I ended my last post on slinkies and posture by explaining that I learned this postural cue from Dr. LJ Lee’s Thoracic Ring Approach. Here’s the story to go with it.
I worked for Dr. LJ Lee, the physiotherapist who developed The Thoracic Ring Approach based on her clinical and PhD work. I spent 5 years at her clinic, where I applied this approach to pelvic health clients, developed the pelvic floor program, and mentored other physiotherapists. I've also been a teaching assistant on Thoracic Ring courses and workshops.
Before we go any further, let’s address the terminology:
- Thoracic means relating to the thorax. The thorax is the area between the neck and abdomen. It includes the ribcage, attaching muscles and other soft tissues, and the vessels and organs it contains.
- A ring is a functional unit of the ribcage.
- Each ring is composed of two vertebrae, one rib on each side, and its connections to the sternum (i.e. breast bone) via cartilage.
- There are 10 thoracic rings because there are 10 ribs on each side that directly or indirectly attach to the sternum. (Note that we have 2 floating ribs on each side that do not attach anteriorly to create rings).
It’s been a few years since I’ve left that organization, but The Thoracic Ring Approach continues to be a mainstay in my practice. Here are some reasons why:
- The thorax makes up a large portion of our trunk. In dealing with trunk control, it’s quite hard to ignore it's existence. Consider that the cervical spine is made up of 7 vertebrae and the lumbar spine is made up of 5. The thorax is made up of 12 vertebrae and 12 ribs on each side.
- I see many patients with abdominal region pain and dysfunction. They are often surprised by how high the abdominal muscles attach. For instance, the external obliques’ highest attachment point is the 5th rib. The rectus abdominis (ie. 6-pack) attaches as high up as the 5th costal cartlilage (ie. the cartilage connecting the 5th rib to the sternum). For reference, the 4th rib is approximately nipple level. The 5th rib is just below that. We often think of these upper attachment points as being the “chest” rather than the abdomen. “Chest” function is often left out in treatment planning for abdominal issues.
- Relating to my previous post on how posture is more than, “chest out, pull your shoulder blades back and down”, it is crucial when dealing with posture to address the thorax. We often attempt to correct posture by moving the shoulders and shoulder blades, but we need to look deeper to correct what the shoulder blades are resting on - the thorax.
Although the Thoracic Ring Approach is not new, it is still a novel way of thinking. In the past, treatment for the thorax didn't integrate ribs with the spine. It was also thought that the thorax was inherently stiff and immobile. Dr. LJ Lee’s research showed that the spine and ribs function together, hence the ring as a functional unit. Rings provide us with a 3-dimensional view of the thorax - as if it were a stack of rings or a slinky.
There are many joints within each thoracic ring, which means the thorax is actually mobile. The problematic thorax is stuck in a pattern where it cannot access all the movement available to it. A clinician trained in this approach will assess to find where and how the thorax is misbehaving. Treatment includes manual therapy, cueing and exercise to improve the movement and control.
Over the years, I’ve noticed some misunderstandings:
- It’s not about treating the thorax for everything. The approach is meant to give clinicians a means to determine if and when the thorax needs to be treated.
- It’s not about manual therapy and creating therapist dependence. Manual therapy is meant to help people get “un-stuck”. Proper cueing and exercise prescription is meant to help people progress and self-manage when they are not with the therapist. Clinicians trained in this approach are introduced to a graded exercise guide and tools for patient self-management.
- It’s not just about the thorax. The thorax can actually be an underlying cause for pain and dysfunction elsewhere in the body. In my case, I often apply it to patients with pelvic health issues.
As with any approach, it’s about appropriate application of the skill to the specific case and patient. This takes time, experience, and care.
For people with chronic pelvic pain or pelvic health issues that have not resolved with conventional, local treatment, it can be helpful to look elsewhere in the body - above the problem and below the problem. The Thoracic Ring Approach provides a means to look above the problem. While the ribcage seems far away from the pelvis, our trunk is one continuous cylinder. Although language can separate our trunk into “chest”, “abdomen”, “back”, “pelvis”, and “pelvic floor”, it is inherently connected through muscular, visceral, and fascial tissues.
