My Other Loves: The Thorax and the Vagus Nerve

I have a confession to make.

I am a little bit obsessed with the thorax.

Actually, “a little bit” is probably minimising the situation. If you've spent enough time with me in clinic, you may have noticed that I have an annoying tendency to bring the conversation back to the ribs.

Knee pain? Let’s start at the thorax.

Shoulder pain? Hmm… thorax.

Breathing dysfunction? Definitely thorax.

Existential crisis? Give me 5 minutes and it’s probably your ribs.

But there is a reason for my obsession. The thorax isn't simply a rigid box sitting between your neck and pelvis. It is a highly mobile, three-dimensional structure involved in breathing, spinal movement, load transfer between the upper and lower extremities and, importantly, it houses our vital organs.

An area our brain knows is definitely worth protecting.

Ribs? More like Thoracic Rings

The ribcage, thoracic spine and sternum work together as functional units. This is a foundational idea behind the Thoracic Ring Approach, developed by physiotherapist Dr LJ Lee, who I was lucky enough to train with and assist a few years ago.

Rather than viewing the ribs as separate bits of anatomy, the approach considers each “ring” as a three-dimensional system that needs to move, adapt and coordinate with the rings around it.

We change our anatomical understanding of the thorax from:

The right rib connects to the sternum which connects to the left rib which connects to the spine…

to something more like a slinky. (Not the ones in my house. My boys have destroyed those and they wouldn't technically qualify as slinkies anymore.)

I use the slinky analogy quite a lot. Hopefully all of you who have been introduced to this concept (you know who you are) have now been reminded to walk around town cueing your open, happy slinky.

When one part of this system becomes restricted, poorly controlled or excessively loaded, the consequences don't necessarily stay in the thorax.

Movement changes.

Breathing strategies change.

Muscles, fascia, nerves and other interconnected structures may start doing jobs they weren't designed to do. Resulting in… unfortunately and commonly… pain, dysfunction, irritability and potentially a sh**y mood.

Partly because pain is miserable, but also because your nervous system is constantly receiving information from the body it is trying to protect.

Does structure = function? And the Vagus

The vagus nerve gets a lot of chat. But it’s pretty exceptional.

Some anatomy… It exits the skull through the jugular foramen, travels down the neck alongside the major blood vessels, and enters the thorax through the thoracic inlet. From there, its branches contribute to the innervation of structures including the pharynx, larynx, heart, lungs and oesophagus before continuing towards the abdomen.

So we've got a nerve travelling from the cranium, through the neck and into the thorax, within an incredibly busy neighbourhood.

Muscles.

Fascia.

Blood vessels.

Viscera.

Lungs and pleura.

The diaphragm.

The spine and ribs.

And all of these structures are changing their position, tension and pressure relationships as we breathe, move and rotate.

It's a pretty dense area. You get the picture.

So if the thorax develops a persistent rotational, compressive or inefficient movement strategy, could that alter the mechanical and sensory environment of the structures passing through the neck and thoracic inlet?

Possibly.

Could this influence the vagus?

I think it's a fascinating question. And I think likely.

To clarify, I’m not claiming that the vagus nerve is directly mechanically compressed by an unhappy slinky…

But… Could we give the Vagus a little more breathing room?

A little Queenstown experiment

Perhaps I’m also a little more convinced of this after my recent trip to Queenstown. I spent a few days walking, hiking, climbing, twisting, breathing in ridiculously crisp mountain air and generally moving my body in ways that felt really good.

And I noticed…My thorax felt more open. My breathing felt easier. And my whole nervous system seemed to settle.

Now, was it the movement? The fresh mountain air? Being surrounded by enormous mountains? Being away from my usual routine and children and husband? The sunshine? Or, perhaps, the mulled wine?

Honestly, who knows. But whatever was happening, my body felt different. And, dare I say, my vagus seemed a little happier too. Now, obviously, this is one person having an experience in Queenstown, not a controlled experiment on vagal regulation!

But it did get me thinking about just how interconnected movement, breathing, sensory input and our nervous system really are.

And this is something I’ve started noticing more and more in clinic. Although LJ alluded to the structural relationship between the thorax and nervous-system regulation, I didn't really understand the clinical implications until I started seeing it happen.

When we treat the thorax appropriately, we're not simply trying to correct a rib position. We're trying to optimise the three-dimensional relationships of the thoracic rings, the neck and their associated structures.

We're considering compression, rotation, muscle tone, fascial relationships, breathing mechanics and how the different parts of the thorax interact.

By changing that mechanical environment, we may change the sensory information reaching the nervous system. Potentially influencing autonomic regulation.

I’m aware that some clinicians would consider this a stretch. But I'm pretty comfortable with it.

Because I see it every day.

A more balanced thorax can produce beautiful, pain-free movement through the neck, shoulders, pelvis and even feet!

But I've also seen changes in breathing quality, heart rate variability, global tissue tone, voice, swallowing, anxiety and mood.

The frustrating part is that seeing those changes doesn't tell me exactly why they happened. They could simply involve changes in the mechanics of this dense area, perhaps proprioceptive or interoceptive input, pain, threat, attention, expectation or autonomic mechanisms.

Probably some combination of several things.

Again, I'm not suggesting that every change in HRV or mood can be blamed on a rib.

The nervous system is far too complicated for that.

What I am suggesting is that we may underestimate how much information the nervous system receives from the mechanical environment of the body.

So what does this mean for treatment?

The goal isn’t simply to make the thorax looser with a good old-fashioned pummelling (which you know I am no longer in to).

First, we need to understand how it moves, where it moves, where it doesn't move, and how it interacts with the rest of the body.

The goal is not to force the thorax into some perfect position. It's to improve its ability to move, adapt and coordinate. We are balancing our thoracic slinky, with breathing, the cervical spine, the shoulder girldes etc…

The thorax sits at a fascinating intersection between movement, breathing, load transfer, sensory information and protection.

And perhaps changing that environment can influence much more than movement alone.

Maybe structure doesn’t simply equal function. Maybe the relationship between the two is much more interesting than that.

Which probably explains why I’m still a little bit obsessed with the thorax. Thanks for humouring me. It’s got a lot to say.

And I’ll be the first to listen and to keep trying to figure it all out.

Gina Kezelman

Aug 2026