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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE December 2021 New Evidence of Essential Thoracic Mobility for Normal Upper Limb Function by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario...What would you do? A 35 yr old male firefighter who enjoys playing volleyball on an intermediate level 6's team at the local indoor courts gradually developed complaints of R dominant hitting arm shoulder pain superior/anteriorly during volleyball hitting > blocking and with overhead work and ADL demands. Plain films are unremarkable. Clinical exam shows tenderness at the supraspinatus and LHB tendons, (+) impingement - Rotator cuff syndrome tests, weakness/pain especially with elevation and ER resistive tests. He has a typical "poor posture" both statically and also during AROM testing. You're ordering Physical Therapy and seeing him back in 4 weeks to consider if he is progressing adequately and to decide if further diagnostic testing is necessary. Your expectations of his PT evaluation/report......subsequent treatment would be...? Palpation, special testing, resistive testing.....modalities + simple shoulder stretching & strengthening program AROM shoulder/trunk, palpation, special testing, resistive testing....modalities, manual therapy to trunk/scap and shoulder prn, stretches prn, strengthening scapulothoracic and shoulder muscles/function per findings AROM, resistive testing...simple shoulder protocol (Jobe's exercises or Thrower's Ten) AROM shoulder + kinetic chain trunk/scapula, special testing, palpation, resistive testing... Class IV laser, stretching sleeper/pec major/Hor Add posterior RC, strengthening RC....address thoracic spine if not improving CURRENT EVIDENCE Heneghan et al. Thoracic Spine Mobility, An Essential Link In Upper Limb Kinetic Chains in Athletes: A Systematic Review. Translational Sports Medicine. 2019, 2(6). 301-305. https://doi.org/10.1002/tsm2.109 SUMMARY: Upper limb injury and pain is a commonplace issue, especially of the shoulder, for many athletes and non-athletes alike. Determining and prescribing what "standard care" is for shoulder and upper limb injuries/pain often focused solely on the local tissues but new evidence presented by Heneghan et al supports the concepts of kinetic chain "regional interdependence" that must understood by all musculoskeletal providers in order to optimally care for our patients. These biomechanics relationships, in this case with the thoracic spine, provide a potential source for contributing factors causing tissue overload and kinetic chain issues that also may delay recovery. Understanding these are critical for prescribing treatment and especially performing successful physical therapy in these cases. Heneghan et al provide some important insights into the relationship between normal shoulder ROM and associated thoracic spine mobility, especially noted during end ranges of shoulder flexion more so than other elevation directions and mutually more so than during other motions. Achieving unilateral or bilateral elevation ranges produced the greatest thoracic spine mobility demand, that being extension during shoulder flexion. Clinically we often see kinetic chain factors either addressed generically or not at all. Prescriptions rarely specify expectations of thoracic/scapular assessment and care. Patients seen due to "failed PT" elsewhere often report being handed a generic exercise sheet to learn and perform at home...the same sheet other shoulder patients were using. Assessing and restoring WNL thoracic/scapular kinetic chain function is necessary for the shoulder/upper limb to perform normally. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) You can read the full version below Background: Traditional exercising and rehabilitation for shoulder limitations and injuries continue to be heavily focused on GH joint function and strength/mobility, and active and athletic populations can at times have recovery programs falling short to achieve full function. This study looks at thoracic mobility in unilateral and bilateral UE overhead ROM to assess kinetic chain connections in regards to necessities with functional movement. Methods: A systematic review through June 2018 of 554 initially retrieved studies resulted in seven meeting eligibility criteria that included a population of healthy 18-40 year old men and women (Males= 33%) with a sample size of 168 individuals, including 20 athletes. Thoracic spine extension, rotation, and lateral flexion were assessed during upper limb abduction, right scapular elevation, flexion, extension and scapular elevation, flexion and abduction, external rotation, functional flexion and (B) elevation using various data acquisition/measurement systems. Results: Unilateral and bilateral UE full flexion elevation resulted in 6.7-8.0 deg and 12.0 – 15.0 deg of thoracic extension, respectively. Unilateral and bilateral UE abduction elevation resulted in 3-4 degrees 9.0 – 12.8deg of thoracic extension. Lateral flexion ranged from 2.7 – 9.0 deg between various studies during different planes