Episode 21: My Aching (Upper) Back: Thoracic Spine Pain

Til Luchau:

Hi, this is Til Luchau. When I was looking for a publisher for a book I wanted to write, I was lucky enough to have had two offers. One from a huge international media conglomerate and the other from Handspring, a small publisher in Scotland run by four great people. And I’m glad I chose them as not only did they help me make the books that I wanted to share with you at the Advanced Myofascial Techniques Series, but their catalog has emerged as one of the leading collections at professional level books written especially for body workers, movement teachers and all professionals who use movement or touch to help patients achieve wellness.

Whitney Lowe:

And Handspring also has a new instructional webinar series called Moot to Learn, which is a regular series of 45 minutes segments featuring some of their amazing authors, including a recent one from Til. So, head on over to their website at handspringpublishing.com to check those out and be sure to use the code [email protected] for a discount. Thanks Handspring so much for supporting The Thinking Practitioner Podcast. So, here we are today, what’s happening Til? What are we going to be talking about today?

Til Luchau:

Whitney, I was thinking we should follow on after our last discussion on cervical issues and look at upper back pain, and continue the theme of giving an overview of how we each might approach that. I want to know a little more about how you think about it and what you do to work with upper back pain. And it seems pretty related to what we’re talking about last week in terms of the cervical.

Whitney Lowe:

Yeah, absolutely. So, I think so challenging and difficult to separate those two issues that are so structurally and functionally related and seem to be probably the bread and butter of what so many soft tissue manual therapists deal with in their practice with people coming to see them. That’s a good thing for us to dive into as we look at that, I noticed when we were both sort of talking back and forth a little bit beforehand about some of the preparation for this and in looking at some of the studies and things that were out there was some question about, there’s a lot of focus on the cervical region, a lot of focus on the lumbar region and a lot of the research literature out there doesn’t seem to be as much on the thoracic region. I thought that was kind of interesting. What were you finding there?

Til Luchau:

Yeah. Well, the same thing. There’s actually very little research on incidents and prevalence of thoracic spine pain, upper back pain. But when I pull clinic owners and therapists about what their clients are saying, I hear this one a lot. It’s probably in the top five certainly complaints that I hear from people that their clients are requesting. So, it’s interesting there’s been so little study on it. And so that brings up questions about how prevalent is because there’s been so little, there’s only two that I was able to find that even talked about prevalence of upper back pain. And one was a French study from Cat from 2015. He talked about how amongst working age adults, 9% of men and 17% of women were reporting at least some upper back pain.

And then a larger 2019 systematic review found upper back pain to be most common in adolescents. This was a study of studies, so I think there’s about 20 studies that they pulled from to get their statistics, but most common in adolescents, which is really interesting, especially female adolescents. And then they also identified some other risk factors to upper back pain being poor mental health, interestingly enough, and a little bit for backpack use. There was some disagreement and debate about that, but that seems to be a minor contributed as well.

Whitney Lowe:

Yeah. And one of the things that was interesting in that brig systematic review that I noticed too, and I see this as a relatively common bias through a lot of the orthopedic literature is when they were talking about potential causes for pain in this region, there was what seemed to be a disproportionate emphasis on major structural problems of the spinal structures themselves. Scheuermann’s disease and spondylitis and dysfunctions of the vertebral structures and very, very little mention of soft tissue pain in this region, which I think is probably a big factor for a vast majority of the people who seem to have pain complaints in that area.

Til Luchau:

Well, and then to take it back, even one more step, the psychosocial contributors to pain are also pretty significant. And there is some evidence that thoracic spine pain in particular has psychosocial influences like there doesn’t seem to be correlates like the mental health thing I mentioned, and that it responds to things like client expectations, which I want to talk to you some about as well. 

Whitney Lowe:

Yeah. So, as we look at those things I think that the people that come in to see us have all kinds of potential different complaints in there. And you mentioned a couple of the things that we want to be focusing on and there are also some important considerations of those things that we don’t think about as often. Systemic disorders, for example, or Ruth Warner just did an interesting podcast that was out from ABMP, talking about a shoulder complaint, a case study with an individual with shoulder and upper back pain. And she talked about running through all of her usual evaluation procedures and it turned out the person had a gallbladder issue. And so I think it’s also important to keep in mind a lot of these things may come from the less common things as well. It’s important for us to keep in mind.

Til Luchau:

Yeah, that’s a good point. Well, what do we know about the causes, Whitney? What’d you find in your reading of brigs, et cetera, but what do you know in general?

Whitney Lowe:

Well, one of the things that I would say certainly from the perspective of our work looking predominantly at soft tissue relationships and their posture and biomechanical stresses from sitting for long periods from the forward head posture, from you had mentioned some about the inactivity and deconditioning, those things seem to be most related to the chronic types of soft tissue pain complaints that we see from people. I mean, I get this all the time from sitting for long periods or doing a lot of stuff at the computers, just like, “Oh man, my back, I just need to get in there, and just really have somebody work on those tissues,” that desire just for those things to be worked on a little bit pressed pulled, stretched, whatever. 

Til Luchau:

Absolutely.

Whitney Lowe:

And that seems to alleviate it a lot. That would certainly tend to indicate that there is a significant degree of soft tissue dysfunction in there that gets alleviated by some type of manual manipulations.

