Assessing The Fundamentals: The Thoracic Connection, Part 2

Coordinating Respiration with Activation

The client lies on his back with fingers just inside his ASIS’s anteriorly and their thumbs just below the 12th rib posteriorly (see image below). There must be simultaneous activation of the abdominal wall along with diaphragm breathing. This activity must be coordinated so that it becomes the primary pattern that is utilized during exercise and higher-level activities. Many clients demonstrate an ability to either stabilize the abdominal wall or breathe - they often lack the ability to efficiently coordinate these activities simultaneously. The client takes a deep breath in and as he exhales, he tenses the abdominal wall. There should be simultaneous activation of the abdominal wall, both under the fingers as well as the thumbs. Maintaining this activation, he continues to breathe both into his fingers and thumbs. Pay particular attention to the expiration phase as this is where most clients will lose the ability to coordinate breathing and activation. This is the exact coordination of activation and breathing that must be patterned and eventually maintained during exercise.

Image 1	Image 2

Poor breathing and stabilization patterns are demonstrated when the rib cage elevates and the abdominal wall narrows (Image 1). The ideal pattern is when the rib cage remains in an inferior position and the abdominal wall is contracted with no drawing in or hollowing (Image 2). This pattern must be maintained with breathing and simultaneous activation.

With all the conflicting approaches to core stabilization, why is this the preferred strategy? In the optimal development environment, infants are the only population that is unbiased by learned behaviors or altered by pain or previous injuries. The child shown in  Figure 1 of Part 1 of this series, does not display abdominal draw-in or even a brace as the child loads his extremities. The child breathes through his thorax and abdomen and develops optimal IAP to stabilize his thorax as he loads his extremities.

Once coordination of respiration and core activation is achieved, the focus shifts to thoracic dissociation. To improve thoracic dissociation, alignment of the thorax must first be achieved. Thoracic alignment begins by mobilizing the thorax utilizing the modified cat/camel and the modified cat/camel with rotation.

Exercises

Modified Cat/Camel

The cat/camel is performed on the elbows rather than with extended arms to improve thoracic mobilization with concurrent activation of scapular stabilizers. The client will also start sitting further back so the movement occurs mainly in the upper thoracic spine. The client maintains activation of the scapular stabilizers as well as the deep neck flexors throughout the pattern.

Modified Cat and Camel w/Rotation

Remaining on the elbows and knees, the client will rotate their thoracic spine by lifting one arm. Alternate slowly between sides focusing on control of the transition from one arm to the next. The client must maintain stabilization of the stationary arm as well as through the deep neck flexors.

Once thoracic mobility is achieved, focus shifts to dissociation. Dissociation is the process of stabilizing the proximal structures and moving the distal structures with optimal joint centration.

The next 2 patterns are used primarily to help dissociate the trunk from the pelvis and the pelvic from the hips while maintaining thoracic stability:

1. Thoracic dissociation: The pelvis will be stabilized and there will be dissociation of the thorax.
2. Pelvic dissociation: The trunk and lower extremity will be stabilized and there will be dissociation of the pelvis.

Standing Trunk Rotations

The client begins by standing in an athletic stance, core activation, with the arms crossed over opposite shoulders. Maintaining the head and pelvic position, he takes a deep breathe in and rotate the trunk to one side. He holds for a count of 3 seconds and returns to the starting position before repeating on the other side. Have the client perform several additional repetitions on the more restricted side. Focus on thoracic rotation - the head and pelvis should not move and the spine should rotate on an axis.

Lying Pelvic Rotations

The client begins in a bridge position with core activation. The client will take a deep breath in and as they breathe out he rotates the pelvis to one side. Holding for a second he will return to the starting position before repeating on the other side. As previously, have the client perform several extra repetitions on the side of greater restriction. The head thorax, knees, and ankles must remain stationary throughout the pattern.

Rotation and Chop Patterns

Rotation and chop patterns are key progressions in improving trunk rotation and stabilization. These patterns are ideal because they allow the trunk to be loaded in any plane of motion and direction (high to low, low to high or parallel to the ground. This is a great way to challenge the client’s ability to both stabilize and rotate efficiently through  the trunk and spine. These patterns can be loaded with dumbbells, medicine balls, or cables.

The key to these patterns is to ensure that rotation occurs primarily at the thoracic spine and lead hip. There should be no shearing (lateral shifting) of the spine or trunk during the patterns. Take caution to not load the client to the point where they cannot maintain stability and diaphragmatic respiration.

