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Addressing Lower Back Pain, Part 2


How a Sagittal Plane Deviation (Forward Bend) of the Thoracic Spine Affects the Lower Back

Whether driving, working on the computer, or watching television, these seated postures are often characterized by a rounded upper back and shoulders.  Over time, this stooped position in the thoracic spine can cause alignment problems and pain in both the upper and lower back. The thoracic spine is comprised of the twelve vertebrae of the spine, located in the area where the ribcage attaches to the spine.  The thoracic spine is naturally curved forward, forming what is called a kyphotic curve, however, when this curvature is excessive it can become problematic. 

When the thoracic spine rounds forward, the head also moves forward.  This forward shift in the torso and head means that additional weight falls forward of the body.  Consequently, the pelvis has to adjust to accommodate this change in the body’s center of gravity.  The pelvis, therefore, will tilt down at the front (which is referred to as an anterior pelvic tilt) to prevent the entire body from toppling forward.  The anterior tilt of the pelvis, however, can cause the lower back to arch into excessive lumbar extension to help keep the spine upright.  Over time, this excessive arching places stress on the structures of the lower back and can lead to pain, dysfunction and/or injury.

Furthermore, when the thoracic spine rounds forward the ribcage drops at the front of the torso.  This compression of the ribcage restricts blood supply to the internal organs and affects the functioning of the diaphragm and the ability to breathe correctly.

How a Lateral Deviation of the Thoracic Spine Affects the Hips

When people sit down at a computer, a great deal of time is spent using the mouse.  A right-handed person will reach to the right side to use the mouse.  As such, their spine may bend to the right and their ribcage will drop towards that side.  Sometimes they even lean on their right elbow as they read emails or at other times in the car while driving.  Ultimately, the soft tissue structures on the right side of the spine get used to this chronic side bending and the spine begins to develop a lateral side bending to the right (or to the left if they are left-handed).

Wwhen this same person stands up or begins to walk, their sideways posture has implications.  Their spine is so used to being bent to the right that they develop a chronic lateral deviation in their thoracic (and possibly lumbar) spine to the right.  Upon weight bearing, (when they stand or begin to walk) the hips must adjust to accommodate the lateral shift in their center of gravity.  For example, a lateral bend in the spine to the right would move the weight of the torso more to the right.  To help the body balance, the hips must then shift in the opposite direction to the left.  Therefore, the most typical compensation pattern for a spine curved to the right is for the left hip to shift to the left.  Eventually, the chronic compensation pattern described in this situation can lead to pain on the right side of the spine or lower back and/or in the left hip.

How a Rotational Deviation of the Thoracic Spine Affects the Hips and Lower Back

When the thoracic spine bends to one side, the spine will rotate out of alignment in the direction of the curve to reduce the resultant pressure placed on the nerve roots as they exit the spinal cord.  For example, if the thoracic spine bends to the right, then the discs of the spine will rotate forward on the right side.  If you were to look down the spine from a bird’s eye view in this instance, the thoracic spine would be rotated anti-clockwise. 

Sooner or later, this malrotation of the spine in the anti-clockwise direction will make it increasingly difficult for the thoracic spine to rotate clockwise.  If the curvature is reversed to the left, then the clockwise/anti-clockwise implications are obviously reversed as well. 

A rotational imbalance in the thoracic spine that prevents effective rotation to one side affects many daily activities.  For example, when you walk your arms swing opposite to your legs (i.e., when the right leg swings forward the left arm swings forward and visa versa).  When the arms swing the thoracic spine should rotate as well.  This opposite rotation of the upper and lower body helps pre-stretch and load the soft tissue structures that attach to the pelvis, ribs and spine, making walking an easy and efficient motion.  However, if the thoracic spine does not rotate effectively in one direction then the pelvis and lower back may compensate to try to make up for the lack of rotation further up the spine.  Over time, this can lead to overuse injuries in the hips and lower back.  

Putting the Pieces Together

Now you can see how the most common deviations in the thoracic spine occur in all three planes of motion.  Excessive thoracic kyphosis is a deviation in the sagittal plane, a dominant side bend in thoracic spine is a deviation in the frontal plane, and a malrotation of the thoracic spine is a transverse plane imbalance. 

To correct these imbalances, it is important to include exercises that can help unlock these dysfunctional movement patterns and/or structures.  It is also essential to incorporate training strategies to get the thoracic spine to extend, to bend correctly to both sides, and to rotate effectively in both directions. However, often when people attempt to get the thoracic spine to move correctly, there is a tendency to cheat and create the desired motion from elsewhere in the body.  For example, when someone with excessive thoracic kyphosis is instructed to arch their back to help facilitate thoracic extension, they will most likely just arch their lower back even more to achieve the desired movement.  Similarly, if that person is asked to bend to one side and their thoracic spine does not bend that way, then the lumbar spine or neck may compensate and overwork to achieve the movement goal.  Moreover, in trying to get the thoracic spine to rotate in a restricted direction, the hips or lumbar spine may cheat or overwork to take up the slack for a dysfunctional thoracic spine.

