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The thoracic spine and diaphragm – important considerations for people with scleroderma, asthma or pneumonia

In August 2005 my father died from Systemic Scleroderma, a complex autoimmune condition that markedly restricted the mobility of his lungs and diaphragm. In working with him many years ago I realised that there are many limitations in the way pilates teachers and physiotherapists work with the thoracic spine and breath. It started me on a very personal journey of reflection, research and considerations, so that I could better assist others to improve their thoracic and lung function. I started to explore gyrotonic as well as many different pilates styles. This article is written 11 years since his death and it is intended to share my observations and reflections about the thoracic spine and some ideas for exercises and modifications. This article is not intended to be read as the only truth, but to give others an opportunity to review their own practice and look at it from a different perspective.

The thoracic spine and its relationship to breath

One of my first realisations when I was taught pilates and later trained in the method was that there did not seem to be a great deal of focus on rib and full diaphragm movement. I began to observe that a lot of long term pilates clients and teachers, including myself, had quite flat thoracic spines. The flattening of the thoracic spine was partly due to excessive tone in the rectus abdominus muscles and an imbalance in the psoas/rectus abdominus rhythm needed for functional movement of the diaphragm. Stiffness in the sacral area and sacroiliac joints were also noted. Additionally, this flattening could also be attributed to poor cueing techniques, which I will discuss later in this article.

I will be honest with you: I also see this thoracic flattening in long term yoga practitioners, gyrotonic teachers and dancers – possibly from the counterbalancing load of excessive eccentric psoas work and thoraco-lumbar extensions.

In addition to the postural issues I have observed in the various practitioners of movement techniques, amongst my clients I have been observing an increase in thoracic/diaphragm problems including:

//   Thoracic stiffness. Remember that thoracic stiffness can be a strategy for poor abdominal control but can also occur because of poor neck and shoulder patterning;

//   Tightness in the diaphragm and the costal arch. The diaphragm is a muscle that in moving facilitates breathing and moves adjacent organs;

//   Increased patterning of apical breathing with its associated problems.

We could spend hours debating whether the modern digital age is to blame. However, for the purposes of this article I am asserting that the change in posture and technology use (since the release of the first iPhone in 2007 and the array of other devices since) has contributed to different shoulder neck and thoracic spine patterning to that faced by Joseph Pilates. My issue is whether we as movement teachers have:

//   Responded appropriately to assisting the clients before us. Or are we contributing to more postural problems?

//   Limited our view of the “core” to simply abdominal stability and a brace mentality which has contributed to poor diaphragmatic movement;

//   Underestimated the importance of thoracic/rib movement and flexibility and how we can program for that in a movement class.

Let us start with some anatomy

As always, we should start with anatomy and think how this applies to movement. Our primary muscle of breath is the diaphragm but there is a huge list of additional muscles that help facilitate movement.

How does the diaphragm move?

When we inhale:

//   The diaphragm descends;

//   The rectus abdominus is worked eccentrically;

//   The psoas concentrically contracts and therefore the vertebrae of the spine are pushed into a small extension;

//   The ribs starting from and 12 are pulled posteriorly in a pincer movement and then progress up the spine to a bucket handle motion for ribs 10-5 and then a pump handle motion in the upper ribs;

//   The vertebral discs are pulled slightly anterior by the psoas major.

//   The sacrum moves slightly forward (anterior)

//   The illiums open out (i.e. they move posteriorly) to allow the organs in the body to drop down

//   The femoral heads are pulled into a slight external rotation and pulled posteriorly in the acetabulum.

When we exhale:

When we exhale, the psoas is pulled upwards and the rectus abdominus is pulled downwards allowing the diaphragm of the body to ascend. A little rhythm should ideally happen in the lower parts of our body:

//   The psoas eccentrically contracts and therefore the vertebrae of the spine are pushed into a small flexion (or imprint);

//   The ribs starting from T12 are pulled anteriorly (and slowly furl the ribs from bottom to top) to allow the lungs to contract;

//   The vertebral discs are pulled very slightly by the psoas major;

//   The sacrum moves slightly backwards (posterior);

//   The illiums open out (i.e. they move anteriorly) to allow the organs in the body to lift up;

//   The femoral heads are pulled into a slight medial rotation and pulled anteriorly in the acetabulum.

