Thoracic Spine Manipulation

Jeffrey A. Turner SPT, CSCS

Special ThanksDr. Jason Simmons DPT

What is a Spinal Manipulation?

Definition (IFOMPT):“A passive, high velocity, low amplitude thrust applied to a joint complex within its anatomical limit with the intent to restore optimal motion, function, and/or to reduce pain.”

Names Used:• Thrust Joint Manipulation (TJM)• HVLA Thrust• Grade V Mobilization

Who can Perform?• PT’s, OT’s, DC’s, MD’s & DO’s

Reasons to Mobilize the T-Spine!

Easy to learn, use, and apply.• Manipulation + exercise = Better than exercise alone for pain/disability• Manipulation + mobilizations = Better than mobilizations alone for pain/disability

Overview of Benefits:• Temporary relief of musculoskeletal pain• Temporary increase of spinal mobility• Increases benefits from HEP • Can help improve compliance to HEP

Contraindications

• Any pathology that leads to significant bone weakening• Osteoporosis, fractures, etc.

• Spinal Surgery*:• Fusions, laminectomies, etc.

• Pathology:• Active infection, active cancer, etc.

• Vascular: • aortic aneurism, bleeding into joints

• Neurological: • Nerve root compression with increasing neurological deficit

• Lack of diagnosis • Patient positioning can not be achieved because of pain or resistance.

Who Benefits from T-spine Manipulation?Mechanical Neck Pain

• Moderate evidence for immediate improvements in pain and disability• Majority of studies done on 2-day or 1-week outcomes • 75% of patients improve >2 points on the Numeric Pain Rating Scale (NPRS)• 70% of patients improve >15% on the Neck Disability Score (NDI)

• Growing evidence for long term improvements in pain and disability• Improvements in pain and disability can last up to 6 months following treatment• 80% of patients had a GROC of 5+ by 6 months following treatment• Global Rating of Change (GROC) of >5+ is indicative of moderate changes in status

Subacromial Impingement Syndrome (SAIS or SIS)• Growing evidence for short-term and long-term improvements in pain/disability• Mostly case studies, and added to programs in RCT’s for other interventions

Mechanical Neck Pain

• 70% of the population will have an episode at some point• Most prevalent in the 4th and 5th

decade of life

• Majority of neck pain is mechanical in nature• Can interfere w/ ADLs and

become a source of chronic pain

Subacromial Impingement Syndrome (SAIS)• Shoulder pain affects 16-21% of

the population• Second only to low back pain in

prevalence• SAIS accounts for 44-60% of all

conditions of the shoulder• Patients not treated may

develop functional impairments with chronic symptoms.

Cross et al. (2011) Thoracic Spine Thrust Manipulation Improves Pain, Range of Motion, and Self-Reported Function in Patients With Mechanical Neck Pain: SR Objective:• Determine effects of T-spine thrust manipulation on pain, ROM, and self

reported function in patients with mechanical neck pain. Methods:• 6 high quality RCT’s examined

Conclusion:• Thoracic spine thrust manipulation may provide short-term improvement in

patients with acute or subacute mechanical neck pain. • May provide short-term and long-term improvement in neck disability.

• Manipulation + exercise = Better than exercise alone for pain/disability• Manipulation + mobilizations = Better than mobilizations alone for pain/disability

• Limited number of RCT’s and limited generalizability.

Effect Sizes for Pain Relief

Effect Sizes for Self-Reported Function

Gonzales-Iglesias et al. (2009) Thoracic Spine Manipulation for the Management of Patients with Neck Pain: RCTObjective:

• Would patients with mechanical neck pain experience superior outcomes with thoracic manipulation compared to not receiving it?

Methods:• 45 participants, ages 18-45, and no contraindications• Control Group:

• Electro/thermal therapy (6 visits over 3 weeks)• Experimental Group:

• Control protocol + T-spine manipulation (6 visits, and 1x manipulation/wk over 3 weeks)

Outcomes:• T-spine manipulation group experienced greater improvements in pain, cervical ROM,

and disability than electro/thermal therapy alone. • Outcomes were maintained at the 2 week and 4 week follow ups.• Average improvement of pain by 2.83 points and disability by 13.2%

Cleland et al. (2010) Examination of a CPR to Identify Patients With Neck Pain Likely to Benefit From Thoracic Spine Thrust Manipulation and a General Cervical ROM Exercise: RCT. Objective:

• Examine the validity of the recently proposed CPR for use of thoracic spine thrust manipulation in patients with mechanical neck pain.

Methods:• 140 participants, ages 18-45, mean age of 40, and no contraindications• Pain and disability collected at baseline, 1 week, 4 weeks, and 6 months.• Control Group:

• 5 sessions of strengthening and stretching exercise • Experimental Group:

• 2 sessions of thoracic thrust manipulation & cervical AROM exercise • 3 sessions of control protocol

Outcomes:• T-spine manipulation & exercise had greater improvements in disability at both the short

& long-term follow-ups and in pain at the 1 week follow-up than just exercise.

