Thoracic Mobility

Part 3: Corrective Exercises

There are tons of ways to address thoracic mobility or stability, and below are just a handful of options that I have come into contact with. Don’t try to use all of them every day -- instead try a few of them and find out what works for you and/or your clients/patients. One corrective might work great for a certain individual, but might not do anything for the next person. Look for improvements, and if they are not occurring try something else.

Mobility Correctives

I will list these exercises from what I feel are the most basic to what are more advanced variations. With all mobility correctives the hip will be flexed to or above 90 degrees on the side to which rotation is occurring, and with some exercises both hips will be flexed. Once again, this locks the lumbar spine into position so movement must come from the thoracic spine. A packed neck is an important part of all these exercises. This is also called a “chin tuck,” and in specific terms is a combination of cervical extension with capital flexion. If you are unfamiliar with this movement check out this article: http://charlieweingroff.com/2010/11/packing-in-the-neck/. Breathing must also be addressed. Don’t hold your breath during these exercises: relax and try to use deep diaphragmatic breathing. Movement proficiency can be demonstrated by attempting to cycle a deep breath at the end ranges of rotation with these exercises. If you are unable to hold the end position while cycling a breath, there is still some work to be done.

These first two primarily address thoracic extension limitations and are great for improving posture.

"Peanut" Crunches

This drill uses two tennis balls taped together making a “peanut”. Start by finding your bottom set of ribs, then place the ball just above that so one half rests on either side of the spine. Use a small mini-crunch movement and return your head to the floor after every mini-crunch. Hands should come forward at a 45 degree angle. Perform around 5 or so crunches, and then slide down about a half roll and work your way up to about the level of your shoulders. Stay out of the cervical and lumbar areas; this is not what is trying to be targeted.

Roller Crunches

This is a similar exercise to the peanut crunch if all you have is a roller. I like using the peanut better, though, as many people tend to use too much lumbar extension when performing this drill. You must concentrate on getting the motion from the thoracic spine while keeping the lower back stable.

        The next series of corrective exercises are performed in the side-lying position. This position minimizes stability requirements as gravity does much of the work to drive the rotation. Leg position can be varied in any of these drills as long as the hip is on the side to which rotation is occuring is flexed above 90 degrees. In addition the bottom arm can be place straight out, overhead, or used to hold the top knee in place. The first time the exercise is performed, gently placing your hands on the shoulder and guiding the patient/client through the movement is a great teaching tool. The PNF principle of Oral-Facial drivers can be used as cues. The eyes should drive the movement, cue this by telling the patient/client to "look into your ear." Also, cue them to push the tongue into the side of their cheeck toward the side of rotation. This may seem strange at first, by give it a try -- it works. Cue also to "exhale as you turn" to get more motion.

Rib Roll

Grab around your ribcage and attempt to pull your ribs up and over as you rotate.

The next two exercises should be used in cases where the client/patient also has deficits in glenohumeral external rotation. That is where the Active Extension Rotation (ER) assessment was limited and the Active Extension Rotation (IR) assessment was normal.  The thoracic rotation should drive the scapular retraction and depression, which in turn should drive glenohumeral external rotation. The eyes and the head should follow the hand with both drills as well.

Side-Lying Extension Rotation

This exercise uses the PNF priciples of diagonal  movement patterns crossing the midline of the body. 

Side-Lying Windmill

Kettlebell Variations

Here are a couple of unique kettelbell drills from Joe Bonyai -- make sure you check out the corresponding article for these drills at http://empower-ade.com/2011/06/kettlebell-exercises-that-i-do-not-use/.

These next two are seated exercises requiring a mix of stability and mobilty in order to complete. The chair might work better for a lot of people if just getting into the cross-legged position provides too much of a challenge for them, or if they belong to the older population.

Seated Rotation

Seated Rotation - Lateral Flexion

The following exercises use the quadruped position requiring a mix of mobilty and stabilty as the movement becomes resisted by gravity. The first takes the shoulder complex out of the picture, and the second adds it in to make the exercise slightly more involved. There are a couple of cool PNF tricks to try with these exercises that will help the person get some extra rotation if they are struggling with the movement. The first would be to just put a foam roller or ball between the knees and have the patient/client squeeze the ball as the exercise is performed. The second would be to have them make sure the bottom hand is flat on the ground, fingers sligtly spread, and then for them to squeeze their fingers together and resist you as the movement is performed. Both of these use the PNF principle of irradition through which resistance in one stronger pattern of the body promotes overflow to a weaker pattern.

Quadruped Extension-Rotation w/ Internal Rotation

Quadruped Extension-Rotation w/ External Rotation

Bent Over T-Spine Rotation

I like this drill because you also get some extra static work to reinforce the hip hinge pattern.

These last four exercises challenge stability and should be used once improved mobility is demonstrated. They are performed in the developmental sequence from quadruped, to half-kneeling, to lunging, to standing; each requires slighly greater degrees of stability to successfully complete.

Quadruped Diagonals (Bird Dog)

Mike gives a great description of the Birddog in this video.