Posterior/lateral breath taught to pilates teachers – is it always appropriate?

Joseph Pilates was an asthmatic, and as a result he was naturally focussed on encouraging and assisting the exhale. It is no wonder that many of the exercises in the method involved C Curve and thoracic flexion so as to improve the tone of the rectus abdominus and the muscles facilitating the exhale. However, the breath patterns taught in a traditional pilates class were associated more with the exhale on effort, which is not always good for intra abdominal pressure. Over time, the concept of posterior lateral breath was taught to pilates teachers to help with this issue of intra abdominal pressure.

With lateral breathing, which is also known as lateral basal breathing, side rib breathing or bellows breathing, air is directed into the sides and back of the ribcage and into the lower ribs (the ribs that move as a bucket handle). The focus of lateral breathing is on having the ribs expand outwards and upwards with minimal movement of the belly, which could work in a four point or plank position. Lateral breathing, like belly or diaphragmatic breathing, directs air into the lower lobes of the lungs where oxygen is most efficiently absorbed into the bloodstream. This technique is commonly used when there is exertion or abdominal work as it allows the abdominal muscles to assist in the exhale on exertion. It is also useful when there is loaded work on the arms, for example plank or elephant on the reformer, where you need to stabilise the shoulder girdle on the thoracic spine and ribs. Unfortunately, over the years (when at conferences or observing in studios) I have seen many clients encouraged to breathe laterally in situations where there is no load on the thoracic spine or effort demand. As a result, clients were not allowing the ribs to do their special little pivot on the vertebral body. That little pivot is necessary for the intercostals to expand and release which allows the Diaphragm to ascend and descend to its full capacity. Furthermore, the lateral breath pattern limits the sternal glide necessary when flexion of the thoracic spine occurs, particularly when the person is in supine.

Experiential

Consideration one: Using posterior/lateral breathing

Try lying supine on the Reformer (or on a mat) and putting your legs up in the air. Bring your arms down to the mat whilst initiating lateral breathing techniques. Observe:

//   How does your thoracic spine feel?

//   Is there tightness in the neck?

//   Does your breath catch in your throat?

//   Does your sternum soften and slide down towards the pelvis as you lower your arms?

Think about your clients when they do this activity and the tension that you observe. Many teachers answer this by cueing the person to “funnel down the ribs,” which tightens the obliques and further limits the range of movement of the diaphragm.

In such scenarios we as practitioners should consider:

//   That in supine the thoracic spine should go into slight extension and therefore favour inhale patterning;

//   That in supine the body’s response to gravity is different to when standing. Think about good alignment in standing; each joint is designed to be upright and in response to the pull of gravity (top to toe direction), joints can ‘hang’ in their resting position with minimal effort from muscles to prevent sag. Whilst in supine the pull of gravity occurs in a front to back direction, pulling the joints out of their resting position.

Consideration two:  Allowing diaphragmatic movement

Lie on the Reformer or the mat and prop yourself up with towels to place the thoracic spine in a slight flexion. Support the neck and allow the humeral heads to sit in a comfortable position in the glenohumeral socket. Inhale as you raise your arms and allow the spine to extend a little and the tummy to slightly lift. As you exhale slowly allow your arms to lower, your sternum to descend and your ribs to open up at the back.

Observe:

//   Is there a slight imprint in the sacrum as the sternum softens?

//   Is there tension in the neck or shoulder?

//   Does the breath flow or catch somewhere?