of unilateral end ranges of elevation, most often in contralateral direction and at lower thoracic segments especially. Thoracic rotation ranged from 2.1 – 11 deg for the various planes of elevation, greatest being scaption and abduction. Lateral flexion and rotation were negligible during (B) maximal elevation. Thoracic movement in early/mid ranges of movement have poor evidence/agreement with singular studies reporting 11 deg extension at mid range flexion and 8.9 deg during ER AROM. Author's Conclusion: There was significant thoracic extension occurring in flexion, abduction and scapular elevation in unilateral and bilateral UE elevation. Although the evidence quality is low, sample size small, and more research would be beneficial in an athletic population, a more thorough thoracic spine focus is warranted for practitioners working with athletes on functional UE movements involving the kinetic chain. THE PEAK PERFORMANCE PERSPECTIVE: As a referring physician you’re often challenged by making determinations of what treatments to recommend or what “good” therapy entails when prescribing physical therapy for various upper limb conditions. Common expectations for traditional physical therapy would certainly include possibly local modalities to reduce pain and inflammation, manual therapy, and local stretching and strengthening. Evidence has been lacking regarding the kinetic chain importance of the thoracic spine’s mobility and shoulder/upper limb function. Heneghan et al provide some valuable data that helps identify the relationship of thoracic motion during arm movements, providing a basis for prescribing and expecting that shoulder/upper limb care will assess and treat related thoracic spine limitations that may be contributing factors or could be a source of slow recovery or “failed” conservative care. Individuals coming into a physical therapy clinic with pain and limitations with their shoulder or elbow do not expect that their pain is caused from joints or muscle limitations from a region not directly at the site of their pain. But what we find as movement specialists during kinetic chain assessments, supported by Heneghan et al's findings, is that thoracic spine limitations in any one of the three planes, can play a role in limiting arm mobility (especially thoracic extension related to overhead function) resulting in negative effects during work, ADL, and/or athletic activities performed. These limitations more proximally at the thoracic spine certainly happen for a variety of reasons, most commonly sedentary work duties (especially with prolonged neck flexion or computer screen use) , poor posturing in general, or activities involving prolonged/repetitive spinal flexion such as masonry and lifting from lower levels. Another key component can be attributed to classic forms of fitness training that many have become accustomed to involving isolated single plane movements such as weight machines or group fitness classe. These are commonly performed with bilateral upper extremities simultaneously which can be safe and effective for some, but if there are other mobility restrictions such as with the spine, then not just the shoulder but the more distal joints can be stressed more and in abnormal locations. Those forms of exercises also do not necessarily train one's body for the stresses of athletic events including spiking a volleyball, swimming freestyle or backstroke for example, or throwing/serving overhand in baseball, volleyball or tennis. The repeated stresses on those more mobile joints such as the shoulder, in the presence of thoracic mobility limitations, can then lead to instability and possible more serious tissue damage and even the need for surgery when not addressed in time. Heneghan et al reminds that there exists very little literature on how more proximal segments in the kinetic chain, including the thoracic spine and pelvis, affect more distal segments in athletic events. They do, however, cite that other researchers have discovered approximately 55% of total force and kinetic energy during a throw is derived from the thoracic spine and approximately 80% of total axial rotation is utilized. They also noted prior research demonstrating a 3x higher elbow/shoulder injury prevalence for softball players with limited trunk rotation mobiity. This leads to the question - “Why do so many shoulder rehab programs only focus the involved shoulder, elbow, or wrist?” It has been our experience that many traditional UE strength exercise movements are not tolerated well by patients in a rehabilitation program for "shoulder pain", including unilateral isolated, typically long lever type movements with either weights or resistance bands, as they can excessively stress GH jt structures, and sometimes even bring on more impingement symptoms or joint crepitus, and pain in general - especially because they are oftentimes taught in very strict postures that prevent thoracic mobility contribution to total motion. Some examples include traditional long lever exercises like flexion and abduction raises, empty cans, full can scaption, T-Y-I (mid/lower trap stimulus), wall walking, door sliders (abd press in ER) among others. While these aren't "bad" exercises, they can easily be inappropriately applied at the wrong time during recovery, through ROM that is irritating, and often are done intentionally preventing scapulothoracic motion under the auspices of "strict technique" and "isolation" concepts. These patients or fitness enthusiasts often have increased thoracic kyphosis and anteriorly tipped scapulae, which then prevents fluid and necessary humeral head mobility and control. So if proximal structures that are limited are not addressed, oftentimes recovery is slow or absent leading the patient to report back to their physician complaining that nothing has changed, or the pain has not decreased, or they still cannot play their favorite sport. The appearance of a potential “failed case” of PT then may trigger more expensive testing or injections etc when, in fact, it was simply more thorough kinetic chain care that was needed. Once addressing thoracic and lumbar spine limitations, the scapular and GH joint mechanics and ultimately functional use tends to improve. A great example would be the financial planner sitting 40 to 50 hours per week and then reporting he/she is feeling frustrated when one shoulder hurts when they play in their once weekly volleyball league. Working on transverse and frontal plane thoracic mobility, as well as thoracic extension, will allow for kinetic chain scapular posterior tipping/adduction/upward rotation. This will allow for full overhead GH jt mobility with successful humeral inferior gliding to prevent impingement when serving/hitting overhead, and ipsilateral lateral spinal flexion for loading into overhand serving. Without the thoracic mobility, the scapula will be blocked and rotator cuff impingement will likely happen. With all UE overhead movements, Heneghan et al’s systematic review noted a constant, that all UE movements initiated some level of thoracic ROM, but only at mid to end range of UE elevation. The greatest thoracic ROM needs were found to be thoracic extension with full UE overhead flexion elevation (6.7-8deg uniliateral and 12-15 degrees for B UE), followed closely by scapular elevation (4-8.9 deg unilateral ) and UE abduction (9-12.8 deg bilateral). The limitations for this systematic review do state only one study looked at an athletic population, and some sports with a greater proximal restriction including wheelchair basketball may require more focus and more thorough assessment. The meta analysis does have some limitations. The quality of studies was generally low, the study population was mostly females, and these were not athletes per say but “of athletic age” rather. Therefore the generalizability to other populations must be considered, however, there was a consistency among studies demonstrating thoracic motion relationship to shoulder elevation end ranges especially. Physicians prescribing PT for shoulder and UE conditions have an evidence basis for appreciating the importance of and expecting a full kinetic chain assessment, especially including the thoracic spine, for their patients being prescribed PT for UE pain or limitation, regardless of age, sex or activity. We may also want to consider including more spine focus in post-operative protocols, along with respect to healing the injured and repaired tissue. By considering the authentic biomechanics effecting and contributing to stresses and healing potential of involved tissues. We will be doing a more positive service to our patients and they may even have improved function and mobility than they have ever had prior. THE PEAK PERFORMANCE EXPERIENCE Greg stated: "I don't have any pain with activities!" HX: Greg was performing push-ups during a workout and felt a pop and grinding in his R shoulder and pain continued with even light exercises and movements from that point on for approximately one year. Using his R arm during his job tasks started to become uncomfortable. Pain levels could reach 8/10 at times. Any lifting and reaching with his R arm became an issue. Objective Data: MEASURE ( *=pain) Evaluation DC Thoracic Posture Kyphotic Scapular Posture Protracted Thoracic Rotation 59 / 50 Shoulder Abd IR 50 56 IR up back T10 T8 Overhead Press Reach Unable * 5# done 10x Speed's (+) (-) O'Brien's (+) (-) Jobe's (+) (-) Sulcus sign (+) (+) Treatment: Manual: Post/inferior humeral mobs, pec minor release, horizontal abd with IR stretching Exercises: Posterior capsule stretching, T-spine extension/SB/rotation stretching, T-spine frontal plane/transverse plane strength with dumbbells, T-spine extension drills with shoulder OH pressing with biases towards rotation, resistance tubing RC strength with in-sync T-spine rotation and SB, dumbbell push-pull drills for scap stability, serratus strength with tubing and DBs progressing in scaption and SG plane OH. Outcomes: Painfree ADLs, Painfree incline push-ups ~3ft elevation table, painfree plyo shoulder drills and no limitations with work tasks. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patient's functional goals.