Supine hook lying, with arms folded across their chest and their head resting on a pillow
Standing at the side of the patient
Briefly roll the patient toward you and place your hand at the level of the segment to be treated.
Your hand should form a fist with the thumb maintained in adduction and the thumb DIP in extension.
Place the gutter formed by your fingers (excluding the thumb) and thenar eminence over the spinous process of the level to be treated
Return the patient to supine ensuring their weight is fully distributed through the fulcrum you have established with your hand
Place your free hand on the patients elbows and tuck their elbows under your axilla
Perform a high-velocity, low-amplitude thrust in an anterior to posterior direction
You may have the patient perform a deep inhalation and time your thrust with their exhalation to aid in relaxation
When you return the patient to supine after establishing your hand position, you may have to "prop" the patient onto your fulcrum by rotating their trunk
Manual therapy interventions for the thoracic spine have been associated with improvements in pain, function and disability in individuals with mechanical neck pain (MNP), cervical radiculopathy (CR), and shoulder pain.
Mechanical neck pain (MNP):
Thoracic spine thrust manipulation (TSM) has been shown to be effective in improving pain, neck function and disability levels in individuals with acute and chronic neck pain over the short and long term (6-month) time frames. TSM plus exercise has been shown to be superior to exercise alone. TSM plus thermo-modalities (i.e. moist heat, infra-red therapy, electrotherapy) has been shown to be more beneficial than thermo-modalities alone.
Cleland and colleagues developed a clinical prediction rule (CPR) to identify individuals with neck pain who were likely to respond to thoracic spinal manipulation (TSM). Six variables were identified as predictors and together formed the CPR. A follow-on validation study found that this CPR was not helpful in identifying individuals with neck pain to respond to TSM. However, individuals receiving TSM and exercise experienced superior outcomes to individuals receiving exercise alone regardless of their status on the CPR, indicating that TSM is a beneficial intervention for the majority of individuals with MNP.
The addition of manipulative therapy to the cervical-thoracic spine and rib cage to usual medical care (UMC) has been shown to produce superior clinical outcomes to UMC alone in individuals with non-specific shoulder pain.
Mintken and colleagues developed a clinical prediction rule (CPR) to identify individuals with subacromial impingement syndrome (SIS) who were likely to respond favorably to thoracic spinal manipulation. Five variables were identified as predictors and together formed the CPR. The variables were:
1. Pain-free shoulder flexion <127°
2. Shoulder internal rotation <53 degrees at 90 degrees of abduction
3. A negative Neer test
4. Not taking medications for their shoulder pain, and
5. Duration of symptoms less than 90 degrees.
The CPR demonstrated a positive likelihood ratio of 5.5, indicating that individuals who were positive for at least three of the five variables increased their likelihood of a successful outcome with thoracic manipulation from 61% (pre-test probability) to 89% (post-test probability). This CPR must be further tested in a broader patient population with a comparison group and long-term follow up in order to validate the findings of this preliminary study.
There are no studies that explicitly examine the effectiveness of thoracic spine manual therapy (MT) interventions in individuals with CR. Thoracic spine MT has been included in multi-modal (traction, exercise, thoracic MT and cervical MT) treatment protocols associated with good outcomes in individuals with CR, however, there are no placebo-controlled trials investigating this management approach. Because of these factors, the benefit of thoracic spine MT for individuals with CR is currently unknown.