Thoracic Opening Thrust (General)

Body Region: Thoracic Spine

Technique Name: Thoracic Opening Thrust Manipulation (General)

Indications: mechanical neck pain (MNP), cervical radiculopathy (CR), thoracic pain, shoulder pain

Instructions:

Patient Position:

Supine hook lying, with arms folded across their chest and their head resting on a pillow

Clinician Position:

Standing at the side of the patient

Technique Description:

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

Key Points:

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

Evidence

Evidence

SUMMARY:

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.

Cleland, 2005, Man Ther
Cleland, 2007, Phys Ther
Vernon, 2007, J Manipulative Physiol Ther
Gonzales-Iglesias, 2009, J Orthop Sports Phys Ther
Cleland, 2010, Phys Ther
Mintken, 2010, Phys Ther
Lau, 2010, Man Ther

Shoulder pain:

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:

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.

Bergman, 2004, Ann Int Med
Mintken, 2010, Phys Ther
Bergman, 2010, BMC Musculoskeletal Disord
Bergman, 2010, J Manipulative Physiol Ther

Cervical Radiculopathy (CR):

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.

Cleland, 2005, J Orthop Sports Phys Ther
Cleland, 2007, J Orthop Sports Phys Ther
Young, 2009, J Orthop Sports Phys Ther

OTHER CLINICAL EVIDENCE:

Rose, 2003, J Manipulative Physiol Ther
Pho, 2004, J Orthop Sports Phys Ther
Waldrop, 2006, J Orthop Sports Phys Ther
Fernandez-de-las-Peñas, 2007, J Manipulative Physiol Ther
Krauss, 2008, J Man Manip Ther

OTHER RELEVANT EVIDENCE:

Campbell, 2010, J Orthop Sports Phys Ther
Bishop, 2011, Spine J