By Lee Jarvis. Editing and proofreading by Taryn Whyte.
The natural tendency of the Thoracic spine is a flexion curve, also known as Kyphosis. The flexion of the thoracic spine is not in any way abnormal. It is by no means a bad thing provided it is healthy and capable of moving into some amount of extension, side bending, and rotation. In many ways, the thoracic flexion curvature is a product of gravity’s downward pull and within certain ranges and motion capacities, it is useful. For instance, the flexion curve must be worked against for larger inhalations of air but the natural inclination back to flexion aids in the expulsion of air making exhalation easier.
However, those in the Osteopathic world, and often elsewhere, would agree that a flexion curve in the thoracic spine that cannot move out of this flexed position is a potential problem. We can never be truly sure exactly how the thoracic curve became so immobile but often our patients will explain the mechanism of injury, which may or may not include past traumas or perhaps “sitting too much”. These will forever be the “potential” mechanisms only, as we were not there at the time of their creation. Regardless, this lack of knowledge of the injury origin does not usually prevent improvement or resolution of the problem.
In an attempt to encourage some extension in the flexion curvature of the thoracic region, the seated position is often used. Utilizing the arms to lift the thorax through the ribs via attached muscles is a wise choice as this would be a normal mechanical process when we reach upward for things.
There are some standard seated position setups for encouraging extension in the thoracic region common in Osteopathic textbooks. For example, those of us who have attended the CAO have a method dubbed the “Genie pose”.
I have found that as much as these are effective and reliable positions, not all patients have the shoulder mobility to flex and/or abduct as far as necessary for this Genie Pose and other similar maneuvers. In addition, the direct chest contact that is necessary for these moves can be uncomfortable for both the patient and practitioner at times. Pillowing the chest area is a very reasonable solution for some but will not always make every person comfortable. If shoulder mobility can be improved these methods can be attempted at a later time, however, shoulder mobility is often so directly related to thoracic movement. This shoulder-thorax relationship can be so significant that the immobility of the thorax prevents the improvement of the shoulder, making it far more difficult to get to the benefit you aim to achieve.
As an alternative, what I will illustrate in this article is by comparison a less firm hold but one that is easily done by almost anyone that I use regularly. This method provides the necessary thoracic extension with little to no discomfort along with an easily achievable arm position for the patient. I will be the first to admit that this position is far more “flimsy” in both hold and appearance than the other methods. However, a tool that works only in specific situations seems useless until those specific situations arise.
I must say that I would feel ridiculous if I were to believe that I am the only one who ever thought of doing a maneuver like this in all of Osteopathic history, even though I have not yet seen it myself. I expect that shortly after posting this article I will receive a flurry of emails from dedicated students referencing numerous books from many years past illustrating and explaining this and other very similar methods. Perhaps not, but should it happen I am well prepared to downplay my work and any feelings of accomplishment, a skill perfected through years of experience.
Setup and Process
As always the first thing that should be done before performing any manual method is to determine the region to work on. A method is useless without the knowledge of where to apply it. In this case, it is a matter of determining an area of significant flexion in the thoracic spine to be worked on. The area identified could be the most rigid or an area you feel will yield somewhat to your encouragement of extension. The latter is usually the better option. The patient is seated and the practitioner stands behind and to the left or right depending on which arm is more comfortable for the patient to move if relevant. A fixed point is created by placing the inside hand on the determined area of flexion.
The patient’s arm, which the practitioner is standing against, is extended straight out by extending the elbow and flexing the shoulder, roughly parallel with the ground.
The practitioner’s arm is placed along the underside of the patient’s arm with the hand on the underside of the elbow. The practitioner’s hand will cross the elbow such that parts of both the humerus and ulna are in hand.
Holding this wider region generally makes for a more secure handhold, and braces the ulna against snapping downward with movement and hyper-extending the elbow, which is uncomfortable at best.
The patient reaches their other hand across and grasps just distal to their elbow. You can incorporate holding their hand into your already established grip if needed, as this tends to be more secure.
When the patient’s other arm lifts to grasp their forearm, just distal to the elbow, it will now have elongated the tissues on both sides of the shoulder-to-thorax connection.
When the hold is made effectively, we can lift the arm up to the height that engages a barrier. Typically, even a slight lifting of the arm creates a small amount of thoracic extension at our fixed point.
Once this leverage has been established to the barrier and we have secured our arm to the patient’s arm we only have to now lean back slightly to encourage extension. This makes the movement as easy on our own body as possible.
The best delivery of this method seems to be with a slight curricular motion made with the arm and body as this slowly and gently introduces the necessary extension.
As with the majority of maneuvers, if the leverage is well constructed only a slow and gentle movement over a reasonable duration of time is necessary to notice more capacity for extension in the selected area. The fixed point can then be moved up or down as needed and the process repeated with little to no discomfort for the patient or practitioner.
Specific Connections
This type of arm-thoracic leverage works because of the myofascial connections between the arm, scapula, and thorax.
As the arms are lifted into shoulder flexion the tricep muscle(s) pull on the scapula. In this position, we will also get some lengthening and pull through the infraspinatus and teres minor of the rotator cuff. As the arms are both forward the scapulae are abducted which creates pull through the rhomboids and middle to lower trapezius muscles.
These muscles connect directly to the thoracic vertebrae and so when the arms move they pull on and can move the vertebrae at the fixed point the practitioner creates.
There is an element of the scapula pressing directly on the ribs and pushing them forward. However, this can be considered part of the larger pull of the muscles and scapula together, essentially forming a “sling” or half-circle of pull around the thorax.
It may be noticed that the practitioner needs to bring the straight arm well across the body to properly engage the barrier. This may be due to an existing rotation in the thoracic spine which must first be overcome to allow for engagement of the sagittal plane. Another possibility is that the tension from the bent arm and forearm grasping arm is insufficient and has to be drawn further across to lengthen the associated arm and scapula muscles enough to create a stronger pull. As always the capacity to palpate the effect dictates the capacity to achieve the intended result.
Remember always that the thoracic spine is just adapting to the way it is being and has been used by the patient. Though it is not beneficial it is somewhat normal to have a very rounded and rigid thoracic spine. This means that punishing the thorax for that adaptation with harsh movements is short-sighted and typically ineffective long term. Sometimes a gentle or flimsy hand works better than a harsh one.