Continuing Education Activity

This procedure outlines thoracic strain-counterstrain and functional positional release. These two indirect techniques are used for somatic dysfunctions of the thoracic spine. The primary indications for using these techniques are back/neck pain and patient intolerance to direct osteopathic techniques or techniques that require the patient to activate musculature. This activity highlights the role of the osteopathic clinician in evaluating and managing patients with musculoskeletal issues and somatic dysfunctions of the thoracic spine.

Objectives:

• Describe the correct procedure for treating somatic dysfunctions of the thoracic spine with strain-counterstrain and functional position release.
• Review the indications/contraindications for treating somatic dysfunctions of the thoracic spine with strain-counterstrain and functional position release.
• Identify potential complications of strain-counterstrain and functional positional release on the thoracic spine.
• Explain the importance of improving care coordination to enhance the delivery of care for patients affected by thoracic segment somatic dysfunctions.

Introduction

Upper back and neck pain caused by somatic dysfunctions of the thoracic spine are extremely common. Common causes include postural changes and injuries.[1][2] A viscerosomatic response can also cause somatic dysfunctions. For example, patients who present with chest pain may have an underlying cardiac issue and, therefore, might have a corresponding somatic dysfunction at the level of T1-T5 of the spine.

There are a variety of osteopathic manipulative treatments (OMT) for somatic dysfunctions. Indirect osteopathic techniques can frequently treat dysfunctions. Strain-counterstrain (SCS) and Functional Positional Release (FPR) are two commonly used indirect techniques. These methods require the clinician to passively take the patient into a position of ease or away from the restrictive barrier. SCS involves placing the patient in a position where the target muscle is shortened, which allows the vertebrae to return to its proper position. FPR uses components of SCS and functional method with the addition of an activating force (compression or torsion).[3] We will discuss these two osteopathic techniques to treat somatic dysfunctions of the thoracic spine.

Anatomy and Physiology

There are twelve thoracic vertebrae in the spine, designated as T1-T12.[4] The thoracic vertebrae form a kyphotic curve.[5] It is essential to note the thoracic vertebrae provide attachment to the ribcage.[6] Injuries, specifically of or originating from the ribs, are a common cause of somatic dysfunctions of the thoracic vertebrae due to the articulation between the ribs and thoracic spine.[2] The thoracic vertebrae are unique compared to the cervical and lumbar vertebrae because of the presence of costal facets.[4]

Each thoracic vertebra has six facets to allow for articulation with the ribs.[4] T1, T11, and T12 are distinct from the other thoracic vertebrae. T1 is the only vertebrae where the entire costal facets provide articulation with rib 1, and it has a very flat spinous process.[4] In contrast to the other thoracic vertebrae, T11 and T12 do not have facets on the transverse processes.[4]

Lastly, T12 articulates with the lumbar spine at the level of L1. The thoracic vertebrae have several muscular attachments, including erector spinae, interspinales, intertransversarii, latissimus dorsi, multifidus, rhomboid major and minor, rotatores, semispinalis, serratus posterior superior and inferior, splenius capitis and cervicis, and trapezius.[4] The arterial supply of the thoracic spine is primarily from the posterior intercostal arteries, branches from the subclavian artery, and the thoracic aorta.[4] The venous supply is primarily from venous plexuses surrounding the vertebral canal.[4] The nervous supply of the thoracic vertebrae is supplied by the meningeal branches which originate from spinal nerves.[4]

SCS and FPR use the body’s intrinsic ability to relax. SCS involves neuromuscular activity between a muscle agonist and antagonist called the Proprioceptive Theory.[7] This theory is based on regulating muscle spindle activity. When lengthening the muscle spindle, there is increased muscle spindle activity and a reflexive muscle contraction, which decreases spindle discharge and reflexive contraction when the muscle shortens.[7] SCS passively shortens the dysfunctional agonist muscle for an extended period to return the muscle spindle activity to normal.[8] Further studies on similar theories, such as proprioceptive neuromuscular facilitation, demonstrated this mechanism increases the range of motion by improving muscle elasticity.[9]

FPR is similar to SCS. The physiology behind FPR involves altering increased gamma motor neuron activity that affects the muscle spindle.[10] A reduction in the gamma motor neuron activity forces lengthening of the extrafusal fibers to their relaxed state.[10]

Indications

Indications to perform SCS or FPR on a somatic dysfunction of the thoracic spine include an identified tender point associated with:

• Back pain
• Chest pain
• Neck pain
• Headache
• Joint hypo-mobility
• Fascial restrictions
• Muscle dysfunction or spasms in the localized area or the thoracic spine.[7]

Indications are also based on the patient’s needs. If the patient is not able to activate their own muscles and needs more assistance from the clinician, both of these passive, indirect techniques are appropriate.

Contraindications

Contraindications of SCS and FPR include:

• Acute fracture
• Shoulder dislocation (specific to thoracic extension somatic dysfunctions)

SCS and FPR are contraindicated in any patient who cannot give feedback to the clinician.[7]

Equipment

Equipment needed for this procedure includes an exam table, OMT table or massage table for the patient to sit or lay and a stool for the clinician to sit.

Personnel

The osteopathic clinician is the only person required for these techniques to be performed correctly.

Preparation

The clinician should discuss the risks, benefits, and alternative treatment options and obtain informed consent from the patient.

Evaluation of the thoracic spine is critical before treatment. Visual assessment, pain scale, muscle strength and range of motion, and identification of tender points (TP) and somatic dysfunction should all occur prior to initiating treatment.

Technique or Treatment

SCS and FPR are indirect techniques. Indirect techniques require the clinician to place the patient into a position of ease, away from the restrictive barrier [11].