Half Kneeling with Trunk Rotation

In this position, make sure the shoulder, hip, and knee are in vertical alignment, the back foot's toes are tucked under, and the chin is tucked. Try to stay nice and tall while performing the exercise.

Walking Lunge with Trunk Rotation

Hands may be positioned behind head or reaching overhead. Be careful not to take too big a forward step so that the knee remains directly under the shoulder and hip. Cue to keep the hips motionless during the rotation.

Single-Arm Row with Trunk Rotation

Squat stance, split stance

Stand facing a cable column or band in a 1/4-1/2 squat stance or split stance with knees slightly bent. With one arm, pull the band/cable back into the side while turning the head, eyes, and shoulders. While pulling the band/cable to the right, turn to the right, and vice versa. The shoulder blade should be pulled back and down. Make sure rotation comes through the thoracic spine while keeping the lower half stable.

Top 3 Reads for the Week

Here's my list of the top reads for the previous week. If you haven't checked out my first two posts on thoracic mobility you can view them here: Part 1: Why You Should Care and Part 2: How to Measure and Quantify It. I will get Part 3 up, which shows a number of corrective exercise options, sometime early this week.

Side Plank Clams and Side-Plank Hip Abduction Exercises - Mike Reinold shares some functional stabilty exercises that train the core while also working on improving hip strength and mobilty.

Aerobic Exercise and Weight Loss Research - Here is a quick read and research review by Alywn Cosgrove. He's pretty much at the leads the field when it comes to wieght loss and body composition improvements.

Groin Pain - Referrals and Soft Tissue Therapy - Patrick Ward gives a great overview of a lot of things needed to take into consideration when dealing with groin issues.

Thoracic Mobilty

Part 2: How to Measure and Quantify It

                There are several different ways to check and see if thoracic mobility is adequate and symetrical. In most cases it will be quantified by a rotation-extension assessment. Testing the motions unilaterally in this manner allows the identification of side-to-side asymmetries. Asymmetries can be due to structural or functional factors or a combination of the two and are a predisposing risk for injury. Structural factors causing assymetry, such as scoliosis, are less likely to be affected by corrective exercise interventions than functional factors. However, if these two factors coexsit, corrective exercise can play an important part against preventing further structural decline. Normal thoracic rotation should be roughly 45-50 degrees.

                A quick and easy way to assess thoracic rotation that can be used almost anywhere and if you are by yourself is the Seated Rotation assessment as described in Gray Cook’s Athletic Body in Balance. As demonstrated in the video below, with this test you simply sit facing a doorway with your back straight and rotate to either side. A passing grade is given if the dowel touches the wall, remains in contact with the chest, and the spine remains straight and upright. If there is any pain with the movement, no grade is given for the test and a medical professional should be consulted.

                This simple self assessment can show whether or not thoracic motion is limited, and corrective exercises can be based on this finding alone to address the limitations. However, there are several other slightly more involved assessments for the exercise or rehabilitation specialist used to narrow down what exactly is limiting the motion. The Selective Functional Movement Assessment (SFMA) uses a system that basically uses a series of breakouts to narrow the issue down into either a mobility or stability/motor control problem. A mobility problem can be caused by an tissue extensibility dysfunction (TED) or a joint mobility dysfunction (JMD). TEDs look at multiarticulate muscles (muscles crossing more than one joint) and could include active or passive insufficiency, neural or fascial tension, trigger points, scar tissue, hypertrophy, and muscle shortenining. Examples of JMDs would be dislocation or subluxation, fusion, adhesive capsulitis, osteoarthritis, and muscle spasm or guarding.  The limitation could also be caused by stability or motor control problem which means that the motion is there but the stabilization necessary to perform it actively is compromised somewhere. A stability/motor control problem takes into account proprioception, coordination, the central and peripheral nervous system, joint and postural alignment, and stabilizer strength measures.

                With all of the following assessments, as well as most of the exercises for improving thoracic mobility, the hips will be maintained at an angle equal to or greater that 90 degrees. This motion locks out the lumbar spine and ensures most of the movement is coming from the thoracic spine. If pain is noted with any of the following tests seek the help of a medical professional. Only after the pain is gone can movement patterns be improved as pain changes everything. There is no way of knowing whether or not the pain is causing the movement problem or the movement problem is causing the pain, it is a dead end until the pain is addressed.

The first assessment to be performed is termed the Lumbar-Locked Active Extension/Rotation(External Rotation) . Have the patient/client get into the quadruped position on a treatment table and sit back butt to heels. One hand is placed behind the head while the opposite forearm is place on the table. Have to individual rotate as far as they can toward the arm behind their head while maintaining the position of the legs and hips. Tell the client/patient to attempt to get their elbow pointing toward the ceiling. Repeat to the other side and compare. The angle of the top shoulder should reach at least 50 degrees relative to the table, and the elbow should be clear of the chest.

