As a physiotherapist working in private practice in the beautiful rural English Lake District, I visited ‘Jo’, a patient complaining of back pain with severe chronic obstructive pulmonary disease (COPD) and dependant on oxygen. Following my assessment, I cautiously treated Jo with Maitland mobilisation techniques directed at the thoracic spine in a sitting position. I was anxious as to how effective the intervention would be given the severity of his COPD and respiratory status.

When Jo returned a few days later he reported considerable improvement in his back pain, but most impressive was the improvements in his breathing. This case fuelled an interest in the relationship between thoracic spine and respiratory function, which followed through as a focus for my Master of Science (investigation of thoracic spine mobility and respiratory function) and then later on thoracic dysfunction in COPD as part of my PhD.

Compared to the cervical and lumbar spine, thoracic spine pain is much less prevalent, although often co-existing with neck or low back pain or symptomatic of serious underlying pathologies. That said, thoracic spine dysfunction is likely much more common, secondary to age-related or functionally adapted changes.

Such dysfunction may contribute complaints in anatomical remote sites (eg, shoulder, by way of the regional interdependence model and functional movement being a product of motion occurring across a number of anatomical regions).

Where clinical practice is often bias to locating and treating a pain source, identification of dysfunction within functional kinetic chains may be of clinical value and improve patient outcomes through precision rehabilitation of thoracic spine dysfunction.

Given the paucity of research, referring to the thoracic spine as the ‘Cinderella’ region of the spine allows us to put a spotlight on the thoracic spine and examine the current landscape of practice and evidence. As an educator, my experiences are that many clinicians have limited teaching on the thoracic spine; perceived to be complex, often associated with rare presentations of serious pathologies, difficult to assess/manage and relatively less important than the cervical and lumbar spines.

Within the publication titled ‘Understanding why the thoracic region is the Cinderella of the spine’, we explore, among other things, the growth in research investigating the use of thoracic manipulation/mobilisation to manage neck or shoulder pain, regional interdependence and make a case for further targeted research. This evidence and narrative has been used to inform a program of research dedicated to advancing our understanding and management of thoracic spine pain and dysfunction.

From our surveys of practice, we established that many techniques and management approaches are being used in the thoracic spine, yet without the supporting empirical evidence: a requirement for contemporary evidence-based practice. In addition to this, many clinical trials have been published investigating and supporting the use of passive thoracic spine mobilisation or manipulation in patients with neck and shoulder pain.

To date very few studies have considered active interventions, which are likely more cost-effective. Current active interventions involving the thoracic spine invariably focused on the ‘trunk’, which fails to differentiate this distinctively different spinal region and its unique contribution to functional motion. We have, therefore, recently completed an extensive evaluation of evidence (mobility, motor control, work capacity and strength) to inform thoracic spine exercise prescription in rehabilitation. In light of all the above points, we need to ensure that techniques taught and used in practice are safe, as well as being cost and clinically effective.

I consider the thoracic spine further as a critical, yet invariably, silent link in functional kinetic chains, and a possible contributing factor to a range of clinical presentations and complaints. Additionally,

I want attendees to feel inspired through the research and work we are doing to place a greater emphasis on the thoracic spine in education, practice and research in physiotherapy.

Nicola Heneghan is a senior lecturer in Musculoskeletal Rehabilitation Sciences in the Centre of Precision Rehabilitation for Spinal Pain (CPR Spine) at the University of Birmingham, UK. Following on from her clinical career Nicola has accrued more than 20 years’ experience of teaching and research in musculoskeletal physiotherapy.

What got you interested in the relation between neck pain, headache, dizziness, balance and visual disturbances?

I first noticed these symptoms were common post-whiplash several years ago when working at the whiplash research and diagnostic clinic at the University of Queensland. We started to investigate methods to measure the impairments associated with these symptoms. This started with proprioception and head movement control but then, realising the importance of the neck for eye movement control and postural stability, we started to look at balance and eye movement control using various methods. In 2004, I completed my PhD looking at sensorimotor control disturbances in those post-whiplash.

Your recent work has focused on impairments after mild traumatic brain injury/concussion. How big a problem is this, and why is it important for physiotherapists to be aware of it? 

I found this to be a natural progression, as my understanding of the need for differential diagnosis in symptoms of dizziness, headache, balance and visual disturbances in whiplash was considerably greater in those post-concussion. Potentially there is greater likelihood of several other possible causes of these symptoms post- concussion such as visual, vestibular, physiological or cervicogenic. The management is very different considering the cause and, as physiotherapists, we are well placed to understand the possible causes and undertake a comprehensive examination to determine the causes and interactions between the systems involved. This is very important not only for those reporting ongoing symptoms post-concussion (about 20–30 per cent) but also with respect to secondary prevention, as we know that not only is there an increased risk of sustaining another concussion but there is an increased risk (50 per cent) of sustaining other musculoskeletal injuries following a concussion. This might be due to unrecognised impairments, for example, in the sensorimotor control system, post-concussion that can be present even in the absence of self-reported symptoms.

What do you hope delegates will gain from attending your presentation/session?

I hope to show that as physiotherapists, our particular skills in conducting a thorough, clinically reasoned interview and skilful physical examination are vital to assist differential diagnosis of symptoms such as dizziness and headache. For musculoskeletal physiotherapists, it is especially important to be able to determine the precise role of the cervical spine in the production of such symptoms in order to direct appropriate management.

Dr Julia Treleaven is a lecturer and researcher at the University of Queensland. She is author of the recent book Management of neck disorders—an evidenced based approach.

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