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Sue Falsone – Thoracic spine

This is an excerpt from Sue Falsone’s lecture, The Thoracic Spine.

Everybody is big into core stability and core programming and obviously the lumbar spine with low back pain is a huge issue in our society today. When we look at the lumbar spine, we have these big buzz words—core stability, the core. When we start to look at all of the things that attach to the lumbar spine, we’ve got the thoracic spine. We’ve got the hips, the iliosacral joint, the sacroiliac joint, the diaphragm. These are all things we’re going to talk about—but the diaphragm and the thoracic spine more specifically today.

When we look at the lumbar spine, we see how it needs stability in order to really give us a pillar of stability so our arms and our legs can work and create power. Our hips need to have a lot of mobility and we’re all, from a clinical standpoint, well aware of how much hip mobility we need. We tend to look down and know along with our lumbar stability, we need a lot of hip mobility, but we have to look up as well—not to mention the physiology and the psychology that comes along as people deal with low back pain.

Sometimes people are too freaked out to move their lumbar spine or to do anything with their back because they’ve been in back pain for so long. There are a lot of psychological issues that come along with that, so often if you start to work on people’s thoracic spine and their hips, totally stay away from the lumbar spine while they physiologically calm down a bit. They are so hypersensitive to what is going on at the lumbar spine that if you hit above and below and do some pain-free things that make them feel good, all of a sudden you have opened them up psychologically and physiologically to address the problem at the lumbar spine more specifically. It really sort of all ties together. When we look at the thoracic anatomy, it’s a kyphotic curve. When we’re born, obviously a baby is curled up into this little ball and has what’s called a primary curve. The primary curve is our kyphosis. We know in the cervical spine we have lordosis—our thoracic spine is a kyphosis.

Our lumbar spine goes down into lordosis and then our sacral area is more in a kyphosis. When we’re born, we’re all sort of curled up into this little ball. Those kyphoses are our primary curves. That’s what we are born with. It’s not until we start to look up to we see something shiny or we can’t see Mom anymore and we’re looking for her that the head starts to pick up. We start to turn the head and gain the ability to roll over. As we start to use those extensor muscles, our cervical and lumbar lordoses come into play—those are called our secondary curves. Our primary curves are our kyphoses. Our secondary curves are lordoses. It’s natural to have a kyphotic thoracic spine and a lordotic lumbar spine. It’s not that you don’t want those things; those are the natural curves of the spine. Some people tend to have a bigger kyphosis or a bigger lordosis than others and that’s okay. It’s just wherever their neutral spine is, but be aware there is that natural sort of curve to the spine and why it’s there.

When we look at the vertebrae of the cervical, thoracic and lumbar spine, we see they are shaped very differently because they have very different requirements in the body. When we look at the cervical spine, we can see the anterior part of the cervical spine and the posterior part. This is the spinous process, and you can see how that spinous process is very much toward the horizontal.  The vertebral body is not very big. It doesn’t have a lot going on from a weight-bearing standpoint. You can see the facet joints are really oriented in the transverse plane. This is why the cervical spine is such a good part of the spine for rotation, because these facets are really oriented in the transverse plane and the vertebral body is not very big. When we look down into the thoracic spine, the vertebral body starts to get a little bit bigger. It starts to support more of the weight of the body. If we look farther down, all of a sudden the spinous process becomes very long. It is no longer toward the horizontal. It’s going downward a little bit. These lower facet joints are oriented a little bit in the transverse plane, but not as much as in the cervical spine.

The way the facet joints are set up in the thoracic spine are good for rotation, but lower down they start to move into the frontal plane as well, making it very good for flexion and extension as well as some rotation. When we go down into the lumbar spine, it has a very, very big vertebral body, because the majority of the spine is sitting on top of it and it requires a lot of weight bearing there. The spinous process becomes a little bit more stumpy and starts to move back up toward the horizontal. As far as the facet joint goes, we can’t really see the facet joints very much, because what really starts to happen is they start to orient themselves in the sagittal plane. The sagittal plane is really good for flexion and extension. You can see how the facet joints of the lumbar spine compared to the thoracic spine, compared to the cervical spine—each section really has a difference in what it is able to do. The cervical spine is really built for a lot of rotation.  The thoracic spine is in all three planes—transverse, coronal and sagittal—so it can do a good job as far as rotation, flexion and extension as well as side-bending. When we get down to the lumbar spine, it is really built for flexion and extension and really not for other things. Now, keep in mind there is that ‘oh my gosh, we don’t want the lumbar spine to rotate’ idea going now. It’s not that we don’t want the lumbar spine to rotate. We do want it to rotate, but not as a compensatory movement pattern to what the thoracic spine and the hips cannot do. When you think about the rotation and the osteokinematics at each section, they are each going to have about two degrees of rotation.

With the thoracic spine, there are 12 thoracic vertebrae, and with two degrees of rotation at each, this is going to be 24 degrees of rotation, whereas in the lumbar spine there are not that many vertebrae. The thoracic spine is going to be a better rotator than the lumbar spine.

We look at the ribs and look at the orientation of the rib onto the transverse process, called the costotransverse joint. Then it also has a second connection to the vertebral body of the thoracic spine, which is the costovertebral joint. There are a lot of joints here. We have this vertebrae connected to the vertebrae above and below. We’ve got two connections to the rib—there is just a lot going on here. You can get a lack of mobility between the vertebrae. You can get a lack of mobility at the transverse spine. If someone’s thoracic spine gets “locked up,” for lack of a better phrase, they have to find mobility from somewhere else, to get it from the lumbar spine. This ends up being why we have so many issues with the lumbar spine and low back pain. As we discussed, the lumbar spine is not really set up for rotation and side-bending as much as the thoracic spine, which really can lead to a lot of issues when we start asking the lumbar spine to do a job it was never meant to do. This places a lot of stress on the discs; it places a lot of stress at the facet joints. If you can restore the mobility up at the rib and at the thoracic vertebrae, you will be doing the lumbar spine a huge service.