Til Luchau:

Or how about this? We can say that working the soft tissue helps.

Whitney Lowe:

Yeah. 

Til Luchau:

I’ll go with you there. Whether it’s a soft tissue dysfunction, that’s maybe where we start to debate, but no, I agree with you that a soft tissue approach can certainly change that experience of discomfort and pain that we’re all getting from sitting in our chairs so long, taking podcasts and Zoom broadcast and all that kind of stuff. 

Whitney Lowe:

That’s right, yeah. So, here’s a question that comes up, when we talk about the bio-psycho-social elements of an upper back pain complaint, let’s say, and we know there is so much, I mean, we’ve talked about it a little bit on this podcast and it’s talked about a good bit now in the current literature that a whole bio-psycho-social role of everything that happens with the client therapist interaction in the treatment room and the soft lighting and the smells and all those things that we know make a person feel better so that just almost any type of hands on manipulation helps. I know for me, getting down on the floor with a thera cane working on my own back without any of that stuff also really helps. So, it seems like, I wonder how much has that bio-psychosocial environment playing out when I do it with myself?

Til Luchau:

Yes. Well, I bet it’s in there, and I think of course the answer is always, it’s both, but I like this topic a lot because it bends the rules in both directions. There do seem to be pretty clear postural contributions to your upper back being sore. We all know that from sitting around too long. And there seemed to be pretty clear psychosocial contributors. Like when you do get a practitioner who really gets what you want and gives what you want, the results are better than if you get a practitioner who doesn’t give you what you want, even if they think they know best, even if there’s a sound, a there’s clinical rationale for what the treatment plan they’re following for you.

Whitney Lowe:

So let me back up just a moment, and ask you to kind of elaborate a little bit, give us some examples of when we talk about psychosocial elements of the upper back pain, what are we talking about here? What are some kinds of examples or ideas of what might be playing into that?

Til Luchau:

Well, I mean, the one that showed up in the literature was a correlation to poor mental health as a risk factor. If you have a mental health diagnosis, then you’re more likely to upper back pain. That’s interesting by itself, but let’s put that aside for a second and just think about what that means in practice. One of the biggest ways we see the psychosocial impact of what we do is through client expectations, what they think is going to help, how long they think they’re going to have the issues, what they expect to get from their sessions, the amount of credibility they assigned to you, all those kinds of questions there seem to help work with all pain.

But in this one in particular, because it’s a general, you could say complaint, because there’s so many things that play into it, I know we’re going to go through some of those as well, it often means that as a nonspecific complaint, it’s almost hard to know where to start. And yet I think because of that, if we leverage our client’s expectations, it’s as simple as asking them, “What do you think might help?” That’s going to give us a really big clue and a really big headstart on doing something that is likely to satisfy what they want to try and feel. And there’s some pretty good evidence that the thing that they most think is going to help is the one that gives them the most satisfaction and lasting results.

Whitney Lowe:

Yeah. So back in the early days, when I was in massage school, there was a fair amount of kind of emphasis, and this is something probably you’re quite familiar with because I think you had even done some specific study in that area of like the Hakomi body work and Ron Kurtz and a lot of those psychologically oriented bodywork practices, for example, that would tend to draw these correlations between certain body postures and emotional states and things like that. And I’m not so much along the lines of saying that there’s a really clear kind of cause effect type of thing. I not sure I buy into that whole idea, but I certainly do think that there’s a potential for relationships there. So, what do you think in terms of like that whole idea that a person with let’s say not so great self esteem or poor sort of a world outlook that tends to kind of move through the world with this, let’s say slumped forward kind of head posture, not feeling good about things. Does that potentially play into the upper back pain complaints significantly? Can we draw any kind of your answer?

Til Luchau:

Sure. Oh, absolutely. I mean, absolutely with a lot of caveats. If your habitual horizon, the place you look is down, that’s going to demand different things from your back and they’re going to get sore after a while. There is a whole mood involved in looking down. There’s a whole mood shift you get, if you look up the horizon. And you can try it right now, as you’re listening, if you just let your gaze drift up a little bit, the world opens up, your sense possibility comes up. There’s different cognitive processes that kick in. So yeah, our emotional state, our predisposition towards certain ideas, our level of imaginative of function and creativity is all related to what we’re doing with our body. 

Those are all body things. That’s why you get such good ideas when you walk, we do something with our body, it stimulates emotional and cognitive processes. So no question about that. Now, the caveats, does that posture mean a particular thing that we can say predictably is true across different people? I don’t know. I don’t know if there’s a dictionary of postures that you can look up someone’s mental issue based on their posture. I think it’s pretty individual. And I think it’s a strategic approach more than a diagnostic approach you could say. 

Whitney Lowe:

Yeah. Probably, like so many things we have to be aware of the trap, which is that there’s potential relationships there and possibly some level of involvement, but be wary of the trap of assuming that you can simplify things into a that whole idea of like, “Oh, you have anger stored in your elbow,” or because you have this previous thing in your history, that means your sore ass is going to be tight. That sort of simplistic cause effect thing I think can get us a little bit off track sometimes.