My suspicion is that you will find that the tummy does lift a little – it has to because when the diaphragm descends on an inhale the organs have to go somewhere. However, the rectus abdominus and psoas rhythm we talk about above means that this is necessary for the diaphragm to fully descend and the organs to descend into the greater pelvic cavity. One solution to this is generally to prop the person up with towels to support their head, neck and thoracic spine so as to put them into a slight flexion allowing tension to come out of the sternum. Without the towels on the reformer the head rest simply juts the jaw forward and does not necessarily result in a relaxing of the sternum and thoracic spine to allow full range of movement of the diaphragm.

Suggestions for improving thoracic spine mobility in a movement setting and to help facilitate better diaphragm functioning

Remember that these exercises are not appropriate if clients have fractured ribs, osteoporosis in the thoracic spine or other rib problems where stability is needed. These exercises are to be included in a balanced program of both stability and movement.

Suggestion one:

Encourage a slight thoracic flexion when a person is in supine and in a position that has them straightening their legs and lengthening/pulling the psoas at the diaphragm and thoracic attachment points. For example, use the towel setup on the reformer as shown below.

Suggestion two:

Encourage a balance of eccentric rectus abdominus with concentric psoas work as well as concentric rectus abdominus work and eccentric psoas. In the exercise below we have used a sling underneath the lower ribs to help facilitate a pull to assist in the release of the diaphragm. If you don’t have a sling try using the safety strap off the reformer and put a fuzzy or soft long pillow on the strap where the person lies. The idea of this exercise is that the person can work against the spring resistance to help rock between extension and flexion to start freeing the lower ribs. As control starts to improve the person can start to lengthen one or both legs to add in psoas challenge or chest lifts etc.

Suggestion three:

Encourage arm and rib rhythm to help the obliques, intercostals and serratus anterior to keep mobile. The ‘spine corrector overhead reach’ exercise is ideal for this. In a reformer setting we have added the variation with a bumpy ball to help keep the client moving and challenge them a little at the same time.

Suggestion four:

Encourage the client to achieve a lateral translation in the thoracic spine before adding rotation. Remember that the facet joints in the thoracic spine have a vertical orientation and as a result generally need a little side shift in order to encourage movement of the spine and ribs into rotation. Whilst I love the side lying work on a barrel for opening the intercostals the static lie generally does not help the shimmy of the facet joints needed to improve rotation and therefore thoracic mobility. I would generally encourage someone to sit or stand with their hands on the side of their ribs. I would have them place their thumb at the back and fingers at the front and use the webbing of one hand to push the ribs and thoracic spine to the opposite side. Have the person push their ribs back and forward between the movement. You can try this exercise now, but before you do test your thoracic rotation.

Example of a lateral bend before you do things like thread the needle:

Suggestion five:

Vary the breathing patterns to allow more diaphragmatic movement and control particularly in supine, standing and sitting positions.

Suggestion six:

Encourage side rolling in a class, using some of the nice Feldenkrais practices.

I am updating this article in 2019 to incorporate a class that I wrote for thoracic mobility using Makarlu

These concepts and ideas are discussed and explored as part of the various Anatomy Dimensions courses that we teach throughout the world from time to time.  These courses are designed to work with practitioners needing to better understand how to better work with the body and many methods of movement.  Our philosophy is to give teachers the skills to critical think and respond to their various clients with compassion and professionalism.

Carla Mullins is co-director and co-owner of Body Organics, a multidisciplinary health and body movement practice with 3 studios in Brisbane. Carla is a Level 4 Professional Practitioner with the APMA and has also studied pilates with APMA, PITC as well as Polestar. She also has a LLB (QUT), M. Soc Sc & Policy (UNSW), Advanced Diploma of Pilates Movement Therapy (APMA), Diploma of Pilates Movement Therapy (APMA), Diploma Pilates Professional Practice (PITC), Gyrotonic Level 1, Gyrotonic JSB, Gyrotoner, CoreAlign Level 1, 2 and 3 and Certificate IV in Training and Assessment. Carla also has returned to University to complete an Occupational Therapy Degree.