Download Current Concepts of Orthopaedic Physical Therapy, 3rd Edition

Current Concepts of Orthopaedic
Physical Therapy, 3rd Edition
APTA
American Physical Therapy Association
CONTINUING
Independent Study Course 21.2.7
The Thoracic Spine and Rib
Cage: Physical Therapy Patient
Management Utilizing
Current Evidence
William Egan, PT, DPT, OCS, FAAOMPT
Temple University
Philadelphia, Pennsylvania
Scott Burns, PT, DPT, OCS, FAAOMPT
Temple University
Philadelphia, Pennsylvania
Timothy W. Flynn, PT, PhD, OCS, FAAOMPT
Regis University
Denver, Colorado
Heidi Ojha, PT, DPT, OCS, FAAOMPT
Temple University
Philadelphia, Pennsylvania
An Independent Study Course Designed for Individual Continuing Education
PHYSICAL THERAPY
EDUCATION
Current Concepts of Orthopaedic Physical Therapy, 3rd Edition
Christopher Hughes, PT, PhD, OCS—Editor
Michael Timko, PT, MS, FAAOMPT—Subject Matter Expert
Beth Jones, PT, DPT, MS, OCS—Anatomy Reviewer
Gordon Riddle, PT, OCS, ATC, CSCS—Test Item Reviewer
Dear Colleague,
I am pleased to welcome you to The Thoracic Spine and Rib Cage: Physical Therapy Patient Management Utilizing Current Evidence by William Egan, PT, DPT, OCS,
FAAOMPT; Scott Burns, PT, DPT, OCS, FAAOMPT; Timothy W. Flynn, PT, PhD, OCS, FAAOMPT; and Heidi Ojha, PT, DPT,' OCS, FAAOMPT. This work is part of the
Orthopaedic Section Independent Study Course series 21.2, Current Concepts for Orthopaedic Physical Therapy, 3'd edition.
Dr Egan received his bachelor of arts in psychology from Rutgers College, New Brunswick, New Jersey in 1997. His master of physical therapy degree was granted
by US Army-Baylor University Graduate Program in Physical Therapy, Fort Sam Houston, Texas in 1999. He received his OCS in 2002 and his DPT and manual
therapy fellowship from Regis University, Denver, Colorado in 2006. He currently serves as Assistant Professor and Director of Orthopaedic Physical Therapy
Residency, Department of Physical Therapy College of Health Professions, Temple University, Philadelphia, Pennsylvania. He also is an affiliate faculty member for
the tDPT program at Regis University. Dr Egan has published in the Journal of Manual and Manipulative Therapy and Physical Therapy. He has also coauthored
two chapters on the thoracic spine in the text, Diagnosis and Management of Tension Type and Cervicogenic Headache (Jones and Bartlett, 2009). His current
teaching responsibilities at Temple University are in the areas of management of musculoskeletal disorders, evidence-based practice, and imaging.
Dr Burns received his bachelor of arts degree in kinesiology from the University of Colorado, Boulder, Colorado in 2001. He also received his master of science in
physical therapy and his transitional DPT degree from the University of Colorado-Denver in 2005 and 2006, respectively. Dr Burns then was granted a fellowship
in manual therapy in 2009 from Regis University, Denver, Colorado. That same year he was awarded board certification as an orthopaedic clinical specialist. Dr
Burns is currently an assistant professor in the Department of Physical Therapy, College of Health Professions and Social Work, Temple University, Philadelphia,
Pennsylvania. His peer-reviewed articles have appeared in the Journal of Manual and Manipulative Therapy, Journal of Physiotherapy Theory and Practice, and
Journal of Orthopaedic and Sports Physical Therapy. At Temple University, Dr Burns teaches primarily in the musculoskeletal tract and orthopaedic residency
Dr Flynn received his bachelor of science degree in physical therapy from Marquette University, Milwaukee, Wisconsin in 1983. His master of science in
biomechanics that included an advanced individual manual medicine tutorial with Philip E. Greenman, DO, FAAO, was awarded from Michigan State University,
College of Osteopathic Medicine, East Lansing, Michigan in 1990. He received his PhD in kinesiology in 1997 from The Penn State University, Center for
Locomotion Studies, University Park, Pennsylvania. Dr Flynn's military education included studies at Fort Sam Houston in Texas and Fort Leavenworth, Kansas.
Dr Flynn is presently Distinguished Professor, Rocky Mountain University of Health Professions and also Associate Professor and Coordinator, Manual Therapy
Fellowship, Department of Physical Therapy, Regis University, Denver, Colorado. Since 2006 he has been owner of Colorado Physical Therapy Specialists in Fort
Collins, Colorado and also is principal owner of Evidence in Motion, LLC. He has been a frequent contributor to the Journal of Orthopaedic and Sports Physical
Therapy and has also published noted works in Physical Therapy, Spine, and Journal of Manual and Manipulative Therapy as well as other peer-reviewed journals.