Til Luchau:

Well, and it’s also tricky in terms of scope of practice, obviously, too. I mean, we don’t diagnose physical complaints and we shouldn’t diagnose psychosocial or emotional issues either. We shouldn’t be telling people what they have or what they have going on, should be working strategically to help them get what they want out of our session, within the sculpts of tools we have. And we have a lot, so it’s great to keep in mind that certainly outlook and habits and attitudes are going to influence this. And I mean, the upside, Whitney, is that, like I said, we can use this as practitioners to really follow say the client centered approach in this case makes a lot of sense to me. Even no. Oh, here’s the paradox too, it’s not just saying to the client, “Where does it hurt? Let me press there.”

It is thinking big picture because there’s lots of things like the way you sit in your chair, which is really your hip joint mobility or the awareness of your pelvis and sitting and your spinal adaptability, say the curves you have in your spine, the mobility of all the way up your spine. Your diaphragm awareness, how much you’re willing or able to breathe into your midsection and how much of that goes forward and how much goes back? I’m going up the body, but there’s something at each level that can contribute to that upper pain.

Whitney Lowe:

So, as you’re working with a client that has, let’s say comes in complaining of upper back pain, would you tend to go through these things as sort of an educational process with them about, “Well, let’s look at these various different factors and see how they may all be contributing because my assumption is a lot of this would be things that somebody wouldn’t naturally think of to be related with upper back.

Til Luchau:

Yeah. It could be as simple as asking, when do you notice it? And that gives me some clues, yeah end of the day. Okay, what have you been doing all day. It could be, do you feel it now, as we’re sitting here talking about it and if they do, I might have them play right there in the chair with something like rolling their pelvis back a little bit, rolling it forward a little bit. And fishing or looking for connections they might make between how that feels when their pelvis is in different positions. But certainly I’m going to want to rule those out for myself in terms of my clinical approach is their hip joint or the hip joints and pelvis mobile enough to give a base underneath their thorax for their upper back to be easy for working.

Whitney Lowe:

Because then the assumption sort of is they’ve got greater capability to adjust to the new and ideal postures potentially if there’s movement throughout, kind of I believe.

Til Luchau:

Yes and no, ideal posture, no. Adjust, yes. At least in my point of view. I’m not trying to get them all stacked up like blocks in our old Ralf logo. I’m trying to help them be adaptable enough that they can adjust the different demands and sensitive enough to their own bodies that they notice when they’re uncomfortable and they move, they do something about it.

Whitney Lowe:

Yeah. So, let me backtrack for just a moment to something you said, because I do think that’s a predominant theme in numerous professions, certainly in this structural integration world of old, that was a theme, but I see it a lot in the physical therapy realm and some in the chiropractic world, a lot in some, a lot of in the massage therapy world of this emphasis on that ideal posture and that ideal position and structural kind of alignment. I think you and I probably both lean more toward the direction of freedom of movement. Probably trumping some of the focus on static, postural alignment factors. But that’s difficult for a lot of people to do who have relatively sedentary jobs for example, or positions where they have to sit in a position for a long time. How do we get people to work with that idea when they have to be stationary for so long?

Til Luchau:

Well, I question to have to, first thing I do. Because absolutely being stationary is the issue. It’s a lack of variety that ends up making things not feel good and cause more problems down the line. So I think there’s a lot of cultural support for different options at work. It’s for those who are at work, when there is a socially prescribed way to work, like are you in a cubicle? Are you in a chair? There’s usually a lot of support within organizations now for trying different things like standing, walking, trying different locations even, but especially a lot of people working at home, they have a lot of control over their environment. Now maybe they haven’t taken the time to really set it up. But yeah, having the option to work in different positions, having a chair that adjusts different distances, different Heights, having a monitor that you don’t have to always be looking down at that you can actually get at eye level or even vary, and then when you can, doing work and conversations and stuff on the move, actually taking your conversations for a walk. Those are sitting at the desk.

Whitney Lowe:

I’ve noticed a solution for me that seems to work as having a lot of animals because like, “Okay, I got to go take the dogs out. Okay, this bird needs to be fed. Okay, the cats want to do something.” It’s like there’s all these what I view perceptually as mental interruptions for taking me away from what I’m doing. But I noticed physically and biomechanically when I have to get up and move around. It helps.

Til Luchau:

Yeah, right. I think I miss my dog. My dog, for a lot of people, was my self care timer. She would let me go out for a walk when I’d miss it. I’d be sucked into the-

Whitney Lowe:

That’s right, yeah. 

Til Luchau:

She didn’t.

Whitney Lowe:

Yeah, right. So well, I want to look, Til, at another couple of things around here, as we talk about some of these postural and structural issues, there are some models that are out there that I think have become highly incorporated into many people’s perspectives and ideas. And just want to kind of hear what your thoughts are on that. We talked just briefly before our outset here, about some of the things like the model of the upper cross syndrome that Vladimir Janda had proposed and has just gotten, if you read some of the discussions about this, it’s interesting them talking about the fact that this model has become adopted by personal trainers, physiotherapists, chiropractors, massage therapists, everybody, because it’s something that everybody kind of can fit into their own particular model. But there hasn’t been a real strong support of research for these ideas that were originally in this model in terms of the actual biomechanics and physiology of some muscles being tied in some muscles being weak around that. And so just curious, your thoughts, I think you said, you mentioned, you hadn’t been focusing on that so much as of late.