During SCS, the clinician first will need to locate a tender point (TP), sometimes called Jones tender points. For the thoracic spine, there are twelve anterior (AT1-12), twelve posterior (PT1-12), and four lateral (LAT5-8) tender points. Each TP corresponds to a thoracic vertebra; for example, AT1 correlates with thoracic vertebrae T1.

For the anterior TPs 1-8, the patient will be supine, and the clinician will be seated at the head of the table. For AT 9-12, the patient will be supine, and the clinician will be standing on the side of the patient where the TP is. AT1 is located at the sternal notch. AT2-8 are all located below the sternal notch in a row down the sternum, ending at the xiphoid process. The clinician will modify the patient's position by flexing the patient's head towards their sternum. AT9 is located superior/laterally from the umbilicus, AT10-11 are located inferior/laterally from the umbilicus, and AT12 is located on the superior portion of the iliac crest.

The clinician will modify the patient's position by flexing the patient's hips and knees and resting them on the clinician's leg, which should be positioned on the table. The clinician should then cross the patient's leg that is farther from the clinician over the patient's other leg, to induce side bending and rotating away from the TP. The lateral TP's are located at the costal cartilages of the rib of the corresponding vertebrae. The patient will be seated, and the clinician will be behind the patient with their leg on the table. The clinician will modify the patient's position by rotating them towards the clinician's leg and away from the TP. The posterior TP's are located at the ends of the transverse processes of the corresponding vertebrae. The patient is prone, and the clinician is standing on the opposite side of the TP. For the upper TP's, modify by pulling the patient's shoulder back on the same side of the TP. For the lower TP's, modify by pulling the patient's pelvis back on the same side of the TP.

After locating a TP, the clinician will ask the patient what they rate their pain at the tender point on a scale of 1 to 10. The clinician will modify the patient's position based on the TP location until the patient reports their pain has decreased to a 3 out of 10 or less on the pain scale. Once the pain is reportedly a 3 out of 10 or less, the clinician will hold the modified patient position for a total of ninety seconds. After ninety seconds, the clinician will passively return the patient to neutral.

Before treating the thoracic spine with FPR, a diagnosis of the spine with Fryette's principles is necessary. Fryette's principle says that a group curve will typically be neutral, rotated, and side bent in different directions (e.g., T1-T3NRLSR). It also states that if there is a single vertebra that is dysfunctional, it will typically be non-neutral (flexed or extended), rotated, and side bent to the same side (e.g., T1FRLSL). Since FPR is indirect, place the patient away from the restrictive barrier or into the diagnosis.

The patient will be seated, and the clinician will be standing behind the patient. To straighten the patient's thoracic kyphosis, have them sit as straight as possible. Ask the patient to cross their arms. The clinician should place their forearm on the opposite shoulder to which the TP is located. The clinician's other hand should be monitoring the thoracic vertebrae of concern. Once both the patient and clinician are in the correct position, induce the patient into their diagnosis, and add a compressive force with the forearm that is resting on the patient's shoulder for 3 to 5 seconds.

Complications

SCS and FPR are safe, noninvasive techniques with no serious complications when performed appropriately. Patients may experience some minor muscle soreness, headache, and lightheadedness following treatment. Clinicians should caution their patients regarding soreness lasting anywhere from 1 to 5 days after treatment.

Clinical Significance

Neck and upper back pain from somatic dysfunctions of the thoracic spine are very common. However, there are limited, non-pharmacologic treatment options. SCS and FPR are options that can provide immediate relief. Also, patients who see osteopathicclinicians will receive a holistic and whole-body approach to care. Clinicians will treat the thoracic spine as well as any associated dysfunctions throughout the kinetic chain, including cervical, lumbar, pelvic, and sacral dysfunctions; this will lead to overall better and longer-lasting treatment.

Enhancing Healthcare Team Outcomes

Osteopathic manipulative treatment for somatic dysfunctions of the thoracic spine may require an interprofessional team that includes the osteopathic clinician, a resident or fellow practicing neuromuscular medicine, a pharmacist, a nurse specialist, a musculoskeletal physiotherapist, and a psychiatrist. Without proper management, acute somatic dysfunctions of the thoracic spine can spiral into severe chronic issues. 

While the primary facilitator of treatment is the osteopathic clinician, a multidisciplinary and holistic approach is now preferred requiring several specialists. Nurses are a critical component of the patient’s care because they monitor vitals and communicate with the patient and family. In an osteopathic clinic, the nurse will take the patient’s vitals before the treatment. A resident or fellow clinician practicing neuromuscular medicine will gather information about the patient’s past medical, social, and family history and provide pertinent information to the osteopathic clinician. They will also assist the osteopathic clinician during the treatment while communicating effectively with the patient.

A pharmacist will help ensure that the patient is on the appropriate pain medication and dosage. The musculoskeletal physiotherapist plays an essential role in treating thoracic dysfunctions of the spine. They will provide the patient exercises to strengthen the musculature around the spinal dysfunctions, which the osteopathic clinician addressed.

When both the surrounding musculature and spinal segments are addressed, the patient will have longer-lasting relief and a better outcome. Lastly, a psychiatrist is a vital component of treating spinal pain according to the biopsychosocial model of care.[12] [Level V5] This model highlights a multidisciplinary approach to persistent pain, because of the intertwined nature of physical and psychological variables associated with pain.[12] [Level 5] Accordingly, a psychiatrist may address the cognitive and behavioral components of pain while the other team members focus on the physical aspects of pain. The emphasis of these studies shows that somatic dysfunctions of the spine and its associated pain require a holistic and multidisciplinary approach that will lead to overall better patient outcomes.[12] [Level 5]