Exercises to Help Alleviate These Problems

The arch on the dome of the BOSU is perfectly suited to act as a fulcrum for the middle of the thoracic spine.  By placing the center of the thoracic spine over the center of the dome, you can ensure that the movement is restricted to the thoracic spine and you can achieve the desired movements from the specific area you are trying to address.  This placement of the BOSU can be utilized to facilitate motion in all 3 planes and will ultimately help create balanced mobility in the thoracic spine and help alleviate compensations of the lower back and hips.

The following exercises demonstrate 4 movements that are specifically designed to increase the range of motion for the thoracic spine in all 3 planes of movement.  Facilitating these movements will not only help increase the range of motion at the thoracic spine, but can also reduce the amount of extra work the lower back has to do to compensate for thoracic spine dysfunction.

This mobilization exercise shown in Image 1 includes self massage which helps release restrictions in the abdominals while increasing extension in the thoracic spine and hips.

Instructions: Support the head.  Align top of dome with middle of thoracic spine.  Self massage the abdominal muscles and fascia to release the front side of the torso to help increase the ability of the thoracic spine to extend.

Thoracic spine extension with abdominal massage Image 1. Thoracic spine extension with abdominal massage

This next mobilization exercise demonstrated in Image 2, helps to increase frontal plane mobility in the thoracic spine and hips.

Instructions. Support the head. Align top of dome with middle of thoracic spine. Reach the top arm over the head.  Drop the knee on the same side as the arm that reaches over the head.  Try to stretch open the ribcage on the top side of your body.  Do both sides to assess which feels easier to bend.  Do three times as many on the side that is difficult.  This will help balance the spine.

Side bending of thoracic spine with lateral hip stretch Image 2. Side bending of thoracic spine with lateral hip stretch

Image 3 shows a mobilization exercise which helps to increase rotation and extension in the thoracic spine.

Instructions: Support the head and keep eyes looking at ceiling.  Align top of dome with middle of thoracic spine.  Let the spine lie back into slight extension.  Straighten the leg on the left side.  Keep the hips level (i.e., do not rotate them) and reach your left arm to your right to rotate the thoracic spine.  Repeat on the other side to assess which side is the most difficult.  Do three times as many on the side that is difficult.  This will help balance the spine.

Rotation and extension of thoracic spine Image 3. Rotation and extension of thoracic spine

The strengthening exercise shown in Images 4 and 5 helps to increase the thoracic spine ability to extend, side flex and rotate under load.

Instructions: Support the head.  Align top of dome with middle of thoracic spine. Keep the pelvis posteriorly tilted to decrease the tendency for extension to happen in the lumbar spine.  Extend over the BOSU to increase extension and then crunch up to neutral.  Do not crunch up too far.  Add side bending and rotation to this exercise to increase mobility in all three planes.

Tri-planar extension crunch (start position) Image 4. Tri-planar extension crunch (start position) Tri-planar extensio crunch (end position) Image 5. Tri-planar extension crunch (end position)

References:

  1. Golding, Lawrence A. and Golding, Scott M.  Fitness Professionals’ Guide to Musculoskeletal Anatomy and Human Movement.  Monterey, CA: Healthy Learning, 2003.
  2. Gray, Henry.  Gray’s Anatomy.  New York: Barnes & Noble Books, 1995.
  3. Petty, Nicola and Moore, Ann, P.  Neuromusculoskeletal Examination and Assessment: A Handbook for Therapists.  Edinburgh: Churchill Livingstone, 2002.
  4. Price, Justin.  “A Step-by Step Guide to Corrective Exercise Program Design”.  Lenny McGill Productions, 2008.
  5. Price, Justin.  “A Step-by Step Guide to the Fundamentals of Corrective Exercise”.  Lenny McGill Productions, 2006.
  6. Price, Justin.  “A Step-by Step Guide to the Fundamentals of Structural Assessment”. Lenny McGill Productions, 2006.
  7. Price, Justin.  “A Step-by Step Guide to the Understanding Muscles and Movement”.  Lenny McGill Productions, 2008.
  8. Schamberger, Wolf.  The Malalignment Syndrome: Implications for Medicine and Sport. Edinburgh: Churchill Livingstone, 2002.
  9. Taylor, Paul M. and Taylor, Diane K. (Eds.).  Conquering Athletic Injuries.  Champaign, IL: Leisure Press, 1988.
  10. Whiting, William C. and Zernicke, Ronald F.  Biomechanics of Musculoskeletal Injury.  Champaign, IL: Human Kinetics, 1998.