Til Luchau:

Upper Crossed Syndrome, it’s a really, like you said, an intuitive model, it’s a very, very common model where you have certain muscles that are tight and certain muscles that are weak. And that from a manual therapy point of view, we would focus on the muscles that are tight if the head’s out in front of the body. No, I don’t take that approach because for few reasons even before the current debate came out about there not being a lot of evidence for that approach, it didn’t seem to get me the results I got when I focused on movement instead, when I focused on awareness instead to really get someone to have all those options of movements and then have them be able to feel what’s going on in their body.

Put me way ahead of any kind of model where I was trying to passively change the static position if that someone was in. So it doesn’t really fit with the dynamic way that I’m making myself think about bodies and posture and pain. It’s more of a static. Okay, so let’s trace out on the body which an anatomical structures could be involved. The beauty of it is it’s a clear map. You go, “Oh, work here, I’m a PhD model, push here, dummy.”

Whitney Lowe:

I hadn’t heard that before. So I’m going to put that in my next book.

Til Luchau:

Great. We’re on to postgraduate stuff now because we’re going, “It’s not as simple as push here dummy,” or that gets us started, but what’s ends up really making the difference is how much the patient or client incorporates it into their own bodies and their own awareness, their own values and their own life. I’m just thinking those things.

Whitney Lowe:

Yeah. And you know what you were saying here, Til, really reinforces something a common thread that I hear throughout the massage therapy profession, when people talk about structural work and working from a structural perspective, it’s, again, a perspective that I just I don’t agree with because I haven’t seen that play out both practically in the clinical environment nor physiologically it does really not make a great deal of sense, but the whole idea of somebody coming in and we do this postural analysis and put them in front of a grid chart and say, “Okay, you’ve got the forward head posture, and that’s why you have back pain. So I’m going to work on your anterior chest muscles, so they open up and relax all those other things.”

And then your posture will be fixed and you will be pain free. But that to me, doesn’t work. If the person goes out and repeats the dysfunctional motor patterns that got them there in the first place, they can just go mess that stuff up in the car on the way home. So unless it’s really reinforcing a change in movement and change in postural awareness sorts of things, the whole idea of just manipulating the soft tissue and then that somehow rather change his posture just doesn’t seem to work a lot.

Til Luchau:

That’s a leap, that the tissues don’t seem to be as plastic as we had hoped and thought for years. The good news of course, is that the brain is even more plastic than we realized. And you can really learn and feel and change movement patterns as you get inside of them. And hands on work is a great adjunct for getting inside of your body and getting inside your move patterns really increasing those functions in that proprioception.

Whitney Lowe:

Which takes us back to that bumper sticker saying that you said numerous issues ago, I can’t remember, or episodes ago when you said that the most important tissue that we’re likely to be working on is the one between the years, so that certainly plays into that concept, a good deal as well.

Til Luchau:

Well, how about anything else around your therapeutic considerations? I got to go through my bullet points there. Do you have any others that you think are important when addressing this?

Whitney Lowe:

Yeah. So one other thing that I want to kind of pick on, again, as a piece that I see as a frequent misconception, I hear this a lot in the massage therapy world of the idea, for example, that we see these sort of postural conditions that seem to accompany the upper back pain frequently, which is the forward head posture, the forward rolled shoulders. And this idea that people say, “Well, don’t focus on working on somebody’s rhomboids in their upper back, because you’re going to over lengthen those muscles and you’ll make it worse.”

And I want to emphasize this idea that you are not going to make a neuromuscular pattern worse by doing soft tissue manipulation of those muscles. And a lot of times what you might do by not working those areas, because what the person on the table is likely to say is, “Please work on my upper back, that’s what hurts.” And I’m not aligning with their therapeutic desire of what gives them the sensations of relief. I think we make a big mistake by trying to foist this biomechanical model if we’re going to over lengthen the already lengthened tissues. And that just doesn’t really happen.

Til Luchau:

I’m right with you in concept and also in practice. There was from upper cross model, you might not go work on those long erectors, “long” renters. But so many times, and in fact, the technique I’m going to offer around for a sample technique, the technique involves actually working on someone in a lengthened position, it’s breaking all of those yonder rules about that, but people feel fantastic and they move better and they end, it helps. It’s like sometimes when we break the rules, we get all kinds of good results. 

Whitney Lowe:

Yeah. And so I think that’s kind of the lesson and takeaway from that is, what’s really going to work and what are they feeling that is going to help them feel better and be able to move more freely? Certainly, doesn’t say, “Don’t work those other areas like the anterior pec muscles and things like that, that might be somewhat chronically shortened in those positions. But I don’t think we need to have this fear about like, well, we can’t work on the upper back because we’re going to over lengthen it and make the thing worse. It’s just not going to happen there.

Til Luchau:

I’m thinking of a question I get a lot from participants in the trainings and maybe you get it too. How do you answer the person that says, “Okay, so how much time then do I spend on what the client wants and how much time do I spend on the rest of my approach?” How do you answer that kind of question?

Whitney Lowe:

The amount of time that it needs?

Til Luchau:

Okay, it’s them coming and saying, “Hey, my upper back or would you just stick your elbow into my erectors there?” How do you know how much time it needs? Until they’re ready to go home or what?

