scoliosis (idiopathic accounts for 70–80% of cases of scoliosis)

26. Copyright 2005 Lippincott Williams & Wilkins Patterns of Scoliosis

27. Copyright 2005 Lippincott Williams & Wilkins Vertebrae and Ribs – Thoracic Scoliosis

28. 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!

29. 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.

30. 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

31. 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.

32. Copyright 2005 Lippincott Williams & Wilkins Stretch Lateral Trunk and Intercostal Muscles

33. 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.

34. 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.

35. Copyright 2005 Lippincott Williams & Wilkins 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.

36. Copyright 2005 Lippincott Williams & Wilkins Supportive Taping for Thoracic Spine

37. 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.

38. 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.

39. Copyright 2005 Lippincott Williams & Wilkins Establish Neutral Spine

40. Copyright 2005 Lippincott Williams & Wilkins Establish Improved Movement Patterns

41. Copyright 2005 Lippincott Williams & Wilkins Establish Improved Movement Patterns (cont.)

42. 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.

43. Copyright 2005 Lippincott Williams & Wilkins Segmental/Regional Mobilization

44. 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.

45. 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

46. Copyright 2005 Lippincott Williams & Wilkins Self-Mobilization

47. Copyright 2005 Lippincott Williams & Wilkins Scoliosis Correction of asymmetrical postural habits (prevention during childhood)

48. Copyright 2005 Lippincott Williams & Wilkins Scoliosis Use asymmetric exercises to promote symmetry.

49. 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).

50. Copyright 2005 Lippincott Williams & Wilkins Modified Middle and Lower Trapezius Strengthening for Individuals with Thoracic Lordosis

51. 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).

52. Copyright 2005 Lippincott Williams & Wilkins Exercise to Promote Thoracic Extension

53. Copyright 2005 Lippincott Williams & Wilkins 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.

54. 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.

55. 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!!

56. 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

57. 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

58. 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

59. 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.

60. 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.

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

62. 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.