Clinical Prediction Rule

• Met 3 or more = “responders”• Met 2 or less = “non-responders”

• Current study did not support the validity of the previously proposed CPR

What this means:• They ALL benefited from

thoracic spine manipulation

Masaracchio et al. (2013) Short-Term Combined Effects of T-Spine Thrust Manipulation and C-Spine Non-thrust Manipulation in Individuals with Mechanical Neck Pain: RCT Objective:

• Does T-spine manipulations + C-spine non-thrust manipulations work better than C-spine non-thrust manipulations alone in the short-term?

Methods:• 64 participants, ages 18-60, >20% NDI, and no contraindications • Control group:

• C-spine non-thrust manipulations + neck AROM exercises (2 treatments, 2-3 days apart)• Experimental group:

• Control protocol + T-spine manipulations (2 treatments, 2-3 days apart)

Outcomes:• T-spine manipulation group demonstrated greater short-term outcomes in pain and

disability when compared to C-spine non-thrust and exercise.• 75% had pain improvements that met or exceeded the MDC & MCID • 70% had disability improvements that met or exceeded the MDC & MCID

Short-Term Combined Effects of Thoracic Spine Thrust Manipulation and Cervical Spine Non-thrust Manipulation in Individuals with Mechanical Neck Pain: RCT. 2013

Short-Term Combined Effects of Thoracic Spine Thrust Manipulation and Cervical Spine Non-thrust Manipulation in Individuals with Mechanical Neck Pain: RCT. 2013

How to Implement

1. Find a patient that you think would benefit• Neck pain with no contraindications• Shoulder pain with no contraindications

2. Explain the procedure to the patient. Get verbal consent• “There is a hands-on technique that we can try that has good evidence for improving pain

and mobility in people with your condition.”• “This technique may produce a “pop” sound and sudden relief, but some don’t feel the relief

until the next day. The “pop” sound is just a side effect of the maneuver, and some people never get one.”

• “I think you would benefit from this technique, what do you think?”

3. Give patient the options for positioning• “There are multiple positions that we can perform the technique: seated, one your stomach,

or on your back. There is no difference in regards to benefits.”

How to Implement

4. Position the patient• Supine, prone, or seated

• Choose based off patient comfort and/or therapist confidence.

5. Re-explain procedure if needed6. Perform technique!

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2 2 2

Seated Thrust Prone Thrust 8

2

Supine Thrust (“The Pistol”)2 2

Self MobilizationProne Mobilization

88 6

Prone Mobilization

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References

1. Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moore JH, Koppenhaver SL, and Wainner RS. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther. 2009; 14(4):375-80.

2. Cleland JA, Childs JD, Fritz JM, Whitman JM, and Eberhart SL. Development of a CPR for Guiding Treatment of a Subgroup of Patients with Neck Pain: Use of Throacic Spine Manipulation, Exercise, and Patient Education. Physical Therapy. 2007; 87:9-23.

3. Cleland JA, Mintken PE, Carpenter K, Fritz JM, Glynn P, Whitman J, Childs JD. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a general cervical range of motion exercise: multi-center randomized clinical trial. Phys Ther. 2010; 90(9):1239-50.

4. Cross KM, Kuenze C, Grindstaff T, Hertel J. Thoracic Spine Manipulation Improves Range of Motion, and Self-Reported Function in Patients with Mechanical Neck Pain: A Systematic Review. J Orthop Sports Phys Ther. 2011; 41(9):633-642.

5. Gonzalez-Iglesias J, Fernandez-De-Las-Penas C, Cleland JA, and Glutierrez-Vega MR. Thoracic Spine Manipulation for the Management of Patients with Neck Pain: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2009; 39(1):20-27.

6. Masaracchio M, Cleland JA, Hellman M, and Hagins M. Short-Term Combined Effects of Thoracic Spine Thrust and Cervical Spine Nontrhust Manipulation in Individuals with Mechanical Neck Pain: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2013; 43(3):118-127.

7. Puentedura EJ, Landers MR, Cleland JA, Mintken P, Huijbregts P, and Fernandez-De-Las-Penas C. Thoracic Spine Thrust Manipulation Versus Cervical Spine Thrust Manipulation in Patients With Acute Neck Pain: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2011; 41(4):208-220.

8. Salvatori R, Rowe RH, Osbourne R, and Beneciuk JM. Use of Thoracic Spine Thrust Manipulation for Neck Pain and Headache in a Patient Following Multiple-Level Anterior Discectomy and Fusion: A Case Report. J Orthop Sports Phys Ther. 2014; 44(6)440-449.

9. Tate AR, McClure PW, Young IA, Salvatori R, and Michener LA. Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial Impingement Syndrome: A Case Series. J Orthop Sports Phys Ther. 2010; 40(8):474-493.