Whitney Lowe:

Yeah, I mean, that is certainly a valid question, and I tend to focus those answers on when do I feel like the tissue appropriately responds in a way that the palpation sense tells me we’ve made some significant changes along with what they report. I’m not a big fan of just coming in and diving in with deep elbows and sharp spikes and things like that. Even though there are people who really want that kind of thing, I think that is somewhat a bit jarring for the nervous system. And I think there’s a lot of benefit in working your way through that. And unfortunately, some of that takes time to do that appropriately, but I think you get a more significant lasting neurophysiological effect from doing that. So, enough things to really make some significant contributions. And then that also might mean that incorporates work on the neck and the upper extremity and the low back and hip and pelvis region as well to get that whole system moving, pliable, et cetera. 

Til Luchau:

So, you do a combination of tissue response and client report and you leave time for the big picture?

Whitney Lowe:

Yeah. 

Til Luchau:

I like it. I mean, when I hear that question too, I think it’s not just about timing. They’re asking about prioritization. How much of this is me following them and how much of this is me doing the models or maps or strategies I want to bring in. I don’t know how to answer that one either, but I mean, that’s the big question when we talk about a client centered approach and different kinds of models we might have.

Whitney Lowe:

And here’s something, Til, that comes into this. This is part of the whole client dynamic, because you might have on the one hand, a client who comes in who really is envisioning themselves as the passive recipient of therapy and wants to be told what needs to happen in the treatment room in order to make themselves better. And then you have the-

Whitney Lowe:

Yeah. What’s that.

Til Luchau:

I’m kidding you. I said I had one of those.

Whitney Lowe:

Yeah, right. And then you have the proactive highly participating individual who wants to do their part and really sort of direct, here’s what needs to happen to me kind of thing. So obviously, I think the treatment approach is going to differ somewhat in terms of how directed you are with each one of those different people. 

Til Luchau:

Yeah, for sure, how participatory people are on their own and then how successful my efforts are at enticing them into participation as well. Because not everyone starts that way, but a lot of people shift there, but then there’s a certain number of clients who just want to receive and that’s also can be just fine.

Whitney Lowe:

Yeah. So, I want to come back and at some sort of approaches around technique stuff here in just a moment, we’re going to take just a quick break to hear from our sponsor, and then we’ll come back and we’ll look at some treatment strategies here.

Til Luchau:

ABMP is proud to sponsor The Thinking Practitioner Podcast. All massage therapists and body workers can access free ABMP resources and information on the coronavirus and the massage profession at abandp.com/COVID-19, including sample release forms, PPE guides and a special issue of massage and bodywork magazine where Whitney Lowe and I are frequent contributors. For more, checkout the ABMP podcast available at abmpa.com/podcasts or wherever you prefer to listen.

Whitney Lowe:

Great. And thank you ABMP so much for supporting The Thinking Practitioner. And we were talking just before our break about some other various different causative factors here and then looking at what we might eventually do to what are some of those other things? There’s a few of the things that we haven’t mentioned that you had called attention to that we might want to consider, things like rib articulations and some other things, the thoracolumbar fascia, shoulder involvement, the nerve roots in this area, we don’t hear very much about nerve root compression in the thoracic region. Are there some other things that we want to kind of think about as possible causes also?

Til Luchau:

Okay. So, we talked about spine hip and cervical adaptability. If those things aren’t adaptable, then you can’t sit in a position or you can’t change your position enough to move. So I just think about that whole topic. We talked about that. We should mention shoulder structures, because sometimes the traps or the rhomboids themselves can be sensitized or tired or fatigued and painful. But sometimes too, if the shoulder girdle in general, isn’t able to adapt around your thorax, it can reinforce or immobilize the back and thorax into a pattern that gets uncomfortable after a while. So a lot of times just general shoulder girdle adaptability, especially where it differentiates with the rib cage can be really helpful. The thoracolumbar fascia is interesting. It’s the complicated structures, lots of wrappings that surround all of your erectors all the way from the base of your skull down to your sacrum.

And it’s got a lot of nerve endings. It’s got a lot of those nociceptive free nerve endings that can generate a signal that your brain interprets pain. And they’ve been shown on the low, but instead of quite a bit in a low back and shown to project onto areas of the brain that do respond emotionally or with an unpleasant response to the signal there. So they seem to have a particularly upsetting type of pain. And the same is probably true, I would guess, I don’t know of any research as we take that same fascial structure on up to the upper back, there are lots of nerve endings in its various layers. And by the way, more than the erectors themselves, the erector muscle tissue itself has far fewer nerve endings than the fascia that surrounds them. On average in the body, the number that was being quoted for a long time, the six times difference. There’s a recent update that Robert Schleip just published that says maybe it’s even more, that in general fascia has about six times more free nerve endings than muscle tissue per se.

Whitney Lowe:

That’s a really interesting relationship there. What do you suppose is the rationale there for such a larger percentage in the fascial tissue compared to in the muscular tissue?

Til Luchau:

In aerological function or?

Whitney Lowe:

Yeah. It certainly seems like there’d be a really predominant role for having a lot of sensory receptors in the muscle tissue for proprioceptive functions and things like that. But the more we’re learning about some of these fascial tissues, the more we’re kind of getting a sense that they’re playing a primary role in kind of being the ears, the tuning in of what’s happening mechanically, proprioceptive ears, so to speak.

