Don’t underestimate the thorax when treating neck pain

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Normal Kinematics of the neck: The interplay between the cervical and thoracic spines (Tsang et al. 2013. Manual Therapy (18):431-437)

This paper offers great kinematic data on functional movement of the upper spine and confirms the clinical approach of many experienced therapists successful in the treatment of ‘neck pain’. I never treat the neck without addressing the thoracic spine.

Why so? No part of the body functions in isolation. As the pelvis is to the lumbar spine, the upper thorax similarly acts as an adaptable platform of support for the head and neck. When our postural alignment changes, the natural movement kinematics of the whole spine and in particular those in the upper spine change.

This further creates altered loading patterns (tension and compression) of the joints and soft tissues. In time, stiffness and pain will predictably ensue.

Altered cervico-thoracic and shoulder girdle alignment is a common finding in people with neck pain
Altered cervico-thoracic and shoulder girdle alignment is a common finding in people with neck pain

This pretty much underlies all neck pain syndromes. Many of us adopt a habitual slumped posture sitting at work and during many leisure activities – most of which also invariably involve use of the arms down in front of the body. The shoulder girdle and head and neck ‘hang forward’ off the thorax. We start to lose the sense of and ability to come back up to ‘neutral’. And in time the cervico-thoracic spine and upper thorax becomes stiff. The cervical joints above become the ‘victim’ and can’t assume a neutral position or move properly. Many ‘exercises’ prescribed for neck pain simply bother it more.

The secret is to address the ‘criminal’ – to get mobility into the upper thorax and through the cervico-thoracic junction. To this end The Fundamental Shoulder Patternsare a good start.

It’s important to realise that it isn’t simply a ‘stiff thorax’ which biomechanically effects cervical function. Changed posturo-movement of the thorax also directly affects the kinematic patterns and loading patterns of the shoulder girdle. Appropriately treat the thorax and you’ll also make better gains with your shoulder patients

Secondly, thoracic joint dysfunction per se has a marked influence not only on the adjacent soft tissues but also upon autonomic function – the autonomic supply to the head and neck is T1-5 and that to the upper limb T2-10. The literature is increasingly showing sympathetic involvement in many central and peripheral pain syndromes.

Thirdly, the changed myomechanics and altered loading patterns also affect the fascial system which functionally connects the thorax to the head neck and upper limb. This tissue is richly innervated and forms a continuous whole body signalling system and structural web arranged in various layers. In healthy function it acts as a ‘sliding system’ to allow 3D movement and probably because of its rich innervation, has a lot to do with facilitating our proprioceptive control. When there is inflammation, the layers ‘bind’ and don’t slide – which not only disturbs and limits movement, but undoubtedly activates nociceptors and pain. This can be local or referred and can partly account for example in changing headaches when treating the thoracic spine.

If you are not addressing the thorax you will achieve limited results in the treatment of not only head and neck pain, but also shoulder and upper limb pain syndromes – not to mention low back and pelvic pain.

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