Thoracic Spine Mobility Drills

The thoracic spine (T-Spine) is an interesting part of the body. In recent times it has taken the brunt of the modern sedentary lifestyle of being hunched over on a chair and working on a computer for hours in a day for many months and years. These  modern sedentary lifestyle changes and new work/office setups have had implications on our musculoskeletal system. What is interesting is that the T-Spine itself presents only with a few symptoms like mid back myofascial pain, stiffness, loss of mobility etc.  However, other joints in proximity of the T-Spine are affected adversely due to this. Here is a list of problems we often see in an physiotherapy office that our closely related to an excessively stiff kyphotic T-Spine.

  1. Shoulder impingement- An excessively kyphotic mid back places the scapula in a downwardly rotated, anteriorly tipping and protracted position. This position of the scapula has shown to decrease the sub acromion space in the shoulder when performing overhead activities leading to a common problem we see often; shoulder impingement/pain. Try this little test, try elevating your arm up to the maximum flexion elevation with a straight Tspine and shoulders pulled down and back and then with an excessive hunched over position. Which one feels better and which is worse? See the video below and try it yourself.
  2.  Neck pain- A kyphotic hunched over posture tips the head (weighing about 10-12 lbs approx.) anteriorly and extends our line of sight downwards to the floor. For compensation, we tilt the head backward which increases Cervical lordosis and causes upper cervical spine to go into extension to have a regular straight field of vision. This causes increase tone/tension in the cervical extensors often compressing the greater occipital nerve and other important cervical structures causing symptoms like neck pain, headaches, radiating symptoms etc.
  3. Low back pain- An excessive kyphotic T-Spine pushes the thorax anteriorly and causes compensatory increase in the lumbar lordosis due to increased tension in the lumbar extensors causing pain at the low back. This is the classic presentation of the ‘Lower Crossed Syndrome’.
  4. Breathing- Along with the above compensation, the thorax lifts up due to inability of the abdominal muscles to provide inferior stabilization (lower ribs flaring) decreasing overall chest expansion and causing poor breathing quality and control.

Furthermore,  if you follow the joint-by- joint model of training by Cook and Boyle, you can see that the thoracic spine is meant to be mobile but has a tendency to get stiff.

So, here our some strategies/exercises we can use to maintain general T-Spine mobility. The angles drawn in the video are not exactly accurate and are used for demonstration purpose only-

  1. Bench/chair thoracic spine extension with stick-
  2. T-Spine extension on foam roller
  3. T-Spine windmill rotation
  4. Cat Cow
  5. Four point T-Spine rotation
  6. Threading the needle

 

Closing thoughts, the mid back is meant to provide mobility but tends to get stiff and excessively kyphotic given our contemporary lifestyles. This can open the floodgates to a myriad of musculo-skeletal problems. It is paramount to keep working on its mobility.

Keep limber

Pursue excellence

Abhijit Minhas

(BPT,MS,CMP,FMT)

My ever evolving thought process on Headaches

I have had a long standing history of suffering from headaches. Since I was little, I have had these bouts of headaches at least once a month, where nothing seemed to help. Nothing except medication. I had been to numerous  doctors and was diagnosed with migraine, tension  and sinus headaches. No matter the diagnosis or the subsequent interventions (I have tried quite a few of them; from different manual therapy techniques working on my trigger points/taut bands at the neck ,to steam inhalation for stubborn sinuses, proper hydration, breathing techniques in a sensory deprived atmosphere, Kinesiology tapes to making dietary changes) the one thing that has provided me relief over the years is, medication. Some of the remedies  have helped me a little but I’d be lying if I said that any of them took my pain away except medication.

As a therapist treating people with headaches I have often found a strong co-relationship between headaches and neck pain. Now for those of us in this profession, this is hardly a breaking news. There is tons of research out there that points out to the fact that a lot of headaches start from the neck and a lot of neck pain symptoms mimic migraine pain. Sure the neck muscles feel stiff and tight and you might find a few trigger points at the upper trapezius, levator scapula, the SCM’s and the other usual suspects. However, the challenge lies in the management of the condition when someone is experiencing an episode of headache.  In my own experience working with patients, when someone walks in my office with a headache, any kind of hands on intervention around the head, neck, TMJ, especially the aggressive kind has yielded me less than favorable outcomes.  I have done this before only to make matters worse and have also been at the receiving end of such treatment interventions. I didn’t like them.

Sticking to the mantra of ‘less is more’ principle as it relates to manual therapy, I have been using a lot of McKenzie treatment principles which has been a game changer for me in managing my own headaches and that of my patients. So now, when I see a patient with headaches, I prefer a more ‘hands off’ approach as I do not want to trigger an already sensitized neuro-muscular system. So instead I do a quick postural assessment and I try to correct what I think are the more common dysfunctional patterns that I have come across in people with cervicogenic headaches. The common pattern resembles our typical upper crossed syndrome pattern of –

  1. Forward head position with increased cervical lordosis and resultant upper cervical spine extension causing compression of important cervical nerve roots and sub cranial dysfunction.
  2. Increased kyphosis of the thoracic spine.

How do I correct them? If the headaches are sever and the patient is highly sensitized, I have them lay down in a supine position with a small pillow under the upper/middle back with no pillows under the head making sure that the chin is in a retracted (tucked in) position.  Now, some of your patients might tolerate this position better than others. For the geriatric population or with people with highly kyphotic, stiff thoracic spine you might want to consider giving them a few pillows under the knees to reduce the tension on the lower back by causing an anterior pelvic tilt (remember, making a person as comfortable as possible helps). Ask them to lay in this position for about 5 minutes. If their symptoms of headache/neck pain seem to subside with this position, chances are that their migraine headaches might be arising due to faulty posture and neck pain. I could and often do classic chin tucks to see if the symptoms subside but again in my experience in the trenches, the less I do, the better. Hence, I regress the chin tucks in a non weight-bearing position and leave them be for a few minutes in a nice quite room. Having your patients do diaphragmatic breathing in this position may be the icing on the cake.

 

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Needless to say, this is not the only method to manage headaches (not to forget there are different types of headaches). However, it is one of the easier ways to do it, very well tolerated by patients compared to the traditional ‘hands-on’ during an acute episode and also a good diagnostic tool to see if the patient will respond well to repeated loading strategies. As the symptoms subside, I’ll start doing some soft tissue work (always gentle, of course) on the hypertonic upper traps, levators and upper cervical muscles etc and follow with exercises. More on that on my subsequent blog on this topic.

I would love to hear your feedback and some of the strategies you use to treat this condition.

 

As always, pursue excellence

Abhijit Minhas

(BPT,MS,CMP,FMT)