Til Luchau:

Yeah. Fascia sensory organ is Robert Schleip’s phrase. And you mentioned it isn’t universally agreed upon, there is some controversy about that, but from that point of view, which has impossibility in my eyes, the amount of nerve endings in the fascia is even more than the muscles because it’s transmitting so many forces and it’s perceiving glide and it’s monitoring all sorts of metabolic processes as well. There’s quite a bit of innovation in muscles because it has to both meteorically control what’s happening there, but also send stretch. But it turns out that a lot of the stretch receptors like the golgi tendon organs are actually in the tendons. They’re not in the muscle cell per se, or it is the connected tissue connections that ended up being the most efficient places to monitor those mechanical forces as well.

Whitney Lowe:

Yeah, fascinating. And then that kind of gets us back into looking at what happens from the treatment standpoint. Are we attempting to make a direct intervention on these tissues or what is it that we’re specifically trying to do? Because one other things just that I find so kind of challenging and frustrating in dealing with these pain problems in the upper back is they don’t tend to fit into some of the neat categories that we sometimes like to create around, well, what do we think is the problem here and what should we do about it? It just seems to be a lot more generalized discomfort and pain complaints that people have, that don’t seem to be highly specific for targeting and creating a targeted response. So when you think about techniques and approaches that you like to use to address this kind of what comes up is sort of the kinds of things that guide the idea of the techniques that you would like to use to address that? 

Til Luchau:

Well, you’ve mentioned this before too, but that careful intake conversation and some movement tests, or some movement explorations, or some description about when the pain sensitivity is there, that’ll give me a lot of clues. Sometimes they say, “Oh yeah, it’s after I sit in my chair all day,” that’s really clear that we can work with the chair, we can work with the desk set up, we can work with varying their posture, but other times it can be a really specific movement. And that movement, like you said, can suggest a particular target tissue. You called it a nociceptive driver in our last episode. That let’s say every time I drop my chin to my test chest, I get a pain down between my shoulder blades. That gives me a lot information. Yeah, both about perhaps the mechanism that’s irritating it, but then also about the specific structures that might be sensitized.

Whitney Lowe:

And I would advocate to just from an assessment standpoint of why it’s valuable to look at that specific movement with, is that done in a vertical position with the head dropping forward the client doing it themselves, or does that same thing happen when they are horizontal and you are passively lifting their head into a flexed position to kind of get an indication of, are we talking about eccentric activity of those extensor muscles doing that, or is this simply a passive movement elongating, some tissue that’s causing that kind of irritation as well?

Til Luchau:

Okay. Let’s say you find a difference. It hurts in one position not the other. Do you use that inductively? In other words, do you think through what is contracting eccentrically concentrically or do you use it empirically or deductively? Do you put them on the table in that position and work them in the position of pain?

Whitney Lowe:

I would say probably the former in trying to tease apart what … Well, perhaps some of both actually. Using it as a method for trying to tease a part and identify, is there a target nociceptive driver there, is there a target tissue that seems to be the most aggravated, and in particular too, is it the same pain sensation that they feel? Because sometimes they’ll say, “Yeah, that hurts, but it’s not quite the same thing that I feel.” And so maybe there’s a couple of different things that are going on there that we may want to tease a part.

Til Luchau:

So you identify the tissue, the quality counts for quite a bit. And then do you work them in the sensitive position or do you work them in a nonsensitive of position?

Whitney Lowe:

Well, I think the goal is to work towards alleviating the sensitivity of those kinds of positions. So, I would tend to work towards the things that give them relief that feel good, that are reinforcing a good sensation and then sort of bump up against the edge of that discomfort to see if we can gradually move it in that direction. But I’d also say that the caveat there is that if in that process we identify some things that tend to point in a direction other than a primary soft tissue complaint, like if there’s something that seems to be indicating major structural issues, spinal structural issues, or nerve root involvement or something like that, then I might be also thinking along the lines of this person might be needed to see somebody else other than me for some component of this as well.

Til Luchau:

Yeah, sure. And we’ve got a list of stuff that we’re going to mention at the end too, rare but a good pathological considerations to be aware of. I like what you said about bumping up to the edge, because I think that’s similar to my general approach too. I want to find out exactly where and how and when and what way it hurts. And then I’m going to play at the edges of that, that idea of increasing adaptive range, increasing pain adaptability around the sensitivity and probably increasing, there’s probably some tissue effects, maybe enhanced differentiation or glide, that kind of thing. But if we don’t find the edge, we often don’t change it. If we start in the painful zone, there’s too much guarding, we don’t get enough of the safety signals going on to really help someone change the pattern either.

Whitney Lowe:

Yeah, right. So we were talking about doing something a little new and different today with our podcast. We’re talking about some technique approaches and things that we might do to address this. And you had a technique speaking of edges, I believe you were calling it the over the edge technique. So, if you want to share and talk about a little bit with some ways to approach this, tell me about that.

Til Luchau:

Sure. No, and we’re actually going to try it as a handout too, that you can go get on the show notes. But in this technique, if I had to pick one, in other words, if there’s one technique, this is one that addresses so many components of what we’ve talked about, that it’s the one I’m going to hold up as the poster child for this particular symptom. And that the over the edge technique is simply draping your client over the edge of your table so that their heads hanging down below the table. And they got to find a comfortable place on the table for the edge. The arms are usually much more comfortable when they’re up on the table and the edge of the table is a few inches below their chin. So just below the clavicles, and you can adjust that with pillows or body cushions and such to make sure it’s comfortable on their chest. 

