Clinical Insight: Thinking Thoracic

In this month’s Clinical Insight, the team have been thinking about the role of the thoracic spine as part of cervical neck pain, low back pain and limb symptoms.

It became clear that this central area of rotational/extension mobility can be considered an area of movement that may be beneficial in a range of conditions. It is not concluding a direct causal link but contributes to a framework of correlating factors in a wide rehabilitation approach.

Biomechanically, thoracic spine extension is synchronised with shoulder elevation, with the lower thorax offering the main contribution. In the upper thoracic spine, we see contributions to scapula-thoracic kinematics (Howe and Read, 2015). In rotator cuff related shoulder pain, when compared to healthy matched controls, a loss of cervical and thoracic spinal motions was identified in those with pain (Manoso-Hernando et al, 2024). Ongoing cervical spine pain can be linked to loss of motion and alterations in both neck and thorax motion (Moghaddas et al, 2019). Changes are noted with those reporting cervicogenic headache and migraine in terms of thoracic posture (Ahadi et al, 2022).

Thoracic Mobility and Its Influence

It is clear that reference to movement in the thoracic cage can influence a range of secondary musculoskeletal movements and dysfunctions. It would be wrong to conclude that a singular factor can ever be the driver or cause of an ongoing pain experience, however as therapists looking to interact with the presentation in a positive way, the improvement in movement may have a beneficial outcome.

Locating a loss of extension and/or rotation through assessment and palpation may lead the clinician to infer a possible inclusion of the thorax into the contributing factors for the pain experience plus loss of function.

Getting the patient to move effectively, more often from areas of lack of mobility, may require close observation and feedback to change a “behaviour” or way of moving. This could be enhanced by any number of supportive handling methods.

Improved Movement can Improve Outcome

By improving movement, what rationale can we offer to an improved pain experience?

There may be a change in tone across the spinal area which could lead to improvement of outcome. Muscle tone, or shortening, may be considered a contraction of motor units led by an activity of muscle spindles, and will occur naturally in anti-gravity muscle groups (such as the thoracic spine).

Muscle spasm can be linked to increased EMG activity, as opposed to shortening which may happen over time. Muscle spasm may be linked to pain due to a range of chemical mediators initiating a peripheral sensitisation to, for instance, pressure or movement (Simons and Mense, 1998). Therefore, improving the tissue movement locally may change this dynamic, leading to an improved sensitisation and a subsequent reduction in tone. Secondary areas (such as neck and shoulder) may also gain a greater freedom.

These changes will improve confidence and function, and as the patient achieves more with less fear, they will see these influences as a positive effect on their pain experience (Nieto-Marcos et al, 2025).

Overall, it would seem sensible when addressing long-term physical function loss across the kinetic chain, to consider the thoracic spine as part of a standard assessment and intervention programme.

Next month’s edition will look at interventions in a little more detail. Follow us on LinkedIn for more Clinical Insight articles.

References

• Ahadi, P., Rezaei, M., Salahzadeh, Z., Talebi, M., Sarbakhsh, P. and Azghani, M.R., 2022. Assessment of the head, cervical spine, thoracic spine and shoulder girdle postures in people with and without chronic headache. International Journal of Therapy And Rehabilitation, 29(3), pp.1-13.
• Howe, L. and Read, P., 2015. Thoracic spine function: assessment and self management. Professional Journal of Strength and Conditioning, 39, pp.21-31.
• Manoso-Hernando, D., Bailón-Cerezo, J., Elizagaray-García, I., Achútegui-García-Matres, P., Suárez-Díez, G. and Gil-Martínez, A., 2024. Cervical and thoracic spine mobility in rotator cuff related shoulder pain: A comparative analysis with asymptomatic controls. Journal of Functional Morphology and Kinesiology, 9(3), p.128.
• Moghaddas, D., de Zoete, R.M.J., Edwards, S. and Snodgrass, S.J., 2019. Differences in the kinematics of the cervical and thoracic spine during functional movement in individuals with or without chronic neck pain: a systematic review. Physiotherapy, 105(4), pp.421-433.
• Nieto-Marcos, S., Álvarez-Álvarez, M.J., Leirós-Rodríguez, R., Castro, A.G., Rodríguez-Nogueira, Ó. and Pinto-Carral, A., 2025. The Role Of Movement Confidence And Kinesiophobia In The Clinical Course Of Low Back Pain: A Prospective Study.
• Simons, D.G. and Mense, S., 1998. Understanding and measurement of muscle tone as related to clinical muscle pain. Pain, 75(1), pp.1-17.