Joseph D. Kurnik, DC
There is a relationship of the thoracic spine to sacroiliac functioning. The thoracic region does manifest itself with many varieties of kyphosis. Some thoracic regions are flat, some are mildly kyphotic and some are moderately kyphotic. Beyond this, we witness the hyperkyphotic thoracic curves. There is a principle which should be applied to the thoracic kyphotic curvature, and which may include the upper lumbar spine. The more thoracic kyphotic curvature, the more lumbar and cervical lordosis or tendency for such.
With regard to the lumbar spine, the lower lumbar regions at L-4 and L-5 levels are most affected. With increased thoracic/upper lumbar kyphosis, there is compensation in the lower lumbars with increased extension. This increased extension does increase lower lumbar facet imbrication (compression). The result of increased thoracic kyphosis, compensatory lower lumbar extension, and lower lumbar increased imbrication is usually bilateral anterior superior ilium fixation (usually muscular type according to Dr. Gillet's classification). The AS bilateral fixations are accompanied by sacral counternutation (as described by Kapandji, Vol. III, Physiology of the Joints). There may also be L-5 or L-4 rotation patterns present.
If there are no significant L-5 or L-4 rotation patterns present, the problem (if there are complaints at the L/S region) would primarily involve lumbar compression at the facet joints and posterior discs at L-5 and possibly L-4. Severe thoracic kyphosis could involve more lumbar levels in hyperlordosis. If there are no significant lumbar rotation patterns or mid or upper lumbar intersegmental extension restrictions, then flexion traction at L-5 and L-4 may be very appropriate as a treatment protocol.
One may find too much tenderness at L-5 and L-4 to traction. An effective alternative is to contact the sacral region about midway or caudally and traction the sacrum inferiorly and anteriorly. Usually, there will be less or no tenderness and response will be favorable.
We now have complicating factors. Evaluation of the thoracic and upper lumbar regions can identify intersegmental extension restrictions (fixations, hypomobilities, etc.). These extension problems will result in increased compensatory extension stress at the lumbosacral level and the possibility of cluneal nerve irritation and referral to the lumbosacral region. The cluneal nerve referral was discussed very clearly by Dr. Hammer in a previous article for Dynamic Chiropractic (see http://www.chiroweb.com/archives/16/10/24.html ).
Such extension restorations (joint blocks, subluxations, etc.) may be corrected variously. They may be adjusted in the prone position, supine position, or the seated position. The prone position of adjusting works well for some patients, but not for others. Adjusting the lower thoracic and upper lumbars can hurt and knock the breath out of the patient when done in the prone position. I most often use a seated position for adjusting extension restrictions.
The "Custom" Table
I had a special table constructed 15 years ago that resembles the Pettibon style made by an existing table company. With this original style, the cepholic end can be raised. The patient, seated and leaning back against the raised table end, is adjusted in the anterior-type style. The problem I have with this is that the nose hole is in the cepholic end, and my fist folds into the hole. Also, the legs are forced far apart as the patient straddles the table, because it is a wider table. I changed the design so that the caudal end raises, instead of the cephalic end. The advantages are two fold. There is no nose hole at the caudal end that absorbs the adjusting hand, and there is a tapered shoulder to adjustable head piece for the comfort of the prone patient, with a more narrow table width.
This arrangement affords an opportunity to more easily correct upper lumbar and thoracic extension fixations. With this table construction and patient position, various patient hand positions can be utilized for different objectives. For example, for lower thoracics and upper lumbars, the patient's hands and fingers should be interlocked behind the lower neck (not possible for short-armed stocky individuals). With this position, you may adjust all the way down to L-4 on some patients. Usual prone and supine adjusting also is made easier.
The discussion regarding table design was a departure from the physical concepts previously described, but it does represent a subject of practical consideration. The reduction of extension fixation in the thoracic and upper/mid lumbar levels can assist valuably in reducing lumbosacral stress. With the reduction of lumbosacral stress, one will see often a bilateral release in AS ilium fixation patterns. If you couple this with flexion traction at L-5/S-1, L-4/L-5; then more sacroiliac joints. They were compensating all the time.
Other considerations of importance regard patient participation in home care. The patient can participate with active care in several ways:
- An inversion device can be used to traction the lumbar spine.
- To reduce thoracic and upper lumbar extension restriction, one may use "health bridges," which effectively reduce kyphotic extension restrictions.
- Another way to reduce extension restriction at the lower thoracic and upper lumbar region is to roll up a towel and lie upon it. Position it at various levels between the lowest ribs and the mid-scapular region.
Good luck with your hyperkyphotic thoracic spines.
Joseph Kurnik, DC.
Torrance, California
