Thoracic spine mobilizations and manipulations

Thoracic spine mobilizations and manipulations

Musculoskeletal pathology of the thoracic spine and ribs is often thought to be self-limiting in nature.1
Introduction: Thoracic spine function and dysfunction
The thorax, from a clinical perspective has been related to the recognition of the thoracic spine and ribs not only as a source of local and referred pain but also the influence of thoracic spine mobility on movement patterns in other regions of the spine and the shoulder girdle.2Range of motion (ROM) in the thoracic region is necessary for a number of daily activities and sporting tasks such as golf, throwing sports, tennis, and rowing. Dysfunction of the thoracic spine can also play a role in breathing difficulties and may be linked to postural issues in the later stages of life.2
Range of motion
Movement of the thoracic spine is coupled with movement of the adjoining ribs.3 Thoracic extension involves concurrent posterior rotation (external torsion) and depression of the posterior ribs with elevation of the anterior ribs.3 Although difficult to separate thoracic spine motion from the movement of surrounding structures, accepted approximate normative values have been described for thoracic spine flexion (20° to 45°), extension (25° to 45°), side-bending (20° to 40°), and rotation (35° to 60°).4-6 These measures are often assessed clinically using a tape measure, standard goniometer, inclinometer, or via visual assessment.6-10Restrictions in motion have the potential to impact performance and may manifest as local or distant musculoskeletal pathology.1,11-13

Measuring the range of motion with the Spinal Mouse
A new skin-surface device for measuring the curvature and global and segmental ranges of motion of the spine. Paired t-tests, intraclass correlation coefficients (ICC), and standard errors of measurement (SEM) with 95% confidence intervals were used to characterize between-day and interexaminer reliability for: standing sacral angle, lumbar lordosis, thoracic kyphosis, and ranges of motion (flexion, extension) of the thoracic spine, lumbar spine, hips, and trunk. The between-day reliability for segmental ranges of flexion was also determined for each motion segment from T1-2 to L5-S1. The majority of parameters measured for the ‘global regions’ (thoracic, lumbar, or hips) showed good between-day reliability. Depending on the parameter of interest, between-day ICCs ranged from 0.67 to 0.92 for examiner 1 (average 0.82) and 0.57 to 0.95 for examiner 2 (average 0.83); for 70% of the parameters measured, the ICCs were greater than 0.8 and generally highest for the lumbar spine and whole trunk measures. For lumbar spine range of flexion, the SEM was approximately 3°. The ICCs were also good for the interexaminer comparisons, ranging from 0.62 to 0.93 on day 1 (average 0.81) and 0.70 to 0.94 on day 2 (average 0.86), although small systematic differences were sometimes observed in their mean values.24
Self-mobilization
The self-mobilization thoracic spine technique can be used in conjunction with mobilization interventions provided by a clinician. Joint mobilizations may be graded on a 5-point scale.14Hypomobility of vertebral and costovertebral joints in the thoracic spine may prevent the patient from attaining full motion of the thorax.2 Most interventions to address thoracic spine mobility are dependent on the clinician providing the intervention. The ability for the patient to incorporate self-mobilizations of the thoracic spine into therapeutic exercise programs may help maximize intervention outcomes. Some soft tissue dysfunction manifests in the form of trigger points, which may be alleviated with sustained pressure.15 Dry needling, medical taping, stretching and self-treatment with a golf ball on the myofascial triggerpoints may alleviate the pain.
Upper and lower thoracic rib mobilization with patient on his her or back with a foam roller.

Upper and lower thoracic rib mobilization with patient on his her or back with two tennis balls taped together.

Rib mobilizations as an intervention
Joint mobilizations are indicated when an impairment in joint mobility or a limitation in accessory joint motion is pathologic. Individuals with a history of back pain or referred pain that is suspected to be caused by a hypomobile joint in the thoracic region may benefit from these techniques.
Lower and upper thoracic rib mobilization technique with patient on his or her stomach.“video demonstration”
Upper thoracic rib mobilization with patient in sitting position.“video demonstration”
Lower thoracic rib mobilization with patient in sitting position.“video demonstration”
1st Rib mobilization technique with patient in sitting position.“video demonstration”
1st Rib mobilization technique with patient on his or her back.“video demonstration”
Expiration mobilization with patient on his or her stomach.“video demonstration”
Inpiration mobilization with patient on his or her side. Expiration position of a rib means that the rib is positioned in an endorotation (internal rotation).

