The Thoracic Ring Approach™ challenges long-held beliefs around the function of the thoracic spine and ribcage, and proposes innovative assessment and treatment frameworks based on a broader understanding of how these areas are designed to optimally function… in the context of whole body movement and optimal health of the whole person.
This approach was developed by LJLI founder, Dr. Linda-Joy (LJ) Lee, and represents the integration of knowledge from a wide variety of sources – LJ’s clinical experiences and PhD research journey, established research from other areas of the spine, peer appraisal and feedback from clinicians LJ has taught and mentored, and LJ’s own personal injury experiences.
Connecting the Thoracic Spine and Ribs – The “Thoracic Ring”
Historically, clinicians have assessed the function of the thoracic spine separately from the function of the ribs, and techniques have focused on determining motion and integrity of the articular structures (facet or zygapophyseal joints, costotransverse joints, costochondral joints, sternocostal joints), with a focus on posterior palpation1. Based on anatomical and biomechanical data, LJ has proposed that the most accurate evaluation of function in the thorax is based on understanding that the functional spinal unit in the thorax is the “thoracic ring,” where there are anterior attachments to the sternum (usually 1st to 10th rings)2,3,4.
The “thoracic ring” consists of two adjacent vertebrae and the related intervertebral disc, the right and left ribs (attached to the vertebra-disc-vertebra complex at the costovertebral joints), and the anterior attachments to the sternum/ manubrium and related cartilages. So the “5th thoracic ring” is defined as the T4-5 vertebral segment and disc, the right and left 5th ribs, and the anterior attachments of the 5th rib to the sternum1,2,4,5,6,7.
Thoracic Ring Approach techniques employ palpation points and forces applied around the anterior, lateral and posterior ribcage to assess and treat the rings in an integrated, 3-dimensional way that assesses connections between the thoracic spine and the ribcage, as well as the connections between neighbouring thoracic rings, and between the rings and other regions of the body2,3,5,6,7,8,9. Due to the strong anatomical connections between the ribs and thoracic spine, motion detected at the lateral ribs reflects vertebral motion and forces applied to the side of the ring impact the vertebral segment as well as the ribs (i.e. the entire ring)10.
LJ has always been passionate about functional movement analysis and changing brain maps for posture and movement to optimize how people live and move in their bodies. In this way negative experiences of the body can change to positive ones, and performance is optimized. In the thorax, development of “ring palpation” techniques allowed LJ to more comprehensively assess detailed function of the thorax during tasks that were problematic or goal-related.
How do you know if the thoracic rings are “The Driver”?
Thoracic ring techniques facilitate assessment of inter-ring (segmental) motion and control during functional tasks, as well as analysis of multiple rings and inter-regional relationships simultaneously. Furthermore, thoracic ring palpation and “thoracic ring correction” techniques2,3,5,6,9 provide a method to evaluate the connections between a dysfunctional thoracic ring and whole body function5,6 in the framework of Meaningful Task Analysis (MTA)3,11.
This clinical reasoning framework allows clinicians to determine when the thoracic rings are the “Primary Driver,” or true underlying problem of the person’s problem related to their Meaningful Task. This is essential because it is common for the thorax to be relatively pain-free but dysfunctional; the dysfunctional thorax creates adverse stresses, loads and forces that can cause pain in any other area of the body. If the thoracic rings are behaving non-optimally for the task, optimal movement and control of the thoracic rings is manually facilitated with “ring correction” techniques, and the impact of these corrections on the patient’s meaningful task performance, pain experience and function of the rest of the body is assessed. In this way, The Thoracic Ring Approach provides the clinician with a robust clinical reasoning algorithm, to determine when to treat the dysfunctional thorax, and when not to, in order to change the patient’s experience of their body (including their pain) and restore optimal strategies for function and performance.
Treatment in The Thoracic Ring Approach
The most common treatment techniques used in the thorax are those that work to increase mobility – which is consistent with the belief that the thoracic spine is stiff and inherently stable. The evidence supports the opposite – that this region of the spine is in fact inherently flexible. There are 13 joints per typical thoracic ring, and each joint has the capacity to move. Therefore, we must consider the requirements for neuromuscular control in the thorax. The Thoracic Ring Approach moves away from conceptualizing the thorax as a static, stiff box, to being a dynamic stack of ten rings, much like a “slinky” or a shock-absorbing spring. This dynamic view of the thorax means that an essential component of treatment is training optimal muscle activation patterns and muscle balance around the thoracic rings. Manual techniques, taping, needling and self-release techniques such as “self stack and breathe” are used to release non-optimal muscle patterns to create a window of opportunity to train new muscle patterns.
