Presented an in-service on the evidence behind and the application of thoracic spine manipulation to the Martinsburg VA Medical Center's rehabilitation staff including: 7 PTs, 8 PTAs, 3 OTs, and 4 students.

1. Thoracic Spine Manipulation
Jeffrey A. Turner SPT, CSCS
Special Thanks
Dr. Jason Simmons DPT

2. 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

3. 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

4. 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.

5. 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

6. 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

7. 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.

8. 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.

9. Effect Sizes for Pain Relief

10. Effect Sizes for Self-Reported Function

11. Gonzales-Iglesias et al. (2009) Thoracic Spine Manipulation for
the Management of Patients with Neck Pain: RCT
Objective:
• 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%

13. 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.

14. 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

17. 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

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

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

20. 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.”

21. 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 needed
6. Perform technique!
8
2 2 2

22. Seated Thrust Prone Thrust
8
2

23. Supine Thrust (“The Pistol”)
2 2

24. Self Mobilization Prone Mobilization
88 6
Prone Mobilization

25. 8

26. 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.