Thoracic mobilization / manipulation for neck complaints according to Cleland
Evidence has begun to emerge for the use of manual therapy, specifically, thrust mobilization/ manipulation procedures, directed at the thoracic spine in people with mechanical neck pain. In a randomized controlled trial, Cleland et al16 demonstrated that people who received thoracic spine thrust mobilization/manipulation experienced immediate and significant (P<.001) reductions in pain, as measured with a visual analog scale, compared with people who received a placebo mobilization/manipulation; the between-group difference was 11.3 mm (95% confidence interval [CI].6.9-15.7). It was also demonstrated that people with whiplash associated disorders who received thoracic spine thrust mobilization/ manipulation experienced a significantly greater (P<.003) reduction in pain than those who did not receive thoracic spine thrust mobilization/ manipulation.17They recognized that a variety of mobilization/manipulation techniques are used by physical therapists as well as other health care professionals.19 However, to improve the generalizability of the findings to clinical practice, they standardized the treatment program to a few techniques that have

been well documented in the literature.16,17,20,21 In addition, the clinicians did not use intersegmental mobility assessments to directly target a specific segmental restriction during our interventions.18,22,23

Thoracic manipulation techniques
Upper thoracic rib manipulation with patient in sitting position.

Upper thoracic rib manipulation with patient on his or her back.

Cervico-thoracic manipulation with patient on his or her stomach.

Upper lumbar and lower thoracic manipulation with patient on his or her side.

Literature
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  2. Edmondston SJ, Singer KP. Thoracic spine: anatomical and biomechanical considerations for manual therapy. Man Ther. 1997;2(3):132-143.
  3. Lee D. Biomechanics of the thorax: A clinical model of in vivo function. J Man Manip Ther. 1993;1(1):13-21.
  4. Magee DJ. Orthopedic Physical Assessment. 4th ed. Philadelphia: Saunders; 2002.
  5. Willems JM, Jull GA, Ng J-F. An in vivo study of the primary and coupled rotations of the thoracic spine. Clinical Biomechanics. 1996;11(6):311-316.
  6. Johnson KD, Kim KM, Yu BK, Saliba SA, Grindstaff TL. Reliability of thoracic spine rotation range-of-motion measurements in healthy adults. J Ath Train. 2012;47(1):52-60.
  7. Hoogenboom BJ, Voight ML, Cook G, Gill L. Using rolling to develop neuromuscular control and coordination of the core and extremities of athletes. N Am J Sports Phys Ther. 2009;4(2):70-82.
  8. Kiesel K, Burton L, Cook G. Mobility screening for the core. Athl Ther Today. 2004;9(5):38-41.
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  10. Norkin CC, White DJ. Measurement of Joint Motion: A Guide to Goniometry. Philadelphia: FA Davis Company; 1995.
  11. Grindstaff TL, Beazell JR, Saliba EN, Ingersoll CD. Treatment of a female collegiate rower with costochondritis: a case report. J Man Manip Ther. 2010;18(2):64-68.
  12. Boyles RE, Ritland BM, Miracle BM, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther. 2009;14(4):375-380.
  13. Karlson KA. Thoracic region pain in athletes. Curr Sports Med Rep. 2004;3(1):53-57.
  14. Maitland G, Hengeveld E, Banks K, English K. Maitland’s Vertebral Manipulation 7ed. Edinburgh: Elsevier; 2005.
  15. Lavelle ED, Lavelle W, Smith HS. Myofascial trigger points. Med Clin North Am. 2007;91(2):229-239.
  16. Cleland JA, Childs JD, McRae M, et al. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Man Ther. 2005;10:127–135.
  17. 1 Fernandez de las Penasc, Fernandez- Carnero J, Plaza Ferna ´ndez A, et al. Dorsal manipulation in whiplash injury treatment: a randomized controlled trial. Journal of Whiplash and Related Disorders. 2004;3:5572.
  18. Maitland G, Hengeveld E, Banks K, English K. Maitland’s Vertebral Manipulation. 6th ed. Oxford, United Kingdom: Butterworth-Heinemann; 2000.
  19. 19. van de Veen EA, de Vet HCW, Pool JJM, et al. Variance in manual treatment of nonspecific low back pain between orthomanual physicians, manual therapists, and J Manipulative Physiol Ther. 2005;28:108116.
  20. 20. Liebler EJ, Tufano Coors L, Douris P, et al. The effect of thoracic spine mobilization on lower trapezius strength testing. Journal of Manual and Manipulative Therapy. 2001;9:207
  21. 21. Pho C, Godges J. Management of whiplash-associated disorder addressing thoracic and cervical spine impairments: a case report. J Orthop Sports Phys Ther. 2004;34:511
  22. 22. Paris SV, Loubert PV. Foundations of Clinical 2nd ed. St Augustine,

Fla: Institute Press; 1997.

  1. 23. Kaltenborn F. The Spine: Basic Evaluation and Mobilization Techniques. 3rd Minneapolis, Minn: Orthopaedic Physical Therapy Products; 1993.
  2. Anne F. Mannion. A new skin-surface device for measuring the curvature and global and segmental ranges of motion of the spine: reliability of measurements and comparison with data reviewed from the literature. Eur Spine J (2004)13:122-136

 

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