Shifting from the paradigm that the thorax is stiff and requiring mobilization to one where the thorax is flexible and requiring optimal neuromuscular control provides greater insight into why the thorax can drive distal problems. When there is loss of optimal sequencing, force modulation, and synergy between the muscles around the thoracic ring, between the ten thoracic rings and between the rings and other regions of the body, there are many possible consequences throughout the whole body. These consequences can result in non-optimal loading of multiple different structures and regions of the body that can drive conditions as diverse as hip osteoarthritis, impingement and groin pain, pelvic girdle and low back pain, incontinence and prolapse, achilles tendinopathy, patellofemoral pain, shoulder impingement, lack of “core stability” and headaches. Furthermore, due to the anatomical relationships to the sympathetic chain and innervation of the viscera, the thorax can drive other non-optimal experiences such as sensitization of the sympathetic nervous system and gastrointestinal symptoms.
There are many different problems that can be “driven” by a non-optimal thorax, and multiple biologically plausible mechanisms have been proposed in The Thoracic Ring Approach to explain how the thorax can be the true underlying problem for a wide variety of conditions. If the thorax is the driver for a problem, the most efficient and effective treatment for the problem, whatever the symptom, is to treat the thoracic rings and train new strategies for thoracic ring control, muscle balance and strength between the rings and other regions.
The Thoracic Ring Approach is an integral part of The Integrated Systems Model (ISM) co-developed by LJ Lee and Diane Lee12 and the new ConnectTherapy Model (Lee LJ 2014). Therapists can learn Thoracic Ring Approach techniques on short courses and the ConnectTherapy Series.
Lee DG. Manual Therapy for the thorax, 1st ed. DOPC, British Columbia: Diane G. Lee Physiotherapist Corp., 1994.
Lee LJ: Thoracic stabilization & the functional upper limb: restoring stability with mobility, Course Notes. Vancouver, BC. 2003
Lee LJ. The essential role of the thorax in whole body function and the “Thoracic Ring Approach”, Assessment & Treatment Videos. Linda-Joy Lee Physiotherapist Corp (www.ljlee.ca); 2012.
Lee LJ. Motor control and kinematics of the thorax in pain-free function. University of Queensland, Australia: 2013.
Lee LJ. A clinical test for failed load transfer in the upper quadrant: how to direct treatment decisions for the thoracic spine, cervical spine, and shoulder complex. Proceedings of the 2005 Orthopaedic Symposium of the Canadian Physiotherapy Association. London, Ontario, Canada, 2005.
Lee LJ. The Role of the Thorax in Pelvic Girdle Pain, Presented at the 6th Interdisciplinary World Congress on Low Back and Pelvic Pain, Barcelona, Spain November 7-10, 2007.
Lee LJ, Lee DG. An Integrated Multimodal Approach to the Thoracic Spine and Ribs. 2008. In: Magee et al: Pathology and Intervention in Musculoskeletal Intervention, Elsevier.
Lee LJ. Chapter 7: Restoring force closure/motor control of the thorax. In Lee DG ed. The Thorax An Integrated Approach. White Rock, BC: Diane G. Lee Physiotherapist Corporation, 2003b.
Lee LJ. Discover the role of the thorax in total body function: Introduction to the Thorax ‘Ring Approach’, course notes. Bergen, Norway; 2011.
Keene C. Some experiments on the mechanical rotation of the normal spine. The Journal of Bone and Joint Surgery 1906; s2-4(1): 69-79
Lee LJ. The Essential Role of the Thorax in Restoring Optimal Function. Keynote presentation at the 2008 Orthopaedic Symposium of the Canadian Physiotherapy Association, Montreal, Canada, October 2008.
Lee LJ, Lee DG. Chapter 7: Clinical Practice – The Reality for Clinicians. 2010. In Lee, DG: The Pelvic Girdle. Elsevier, pgs. 255-282.