Whether the presenting complaint or a cog in the chain of dysfunction I have found a restricted hyperkyphotic thoracic spine a recurrent finding in patients of all ages. Seemingly caused by the repetitive demands of daily life i.e. sitting, driving, and poor posture, this is one of the most important areas to address with patients. This article will go into detail why I think this is the case and how I go about treating it.
The knock on effects of a restricted hyperkyphotic thoracic spine are numerous. Lets go through a few of them:
Increased degenerative changes to the thoracic, lumbar and cervical spine. The curves of the spine work as the body’s suspension system. Beautifully distributing load,weight and forces through the frame into the ground without over-loading one area. The thoracic spine is the middle link in this suspension chain. An increase kyphosis and reduced flexibility of the thoracic means that this load cannot be distributed evenly instead being focused on key linkages of the spine, namely: C/T junction, mid-lower thoracic spine and lower lumbar spine.
Altered respiratory function: Reduced thoracic mobility will in turn reduce rib motion and lung capacity. The accessory respiratory muscles become over activated (Sternocleidomastoid, Scalenes group and Pectoralis minor) and the primary respiratory muscle (diaphragm, intercostalis, upper abdominals) become tight. This is a hot topic for research with some links between chronic disease and increased kyphosis being found.
Reduced scapular and shoulder function. An increased kyphosis is often accompanied by tight anterior neck and chest muscles. The shoulders becomes drawn forward placing the scapulars in a chronically protracted position. The scapular stabilisers become weak and under-activated whilst the upper traps become over-activated. This position of the scapular shortens the rotator cuffs leading to trigger points, shoulder pain and possible knock on effects of sub acromial bursitis and rotator cuff tendinopathy.
Forward head position: The anterior position which the head tends to adopt with this presentation can often lead to headaches, reduced concentration, migraines and neck pain. This in itself can lead to reduced sleep quality and fatigue.
So the chronic effects of a forward drawn / slumped posture are much more than just low back or shoulder pain. Worryingly this is becoming more common in children who are picking up bad postural habits from sitting at school and having to carry a heavy backpack. Highlighting the importance of correct posture to kids and showing them how to effectively pack their back packs to reduce strain on the spine is tremendously important in the prevention of long term dysfunction.
I like to use the following analogy to describe the issue with my patients.
The spine is influenced by muscles at the front and back to keep us upright. Like the guide wires of a tent these need to be pulling evenly for a balanced, stable platform. Prolonged sitting, slouching, working with laptops, carrying bags etc cause the front muscles to become tight, pulling the mid back and shoulders forward. This is the same as tightening the guide wires on one side of the tent only. As you can imagine this causes the spine to be unbalanced. The body tries its best to correct this by recruiting other muscles but adopting the troublesome postures everyday means it is in vein. Chiropractic can help re-establish the normal balance and movement to the spine and muscles. When you’re moving better and more balanced we will then look to strengthen the muscles which have become weak to get you more stable.
This can be elaborated or stripped back to suit the needs of your patient.
How do I tackle this postural epidemic.
Firstly its important to mention that this pattern of symptoms is not caused by the dysfunction of the thoracic spine alone. As I mentioned in my earlier article :Tight Hip Flexors: A Catalyst For Dysfunction, prolonged sitting causes shortening of the hip flexors which has numerous knock on effects. I have found that addressing this dysfunction in conjunction with the thoracic spine has great outcomes.
When treating patients with this presentation I focus on a few key areas.
Correct spinal restrictions / dysfunction with adjustments.
Release anterior tight muscles (Psoas, Pecs, abdominals, Scalenes, SCM) with soft tissue techniques (Active release, PIR, massage, Dry needling, Graston technique – all work well)
Home exercise prescription: Hip flexor stretching, pectoral stretching- 3 x 30 second holds twice every day. Foam roller thoracic extension stretches. Ergonomic advice
Once the patient is moving better I start to incorporate strength and stability work.
Dead bug exercises,
‘Y’ exercises for scapular stability,
gluteal activation exercises (see What is Hamstring Dominance?)
Bruggers relief position whilst at work – every hour for the first week. Progression to Bruggers relief with theraband.
All the while continuing with the home stretching
Of course every patient is different with their presentation. The stresses and strains they put on their bodies will be unique to them and their bio-mechanics. The above treatment techniques are a rough guide to what I have found useful. However assessing the bio-mechanics of a patients feet, pelvis, looking at their pillow, exercise routine and stress levels are also useful to rule out other possible contributing factors.
Education is also a key step in the long term health of any patient. A real understanding of the importance of good posture, keeping mobile and functional is just as important as any home advice. Arming the patient with knowledge and tools so they can go onto educate their family, friends and colleagues is a duty of care we should all be implementing.
Encouraging Yoga, Pilates and exercises classes are a great way for patients to stay mobile in a fun structured way. Encouraging mobility exercises as part of their already existing exercise routine is a great way for patients to stay compliant. Patients who have to make changes in their routine to accommodate their exercises tend to give them up.
In summary the numerous knock on effects of a dysfunctional thoracic spine means that its correct identification, treatment and rehabilitation is crucial for the health of our patients. This includes looking beyond the thoracic spine as the sole area of dysfunction. Giving our patients the tools and education on how to prevent recurrences empowers them to take control of their own health and function.