In the last article we discussed Physiological Scoliosis. In this article we will review the effects of the thoracic kyphosis and how the body organizes itself around that.
In physiological scoliosis, the difference in the ROM in side bending of the thoracic spine results in compensation by both the cervical and lumbar spine in the coronal plane. The thoracic kyphotic pattern causes compensation in the saggital plane.
The thoracic kyphosis is the first spinal curve to be established. It arises in utero and is maintained throughout life. The cervical lordosis is created as the child begins to crawl and the lumbar lordosis is created as the child begins to stand and walk.
If we observe a person from the side, hopefully, there should be a balanced organization around the gravitational line. Imagine a line hung from the ceiling that goes to the floor that bisects the external auditory meatus (EAM). If the EAM is used as a reference and if the body is in a balanced posture then certain elements of the body should also be in line with the EAM. The line should pass through the center of the humeral head, the center of the greater trochanter, the center of the knee and through the lateral malleolus. Of course, these are general guidelines to observe the saggital posture. The person should also appear balanced and relaxed even if they fulfill the criteria of having a good posture according to this method.
In general, the great majority of people do not have a balanced posture in this plane. Many people will have a forward head with an increased cervical lordosis and an increased lumbar lordosis. These are the more obvious findings. Typically, the majority of clients will complain of neck and/or low back tension or pain as a result of tight muscles in these areas. What is overlooked however is that the cervical and lumbar spine are in this lordotic position in order to compensate for the thoracic spine’s decreased ability to attain a more extended position. As we discussed in the article about physiological scoliosis, the body tries to keep the majority of the body’s weight over the pelvis and feet. With the physiological scoliosis this occurs by the cervical and lumbar spine being in a right side bending position. In the case of the thoracic kyphotic pattern, the body compensates by extending the head backwards to get more weight over the shoulders and by extending the lumbar spine backwards to get more of the entire body weight over the pelvis. As a result both the neck and low back will have tight muscles and this will be typically where the complaints will be. The muscles that typically are involved in the neck are the suboccipitals, cervical mutifidi, splenius capitus/cervicus, trapezius and the levator scapula. In the low back, it is primarily the quadratus lumborum and some of the erector spinae muscles. These muscles are usually tight due to there chronic contraction trying to pull the body upright. Also muscles that can be tight in the upper body due to the kyphotic posture include the pectoralis minor and major and the scalenes. These muscles are usually shortened and tight due to rounded, anterior shoulder that is associated with the kyphotic posture.
Another less obvious finding is that the sacrum will also compensate for the overall pattern in the body due to the thoracic kyphosis. The sacral base will often be more anterior which results in an increase of the lumbo-sacral angle. Over time this can put significant stress on elements of the lumbar spine. The L5-S1 intervetebral disc (IVD) is typically the most common disc to herniate. The L4-L5 disc is the next most common disc to herniate.
Compensating for the thoracic kyphosis leads to many problems in both the lumbar and cervical spine. Imbibation is the way the intervertebral discs obtain nutrition from there surroundings. Imbibation is basically similar to how a sponge can absorb a liquid. If we have a dirty sponge we can submerse it into water and with several squeezes can get the dirt out. The IVD has no direct blood supply, it relies upon bodily movements to squeeze and unsqueeze it to allow for nutrition and waste products to flow in and out of the discal material. It may be that when the body is compensating for the thoracic kyphosis that the lumbar and cervical spine has less overall range of motion, and as a result full imbibation is impeded. Over time the decreased imbibation and thus nutritional exchange will lead to a decreased repair of the normal wear and tear and possibly lead to the observed findings of increased disc herniation at L5-S1, L4-L5, and in the neck, the third and forth most common sites, C6-C7, C5-C6.
The relative immobility of the sacral joint system, especially when there is an anterior tilt of the base, causes more movement to occur in the lumbo-sacral area, instead of being spread out through the lumbo-sacral and sacroiliac joints. This leads to more wear and tear of the lumbo-sacral area. Combined with the lack of imbibation throughout the entire volume of the disc, because the lumbar spine has less total range of motion, there may a gradual weakening of the discal material, which would lead to an increase of the possibility of discal problems.
The cervical spine will have similar problems due to the overall reduction of range of motion due to adaptation to the thoracic kyphosis. Since C6-C7 and C5-C6 are at the transition area between the thoracic and cervical spine, they tend also have greater forces imposed on them.