The client assumes an athletic stance with neutral spine position and core activation. Feet are placed about shoulder width apart. Grasping the cable, the client rotates his trunk, pivoting around the stationary leg. To spare the lumbar spine, there is minimal lumbar rotation and more moderate amounts of thoracic rotation. The client returns to the starting position and repeats on the other side.

High to Low Chop with Rotation

The client assumes the set up position as described above. In the preliminary progression, as is used when learning the pattern or with individuals with spine pain, the trunk remains relatively neutral as the cable is brought towards the left knee (see image below). As clients learn the pattern, they can be progressed to relatively greater degrees of trunk rotation.

The high to low cable chop with rotation works on stabilizing the hip and lumbar spine while rotating the thoracic spine around a stable hip which is the left hip in Image 3.

Pushing and Pulling Patterns

Exercises that are in direct violation of functional development were discussed in part I of this article. To reiterate, this does not make these exercises, bad but rather points out how certain exercises contribute to thoracic rigidity and hypermobility of the lumbar spine and scapulae. So, how are common exercises performed that can maintain or even promote thoracic mobility? Similar, to the developing child, one arm and one hip will serve as fixed points while the other arm becomes the moving limb. Additionally, single limb or alternating patterns will be utilized to drive thoracic mobility as opposed to bilateral patterns, which tend to drive stiffness of the thorax.

Pushing Patterns

• Example: Cable alternating chest press
• Performance: The client assumes a split stance with the spine neutral and the core activated during the pattern. One arm will be fixated by the cable (if performing alternating patterns) or held stabilized against a solid object (if performing single limb patterns. The right arm pushes the cable until the arm is extended and returns to the starting position. This pattern is repeated on the other side. Similar to the chop patterns, the spine should rotate on an axis and around the stationary limbs (left arm and hip). This pattern is demonstrated in the image to the left below.

Pulling Patterns

• Example: Cable alternating low-to-high row
• Performance: The client assumes an athletic stance and maintains core activation during the pattern. He pulls the left cable as the right arm and left hip remain stationary pivot points. He returns to the starting position and repeats on the opposite side. Similar to the chop patterns, the spine should rotate on an axis and around the stationary limbs (right arm and right hip) in the right image below.

Image 4	Image 5

Alternating cable chest press (Image 4) and alternating cable row (Image 5) enables one limb to remain fixated while the other side drives movement of the thorax.

Conclusion

Improving function, reducing pain, and helping clients to achieve an active lifestyle requires attention to the principles; the principle of breathing, stabilization, and integration. The goal of this article was to help the fitness professional recognize the role of the thorax as the key to function because of its relationship to breathing and stabilization of the entire kinetic chain. This begins with improving the alignment of the thoracopelvic canister and diaphragmatic breathing. Next, optimal stabilization and dissociation is developed at the appropriate regions of the kinetic chain. These concepts are then integrated into functional movement patterns though which clients are progressed appropriately based upon their needs and goals.  By adopting the discipline to follow these three fundamental principles, the fitness professional will be the professional the fitness industry requires. By performing these 3 fundamental principles, the fitness professional will be the solution clients need to help them manage their neuromusculoskeletal issues in addition to achieving their health and fitness goals. Practicing radical discipline to the fundamental principles will enable the fitness professional to live up to the moniker: ‘Fitness Professional - The solution to the health care crisis!

References

1. Hodges, Paul, Richardson Carolyn, Hides, Julie. 2004. Therapeutic Exercise for Lumbopelvic Stabilization. 2nd Ed. St. Louis MO: Churchill Livingston.
2. Liebenson, Craig. 2007. Rehabilitation of the Spine. 2nd Ed. Philadelphia, PA: Lippincott Williams & Wilkins.
3. Lubeck, Deborah. 2003. The Costs of Musculoskeletal Disease: Health Needs Assessment and Health Economics. Best Practice & Research Clinical Rheumatology: Vol. 17, No. 3, pp. 529 – 539. www.elsevier.com.
4. Michaud, Thomas. 1997. Foot Orthosis. Newton, MA: self-published.
5. Osar, Evan. 2008.Complete Rotary Conditioning. Chicago, IL: self-published.
6. Osar, Evan. 2010. Complete Trunk Conditioning. Chicago, IL: self-published.
7. Pavel, Kolar. 2009. Exercise and the Athlete: Reflexive, Rudimentary, and Fundamental Strategies. Chicago, IL: course manual.
8. Sahrmann, Shirley. 2002. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis, MO: Mosby.