By Sean Fyfe
Sally is a very active young woman, working in the City. Although she does not practise a particular sport, her five or six gym classes a week have been important in bringing her relaxation, friends and a feeling of well-being.
Her recent driving holiday in France, however, was not a happy experience. Gradually she developed a searing pain on the right side of her mid- to lower thoracic spine, pain that was almost intolerable when she was sitting for any length of time.
The pain was associated with severe lower thoracic stiffness and over-activity through the quadratus lumborum and erector spinae muscles on both sides. To make matters worse, Sally has a daily two- hour commute by train and a sedentary desk job. Sally’s pain progressed to central pain throughout the T6 to T9 region, which was intensified with thoracic rotation and slump testing.
I started off Sally’s treatment with joint mobilisation, soft tissue massage and trigger point manipulation, advice on ergonomics and sitting and a set of flexibility exercises. While her symptoms soon diminished, they remained, and continued to be quite variable.
A thoracic spine X-ray revealed moderate degenerative changes in the upper-/mid-dorsal spine with some osteophyte formation. At 31 years old, Sally is rather young to have these changes in her spine. The report from a subsequent MRI scan ordered by the consultant read thus: ‘Small posterior disc bulges are seen at T6/7 and T7/8. At T6/7 the disc is small and right paracentral, abutting the right side of the cord, but with no cord compression or stenosis and at T7/8 a similar small disc is seen, which is in the left paracentral location. Again, it is slightly indenting the left central side of the cord but it is not causing marked cord compression.’ The consultant concluded that Sally should expect this at her age and she would just have to put up with the pain.
That’s not how I see it and this is the first lesson I would draw from this case study. Health professionals must look beyond structural pathologies. What was causing these changes to occur in Sally’s thoracic spine? I have described Sally’s history, symptoms and aggravating factors, but I needed far more information to be able successfully to address the underlying causes and prevent further degeneration. I needed to know exactly how Sally was moving and how this could be adversely loading the injured area.
Sally’s pattern of muscle activation demonstrated significant imbalance and this had led to poor posture and lack of ability to move in specific directions. In standing, Sally was very anteriorly tilted. She was extremely overactive through her lumbar spine extensors and hip flexors and had no ability to activate through her lower abdominals. In effect, she stood with her lumbar spine locked in an extended position and when she needed to flex through her spine she did this through the mid-thoracic region. She could not move through a controlled range of lumbar flexion, a deficiency that, over time, had led to soft-tissue restriction to lumbar flexion.
Most notable was Sally’s complete inability to posteriorly tilt her pelvis. When trying to perform this movement, she automatically flexed her mid- thoracic spine. When trying to sit with good posture, she just used her lumbar spine extensors to tilt anteriorly and there was no change in her lower thoracic spine position. When she tried to rotate and extend, she had very limited movement in her spine from T12 to T8. In sitting, her rotational movement all occurred through the mid-thoracic region – where (not surprisingly) the degenerative changes were taking place. These movement deficiencies needed to be corrected if Sally was going to offload her mid-thoracic spine and halt the degeneration.
She was already performing the regular, targeted flexibility routine. For long-term benefit, however, she was going to have to learn how to move her spine and correct her muscle imbalances. And this is the second lesson of this case study. The client needs to understand exactly how, where and what they are trying to move; which muscles they are supposed to be using to isolate a movement or hold a position. Only then will they be able to replicate the exercise at home without supervision.
My first task was to re-educate Sally’s pelvic movement. It was essential that she was able to see herself moving in the mirror (video feedback is also an option). She needed to be able to isolate movement at her pelvis and lower lumbar spine, and especially to posteriorly tilt her pelvis without flexing further up her spine, by activating through her lower abdominals and not overactivating through her upper rectus abdominis.
This brings me to the importance of breathing. Sally was an abdominal and accessory (elevation of upper chest) breather and there was very little contribution from lateral or posterolateral expansion (expansion of the lower chest when air fills up the lower lobes). I believe this was the result of the overactivity of her upper abdominals, quadratus lumborum, psoas and erector spinae, causing stiffness through the costovertebral joints of the lower thoracic spine. So we needed to focus also on retraining Sally’s breathing pattern. We did this by creating awareness of her breathing and my hands applying pressure to facilitate the movement of the posterolateral and lateral ribcage when breathing. Whenever Sally was doing exercises she had to focus on trying to relax her upper chest and let the lower chest wall expand.
Back to the pelvic re-education… Sally spent a lot of time in crook lying (on her back with her knees bent and feet flat on the floor), just isolating her lower abdominals to flatten her lower lumbar spine gently to the floor while monitoring her spine movement with one hand behind her back and the other checking her abdominal muscle activation (relaxing the upper abs while activating the lower rectus and transversus). Once this was achieved, the same movement was progressed to standing and on hands and knees.
The next stage was to load the lower abdominals. We did this with three exercises:
The leg extensions were done in crook lying by extending the left or right hip and knee horizontally, with the long leg hovering just above ground, and then returning to the starting position while holding a slight posterior tilt.
The plank (weight bearing on forearms/elbows and knees or toes in a prone position) is performed a lot both in physiotherapy rehab and in the gym with trainers. It is important that it is done with the correct posture to achieve activation and strength through the right muscles. Sally had to pay particular attention to maintaining a slight posterior tilt and avoiding becoming flexed through the thoracic spine, in order to maintain an overall flat (neutral) spine position.
The lying hip extensions were done in prone with a pillow under her stomach, once again starting with the lower abdominals drawing on a slight posterior tilt and contracting one glute max and lifting the leg a little without extending the lumbar spine.
Sally next needed to increase her active flexibility through the hypomobile areas of her spine. We combined the pelvic positioning (the movement out of anterior tilt) with active thoracic rotation in sitting and standing. Sally held her arms across her chest and tried to isolate the movement to the lower thoracic spine.
Lastly we devised an exercise that concentrated on getting active movement in the other major plane through the thoracic spine. Sally performed this on her hands and knees, similar to a cat stretch. She started by flattening her lumbar spine and maintaining that position while she tried to flex and extend through her thoracic spine. Only a small range of movement was possible, but what was important was for her to be able to isolate movement at the different levels of her spine.
These are all very simple exercises but they were very effective, because eight weeks after starting the programme, Sally was pain free. This movement re-education eliminated the loading pattern that was causing the structural breakdown of the discs, thereby changing Sally’s pain state. We also altered her weekly exercise routine so she incorporated the types of exercises we had learnt, rather than just reverting to the body pump type of sessions that had seemingly been contributing to the muscle imbalances in the first place.
Reflecting on Sally’s case leads me to highlight a couple more lessons. We need to remember that just because elite athletes can perform at such high levels on the sporting field, it doesn’t mean they are immune to poor movement patterns such as Sally’s, which can cause abnormal loading through the body. Often, elite athletes and dancers need to be brought right back to basics with rehab exercises before they can effectively perform higher level exercises with the correct posture and muscle activation.
My final point relates to the comments of Sally’s consultant upon analysis of her MRI results. I believe this example underlines how important it is for health professionals to keep promoting themselves and educating others in the health industry about exactly what we do and how we can make an impact on chronic injuries such as Sally’s.
Sean Fyfe is a physiotherapist working with Metis Physio Centres in London, a multi-disciplinary clinic. He works with elite dancers and theatre performers