The concentration of forces at both the lumbo-sacral and cervical transition area is similar to how one would break a paper clip in half. In order to do this, the clip is held in the middle and bent back and forth until the clip breaks in two. The force is similar to what occurs in these areas. Due to the relative immobility of the sacrum and thoracic spine and the resulting compensation, the forces applied to these transition areas are similar to those experienced by the paper clip. Our job as therapists is to increase the movement of both the thoracic spine and sacrum so that the forces are more broadly distributed. Treatment enables the thoracic spine to have a greater range of motion, especially into extension near the cervical spine. With treatment, instead of extension just occurring at the cervical/ thoracic hinge, movement would also occur down into the upper thoracic spine. Mobilizing the sacrum getting it to move more within the sacroiliac joint will also de-stress the lumbo-sacral joint, allowing movement to occur across a broader length of the spine.
The principle of treatment is similar to the paper clip model, but in this case if we were to hold a paper clip at the ends and bend it back and forth, it would take a substantially longer time to break if it ever did. The force of bending is not concentrated at one point.
The most usual symptomatic complaints that practitioners hear are that of posterior neck pain, low back pain or both. The typical treatment approach is to directly address the painful areas in the hope of relaxing the involved structures. With the understanding that the body is compensating for the thoracic kyphosis by increasing muscular tension in both the neck and low back, we actually need to address treatment to the thoracic and sacral areas in order to increase the range of motion especially into extension.
Observing the supine client often shows that they have a posterior head tilt, in some cases enough tilt is present for them to be very uncomfortable without using a pillow. Sliding a hand under the arch of the low back area will often be easily achieved, as there is a space between the lumbar spine and the table due to the increased lumbar lordosis. Often the sacral base will feel like it is tipped anteriorly.
By decreasing the kyphotic curve there will be less need for compensation of the neck and lumbar curves. They too can respond to the decrease of the thoracic curve by becoming softer, less lordotic and the muscles associated with them will become less tight.
There are several primary techniques that address the thoracic kyphosis and its effects. The first is the thoracic lift:
The client is supine. Reach under the thoracic spine and when you reach the apex of the kyphosis form a fulcrum with either your finger tips, palm or fist. The idea is to provide a place where the kyphosis can bend into extension. With your other hand, grasp under the occiput and providing slight flexion to the head, and gently traction the head. Hold this position for 20-30 seconds or until a release is felt. After a release is perceived then move the hand that is under the thoracic spine to the next area that is stiff. Many times you will need to move about ½ inch each time until you have treated the entire length of the thoracic spine.
The other major technique to treat the thoracic kyphosis is a percussion technique.
The client is prone. Make the client as comfortable as possible, place a support at the ASIS’s to create a slight lumbar flexion and some support under the ankles. The gist of this technique is to pound the thoracic spine for five to fifteen minutes. Typically, as it is practiced, percussion is not performed for very long. But in this case the long time frame is necessary to achieve results. You can either use one or two hands in whatever way you want. The important thing is that the rhythm of the percussion is based on how the hand seems to bounce off the body. There are several things to notice. Initially, the thoracic spine will seem stiff and as you continue with the percussion this stiffness will decrease. Also, the sound of the percussion will get deeper and “thuddier”. Just like a drum, when the drum is tight, it produces a higher pitched sound and when it is loose a lower pitched sound, the body as it becomes looser will also sound deeper. Many times your client will fall asleep during the percussion.
A third technique also involves percussion. This time, percussion to the sacrum. Again the client is prone and made comfortable with supports under the pelvis and ankles. Using the ulnar side of the hand percussion is done again using a rhythmic, bouncing pounding. This technique should be done for 10 to 20 minutes. What will be noticed is that the sacrum will feel significantly less stiff and the thoracic spine also will be also significantly less stiff.
In order to be time efficient, both the thoracic spine and sacrum can be percussed simutaniously.
What will be noticed when either the sacrum or thoracic spine are treated the lumbar and cervical curves and associated muscles will be significantly more relaxed. Following up the treatment of the sacrum and thoracic spine with treatment of the lumbar and/or the cervical spine will result in significant changes to those areas.
Another technique to follow up the percussion techniques is to do direct Myofascial release on the thoracic spine. Either using the thumb or heel of the Palm, pressure is applied on the spinous processes directed towards the low back in order to help the thoracic spine achieved more extension. If low frequency vibration is added results will be quicker.
There are a few more auxiliary techniques that will help reduce the thoracic kyphosis. There are several muscle groups that seem to shorten as a result of the kyphosis. The Pectoralis major/minor will shorten and the rectus abdominis will also shorten. These muscles tend to shorten due to the chronic forward bend. Treating these muscles to help them lengthen and will prevent them from sustaining a forward bend. These muscles should be treated after addressing the kyphosis.
In using these techniques, often there will be a significant change in the body’s relationship to the gravitational line as observed from the side. Often clients will say they feel significantly taller and they feel like they’re floating.
In the next article, we will discuss the torsional pattern which again significant population has.