The thoracic spine is oriented in all three planes—in the transverse, the sagittal and the coronal plane—so it can do rotation, flexion and extension as well as side-bending. Even though the vertebrae are set up for side-bending, the connection between the rib and the vertebrae blocks that side-bending, meaning there isn’t a lot of side-bending at the thoracic spine. This is not because the vertebrae cannot handle it, but because of the connection between the rib and the vertebrae. As we start to look at rib mobility during breathing, we have really two different directions. One is a sort of lateral movement, sometimes described as a pump handle. If you think about taking a deep breath in, those ribs are going to be moving a little bit laterally. They are going to be moving really anterior posteriorly like a pump handle. As you take in a deep breath, the rib is going to elevate itself up and back down, so these ribs need to have mobility to them. They need to be able to spin and the connection at the costotransverse and the costovertebral joints need to have a little bit of mobility.

Basically what happens is the rib spins within those joints in order to create some mobility as we breathe—that happens in the anterior posterior direction and it happens in the lateral direction. When we look at the lower ribs, these are what we call bucket handle movements. If you had a bucket with two handles, that’s exactly what happens as we take in a deep breath.

The ribs really need to move anterior and posterior as well as laterally. These ribs need to have a lot of mobility as we’re breathing, and this is really going to affect the mobility between the rib and the vertebrae, which in essence is going to affect how the one vertebrae of the thoracic spine is moving on the other. Rib mobility is going to be really important to general thoracic mobility as well. To get back to the osteokinematics, when we look at the thoracic spine and how those facet joints are oriented, it’s set up for flexion and extension, and it’s set up for rotation. Again, there are about two degrees of rotation at each thoracic segment. There are 12 thoracic vertebrae, times two degrees, meaning about 24 degrees of total rotation at the thoracic spine. When we look at the lumbar spine, we see the same thing, about two degrees of rotation at each lumbar vertebra and maybe three to five at the L5-S1 area. Let’s just say two degrees, knowing there is going to be a couple of additional degrees down there at L5-S1. There is five lumbar vertebrae times two, so 10 degrees. Add a couple more degrees for L5-S1 and we have about 10-12 degrees of rotation at the lumbar spine. It is not that there isn’t rotation there; there just isn’t a lot of rotation.

When we compare that to the thoracic spine, the thoracic spine has the ability to do double the rotation of the lumbar spine. Again, it’s not that we don’t want the lumbar spine to rotate, but that it just wasn’t built for rotation. The thoracic spine has double the rotation. When we think about what happens at the hips from a book standpoint, if we have 45 degrees of external rotation and internal rotation, that’s 90 degrees of rotation at the hips. As we look at this unit—the thoracic spine, the lumbar spine and the hips—the hips have a ton of rotation. The thoracic spine has a ton of rotation. The lumbar spine does not have a lot of rotation, and that’s why we don’t want to emphasize or force lumbar rotation. We just want it to have as much rotation as is needed in that chain, with the majority of the rotation coming from the hips and the thoracic spine. Again, the thoracic spine is good for side-bending, but it’s really limited by the ribs.

You can picture as somebody is side-bending how the ribs sort of approximate. If somebody is side-bending to the right, the ribs are going to approximate to the right, so the ribs are going to be a limiting factor in side-bending at the thoracic spine. As we look at associated osteokinematics, go ahead and try these movements so you can get a feel for what I am talking about here. If you take your arms and raise them up—both of them, raise them up above your head—you can feel how you need to have a little bit of thoracic extension in order to really do that. The same thing if you take both of your arms and move them behind you and go in a bilateral shoulder extension—you need to have some thoracic extension in order to do that. Now if you take one arm…take your right hand and put it behind your head so you are in a position of flexion and external rotation. This requires extension—thoracic extension—and ipsilateral rotation. If you take your right hand and put it behind your head, you need thoracic extension and right rotation. Now if you take that same right hand and put it behind your back as if you were getting arrested, it requires thoracic flexion and contralateral rotation. If it’s the right hand going behind your back, you need thoracic flexion and you are going to have left rotation. Take your arms through those motions and feel how you need to have that appropriate mobility.

If you’re using the Functional Movement Screen looking at a shoulder mobility test and score a ‘1’ in shoulder mobility, but when reviewing glenohumeral joint motion in a lying position you see normal rotation, whether it’s 90 degrees of external rotation and then 40 degrees of internal rotation at a 90-90 position when someone is supine—if there’s full glenohumeral joint motion but the person gets a ‘1’ on the Functional Movement Screen in the shoulder mobility test, it is not coming from the glenohumeral joint. It is coming from the thoracic spine. If you work on improving glenohumeral joint rotation, that score on the Functional Movement Screen very well may not change because that person needs thoracic mobility. You need to provide these associated osteokinematics in order to restore mobility.

If you restore mobility at the thoracic spine, all of the sudden shoulder mobility seems to improve because these movements are so closely related. When you’re dealing with someone’s shoulder issues, you have to look at thoracic spine mobility. This ties into everything above and below. It’s definitely an area that gets ignored, but once you start addressing it, you are going to see some really cool changes in the programming of your shoulder patients or shoulder clients and clients who have low back pain.

Here’s a link to the rest of her The Thoracic Spine lecture, and here’s a link to all of Sue’s OTP products.