Whitney Lowe:

Okay. So let me back up for just one second. Are they supine or prone?

Til Luchau:

Prone, face down. 

Whitney Lowe:

Okay.

Til Luchau:

Yeah, so they’re faced down. Thank you. Face down over the edge of the table, head hanging below the table, comfortable on the edge there. No, we’re not going to leave them there really long because you can imagine the bloods running to their head, and forget it, don’t do this if they have any kind of sinus issues going on, as well as a couple of medical considerations like glaucoma, uncontrolled high blood pressure, stroke history, those are cautious contraindications against putting their head lower than their body. But for most of us, hanging your head off the table for a couple of three minutes is just fine. But what that does is it puts the spine into some flection. It asks all of the structures along the back there that we’ve mentioned, the erectors, thoracolumbar fascia, et cetera, to glide in such a way as they would inflection.

It asks the facet joints to open because the facet joint capsules and the joints themselves can be a source of nociception. And the joints are now opened up as the ribs open out away from the spine, or the transverse process is open out away from the ribs. So there’s just things have been opened up in a way that allow me to start superficially. So I might start with really literally skin work to make sure all the skin glides easily and then work down layer by layer to make sure that each of these things we’ve mentioned has some mobility and has some comfort. As my client’s talking to me, I’m checking in how’s the pressure, how’s the direction? Or is this good? Those kinds of questions.

Whitney Lowe:

So, you’re doing some soft tissue manipulation with them in this position to try to enhance the … Yeah.

Til Luchau:

Oh, yeah. So the position, it’s a positional technique. I put them in the position and then I’ll work through the layers in their back checking each structure in turn for mobility and sensitivities.

Whitney Lowe:

Nice, yeah. That sounds great. That sounds like one of those things that I could envision trying with self-treatment next time my upper back is bothering me.

Til Luchau:

Well, so then, like I said, that violates Janda’s idea of what’s already long. And it does feel good to do some sort of counter balancing to that as well. And it may be that’s just about to my heritage where we wouldn’t just work in one direction, but then often I’ll have them face up or supine and maybe a little bolster under the upper spine. So it’s a gentle opening in the front to help get the sense of spaciousness both in front that embark. 

Whitney Lowe:

Yeah. That sounds like a great strategy. And again, going in the direction of what people will say, I mean, as you described that, I was just like, “Oh man, I can see that feeling so good.” That sensation of like this really helps in generates appropriate susceptive sense of improvement and doing some things that will really feel good. And that’s such a powerful treatment strategy over and above what we think biomechanically about what we’re trying to do with each person.

Til Luchau:

I think I was listening to a podcast, where I think it was Chad Cook who was being interviewed. And he said about basically the debates around manual therapy. And he says, “One of the biggest thing manual therapy does is it can help you relieve pain for the client and show them that there’s hope, show them that their pain can change.” That’s one thing. And then when you do something that feels good and makes that back feel better, not only do they have some hopefulness, but there you’re building that rapport and building essentially that therapeutic alliance and that healing scenario, where in that context they’re more available and more open to your suggestions about maybe changing their monitor height or getting up and moving around a little bit. One of the biggest factors in patient compliance is how much patients follow their doctor’s recommendation is rapport between the patient and the practitioner. So, no better way to help rapport them to relieve their pain. 

Whitney Lowe:

Yeah. So these are some important strategies I think, for so many of us because it’s interesting at the very beginning when we were talking about this, the sort of lack of focus and emphasis in some of the research literature on thoracic spine pain and pain conditions in this region, because there is so much emphasis on cervical and lumbar problems. Yet certainly in our fields, so many people who come in it’s just almost uncommon for you to not have somebody saying, “Oh, my upper back needs attention.” And certainly from, I remember day one in massage school, when we first started doing work on each other, everybody’s kind of like, “Oh, work on my upper back,” because that’s kind of what so many of us grapple with a great deal, I think just structurally, mechanically and just what our lives tend to create for us.

Til Luchau:

Yeah, that’s right. They haven’t observing something to do really thorough back work around your erectors, down your thoracolumbar fascia, just working that, there’s nothing like it. We should … Are we ready to mention our pathologies you think?

Whitney Lowe:

Yeah, I was going to say we’ve got a couple other things that you wanted to mention in here of other things to look for. So, what other things should we be potentially thinking about as other possibilities that might be causing some of those pain complaints?

Til Luchau:

There’s a lot of things that can make your upper back hurt. And like you said, it’s good to be aware of those, fibromyalgia, Lyme disease, infections, tumors, nerve root irritation is more rare in the thoracic spine, but it can happen for sure. The complications around osteoporosis, secondary osteoporosis, you could have vertebral body fractures, or a kyphotic position of the spine as a result of those that can cause discomfort and pain over time, as well as osteoarthritis or rheumatoid arthritis. Those are all other conditions that can result in upper back pain. So it’s good to be aware of those, especially some of the ones that should have a medical primary care person really monitoring them. So, things like symptoms of fever, headache or a change in severity are reasons to really recommend somebody go get an updated medical eval for this things going on.