                If the previous test is limited, perform it again except this time have the patient put the top hand behind the lower back. This test is called Lumbar-Locked Active Extension Rotation (Internal Rotation). Repeat on each side and compare. Again an angle of 50 degrees relative to the table should be reached. If this test is still limited, next perform Lumbar- Locked Passive Extension/Rotation (Internal Rotation). To do this have the patient in the same position with one hand behind the back in internal rotation and the opposite forearm resting on the table. Have the patient relax and then passively rotate the patient’s top shoulder up and back to the limit of rotation.  The angle should reach 50 degrees. Repeat on the other side and compare.

                The Active Extension/Rotation(External Rotation) where the hand was behind the head presents a challenge to the shoulder girdle as well as the thoracic spine. If this movement was limited and when the client performed the Active Extension Rotation (Internal Rotation) where the hand was behind the back, it was normal, assume thoracic spine mobility is adequate and there is a problem in the shoulder girdle that needs to be addressed. If the Passive Extension/Rotation (Internal Rotation) was normal and the Active Extension Rotation (Internal Rotation) was limited, assume there is a stability or motor control problem. If the passive test is limited the limitation is due to rotational tissue extensibility or joint mobility problem.

                Now that the limitation has been narrowed down to either a stability/motor control or mobility problem we can give specific corrective exercises based on either category. In part 3 I will get to the fun part give a number of corrective exercises for each category as well as some tips get the most bang for your back from each of them.

Thoracic Mobility

Part 1: Why Should You Care?

The thoracic spine is the only system in the body that directly impacts four other systems. These systems from top to bottom include the cervical spine, thoracic cage (ribs), scapula/clavicle and lumbar spine. In addition, it shares many muscles with the shoulder and cervical segments. Very few individuals display the required thoracic mobility needed to optimize the functioning of these four systems.  Thoracic mobility problems can thus be a possible root of many problems from neck and shoulder to low back pain. The problem lies in the fact that the human body is very good at compensating, sacrificing movement quality in order to gain movement quantity. So when thoracic mobility is lost, these other segments must undergo additional biomechanically disadvantageous movement.

To show the importance of thoracic spine extension, shoulder pain will be used as an example. Due to the interdependent relationship of the glenohumeral joint, the scapula, and the thoracic spine, all three of these systems should be examined for problems causing the associated pain. Relevant to this post, the orientation of the thoracic spine determines scapular positioning, creating the platform for normal glenohumeral movement. If a certain degree of thoracic kyphosis is present, the curvature of the ribs interferes with the scapular upward rotation and depression necessary to complete shoulder flexion. To illustrate this, simply crouch over, slumping your shoulders forward (by the way, what you just did is called a “crunch”, but that topic will have to wait for a future post) and raise your arms forward as high as you can without extending your low back. Now, stick your chest out and stand as upright as possible and perform the same movement. Proper scapular positioning allows prerequisite stability for the optimal degrees of posterior tilt and upward rotation as the arm goes into either flexion or abduction. Further down the chain, this allows the humerus to remain centered in the glenoid as the motion occurs preventing excessive impingement.

When the scapula is not moving or is not positioned properly, shoulder pain can develop, as accessory movements including excessive anterior and superior glide must occur to complete movements. In addition, when addressing range of motion limitations in the glenohumeral joint, thoracic mobility must again be taken into account. There are instances where either shoulder internal or external rotation deficits are indeed due to a problem confined to the joint, but more often than not the problem lies elsewhere. An upright posture and some thoracic extension is required for both patterns, so if this is restored range of motion will automatically improve without ever touching the glenohumeral joint.

The shoulder pain example primarily looked at limitations in extension, but now let’s briefly look at what happens when rotation is limited. Thoracic spine rotation is a combo of extension on one side and flexion of the other. That means if thoracic extension is limited, rotation will be limited as well. Rotation should primarily occur throughout the thoracic rather than the lumbar spine. This is due to the anatomical differences in the two regions. The apophyseal joints which connect the vertebrae are orientated in the frontal plane throughout the thoracic spine, making them better suited to rotation, whereas their transition to a sagittal plane orientation in the lumbar spine makes them better suited for flexion and extension. When looking at rotational sports, one can see the importance of adequate thoracic rotation. If rotation is limited, it will occur somewhere else -- most likely in the lumbar spine. This creates a predisposition towards low back pain as the lumbar spine is being asked to do extra work to make up for the mobility deficit in the thoracic spine.

That concludes Part 1; in Part 2, I will explain how to assess thoracic mobility and sort out what the root cause of the limitation is.

Getting it Started

Hello, I have been thinking about getting a blog started up for a while and since I have a little down time now after getting married this summer I though it would be as good of time as any to get it up and going. I just finished my first year of PT school this June and am getting ready to start my next one here in a week. I did my undergrad at Northwestern College in Athletic Training, also being very much involved with the strength and conditioning programs there. After that I completed both my ATC and CSCS tests and took a job for a year working as an Athletic Trainer and Strength Coach at the High School level before attending the UNMC PT program. This blog will explore a range of topics including physical therapy, strength and conditioning, nutrition, general fitness information, and how all of these things tie together. I will try to include updates on what I am reading and learning, some videos, and other random things. It might be a little choppy at first as I learn how this whole thing works, but I hope you will enjoy the postings. Please feel free to leave comments, questions, or ideas for topics you would like to be discussed.