Whitney Lowe:

Yeah. And also I noticed in the Briggs paper too, they were mentioning a lot of these symptoms of upper thoracic or thoracic spinal pain were more prevalent or frequently more prevalent in young people, and in adolescents in particular. And there are some structural conditions that also do appear more frequently like Scheuermann’s disease, which happens to be a condition affecting the growth of the vertebral body of the spine causing structural problems in there. Some of those are other considerations as well. One other thing I wanted to just mention here in talking with people, and I was also interested to see how much this did not appear in some of the literature when they were talking about some of the populations that experience this differently.

There’s very little mention of the … Well, first of all, there was mention of increased likely or increased incidents of thoracic spinal pain in women compared to men. But I didn’t see very much mentioned about the role of heavier breast tissue being something that is a role for biomechanical stresses in that region. And I think that affects a lot of women in particular with chronic upper back pain is something to think about as well. 

Til Luchau:

That’s a good point. 

Whitney Lowe:

Okay. And what else? You mentioned some of the other symptoms and things that we would be potentially looking at there. So, these are all factors that we would want to think about in the big picture as possibilities to be screened.

Til Luchau:

Yeah, that’s right. Did we miss any of yours? Did we get everything in there that you wanted to mention?

Whitney Lowe:

That’s kind of the other things. Well, one of the things we kind of touched on earlier, this is not a real common thing, but I had a couple of interesting case study instances involving the potential rib head subluxation. And that’s something that also may come about with some pretty severe upper thoracic pain close into the spine. Interestingly, that particular pathology is even somewhat controversial in some of the orthopedic literature about whether or not it really happens with the degree of frequency or incidents that it does.

Til Luchau:

Obviously, the controversy around mechanism, I don’t think anybody’s denying that people get pain there. It’s more like, what is the explanation? Is it read this quote, or is it sensitized for now.

Whitney Lowe:

Yeah. So, I think it’s just important for us to remember that those costovertebral articulations are synovial joints with joint capsules and a richly innervated capsular tissue. And so slight malposition things or stresses at those very sort of delicate joints that are not structurally very sound could certainly be a cause for pain, especially if it’s along the region of the spine close to where those joints are located. And that would, because I think a lot of people don’t tend to think about that as a possibility, I had a client at one time who had what we suspected eventually to be that very problem of going to the emergency room because she was having extreme difficulty breathing. And they were saying that they suspected a heart attack and all kinds of other strange things. And nobody began to really look at some structural problems. And then she went to a chiropractor a couple of days later and they thought that she had a rib head problem and they did adjustment procedure and, boom, it’s done.

Til Luchau:

So, new stories, so many stories. Because you mentioned the debate are used in the argument that says, “Well, look, her rib was out, I put it in and they were better.” There’s there are so many stories of people feeling better once they’re rich or mobilized, which is the mental discipline I try to have for myself, just in my own thinking about teaching, I’m pretending like malposition isn’t a thing. I don’t know if it is or not, but I know that that mobility is a thing. And I know that if I get things moving, they feel better. And especially moving in the ways that feel good. If they’re moving in ways that feel bad, that’s worse, but I help them move in the ways that feel good and it makes them better. So yeah, there’s a lot of ways to mobilize the rib heads. Like you said, they really change someone’s upper back pain.

Whitney Lowe:

Yeah, absolutely. Well, that sounds good. And I’m sure we can revisit some other facets of this topic and some of our future episodes as well, but this is a good sort of introduction into looking at a very common complaint that lots of soft tissue manual therapists are going to be dealing with on a regular basis here. 

Til Luchau:

Yeah. Hopefully, get you some ideas to go try for sure. Go download that handout, et cetera. 

Whitney Lowe:

Yeah, that sounds good. So, we’d like to say thank you very much to all the listeners who hung in there, listened to our discussions today. Hope you get some good beneficial aspects out of it. And a big thank you to our sponsors as well. We really appreciate you supporting The Thinking Practitioner Podcast

Til Luchau:

What about those show notes, Whitney, where do people get those?

Whitney Lowe:

They can get the show notes on thethinkingpractitioner.com. And we did mention today a handout that we would have available highlighting this technique. So, head on over to AT where can they find that handout on your site over there.

Til Luchau:

Advanced-trainings.com, just click the podcast link up at the top of any page advanced-trainings.com. And I should definitely mention our upcoming spine principles class, we’re doing another one of our live online hybrid training starting early September, and you can register up through mid September. The discount is late August. Check it out on our site to advance-trainings.com, exciting combination of live lecture and small group discussion, looking at spine ribs and low back issues in this case. How about yours, Whitney?

Whitney Lowe:

Great. They can also find stuff over on our site related to the podcast at academyofclinicalmassage.com. And as always, please send us questions or input anything that you’d like for us to know at [email protected] And where can people find you out on the social media world, Til?

Til Luchau:

Just at my name, Til Luchau, T-I-L L-U-C-H-A-U. How about you, Whitney?

Whitney Lowe:

Yeah, same thing, Whitney Lowe. People can find me there on social as well. And please do follow us on Spotify, Rate us on Apple podcasts, so Stitcher, or wherever it is that you listen to your podcast, share the news and tell a friend, let other people know that it’s out there and available. And we hope to keep having some interesting discussions that will help you all out. 

Til Luchau:

Thanks, Whitney. 

Whitney Lowe:

That sounds good. I’ll look forward to it, and we will see you again in two weeks.

 

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