He also serves as manuscript reviewer for many of these publications.
Dr Ojha received her bachelor of science in health studies and a minor in psychology in 2001 from Boston University, Sargent College, Boston, Massachusetts. Her
MSPT degree was also granted by Boston University in 2002. She then completed a clinical residency program and earned her certificate in orthopaedic physical
therapy from the University of Southern California (USC), Los Angeles, California in 2006. She also received her postprofessional doctor of physical therapy in
2007 from USC as well as her OSC from the American Board of Physical Therapy Specialties. In 2010 she obtained fellowship status in Orthopaedic Manual
Physical Therapy from Regis University, Denver, Colorado. Dr Ojha is currently appointed as course instructor for several courses at Temple University. She also
serves as the Director of Temple Faculty PT Clinic.
In their monograph, the authors first provide a discussion on the relevant clinical anatomy of the thoracic spine and rib cage to allow for an accurate clinical
examination of the thoracic spine. This section includes a review of neurovascular structures that account for thoracic pain referral patterns. A nice overview of
clinical biomechanics and pathomechanics of the thoracic spine and rib cage grounds the reader in understanding the basis of developing a sound impairmentbased diagnosis and treatment program. Screening for possible sources of thoracic spine pain that require medical referral is covered in the next section of the
monograph. This information provides for an evidence-based examination of the thoracic spine with an emphasis on tests that guide the selection of treatment
procedures. Intervention techniques with specific emphasis on joint manipulation treatments are described in detail and supported by clear figures showing
patient-therapist positioning. Therapeutic exercises are also highlighted by the authors with the goal of increasing joint mobility and muscle re-education. Common
outcome measures are then reviewed. The interpretation of these appropriate outcome measures and scales should be of value to clinicians in documenting patient
improvements. Finally, 5 case studies offer a variety of patient scenarios to help the reader apply the knowledge and support the authors' rationale for choice of
intervention and treatment planning.
I believe the authors have done an excellent job writing on a topic and body region that many therapists admittedly are not as clinically competent with
compared to other orthopaedic areas. My sincere thanks to the authors for sharing their expertise on a topic that is often a misunderstood area of physical
rehabilitation.
Sincerely,
004".9 Y#17/4
Christopher Hughes, PT, PhD, OCS, CSCS
Editor
2920 East Avenue South, Suite 200 I La Crosse, WI 54601 I Office 608-788-3982 I Toll Free 800-444-3982 I Fax 608-788-3965
TABLE
IcLsE OF CONTENTS
LEARNING OBJECTIVES
1
INTRODUCTION
1
CLINICAL ANATOMY
1
Surface Anatomy
1
Osseous and Ligamentous Anatomy
1
Key Muscles
2
Neurovascular Structures
2
Thoracic Pain Referral Patterns
3
• CLINICAL BIOMECHANICS AND PATHOMECHA
4
Thoracic and Rib Cage Motion
4
Flexion and extension
4
Side bending
4
Rotation
5
Inspiration and expiration
5
Neural Dynamics
5
Pathomechanics
6
Rib joint pathomechanics
PATHOLOGIC CONDITIONS
Nonmusculoskeletal Thoracic Pain
6
7
7
Visceral causes of thoracic spine pain
7
Serious causes of thoracic spine pain
8
Thoracic Vertebral Fractures
8
EXAMINATION PROCEDURES
9
Diagnostic Imaging
9
Physical Examination
9
Inspection
9
Active range of motion
9
Measuring thoracic range of motion
9
Assessing for centralization
10
Cervical spine screening
10
Segmental examination of the thoracic spine
10
Segmental examination of the chest wall
11
Mechanical Movement Impairments Diagnosis 12
INTERVENTION TECHNIQUES
12
Joint Manipulation Techniques
12
Thoracic spine
13
Rib cage
17
Selected soft tissue techniques
20
Selected therapeutic exercises
21
REGIONAL INTERDEPENDENCE
22
Cervical Spine
22
Shoulder
23
REVIEW OF OUTCOME MEASURES AND SCALES
24
CASE SCENARIOS
24
Case Scenario 1
24
Case Scenario 2
25
Case Scenario 3
26
Case Scenario 4
27
Case Scenario 5
28
REFERENCES
29
•
Opinions expressed by the authors are their own and do not necessarily reflect the views of the Orthopaedic Section.
The publishers have made every effort to trace the copyright holders for borrowed material.
If we have inadvertently overlooked any, we would be willing to correct the situation at the first opportunity.
© 2011, Orthopaedic Section, APTA, Inc.
Course content is not intended for use by participants outside the scope of their license or regulations. Subsequent use of
management is physical therapy only when performed by a PT or a PTA in accordance with Association policies, positions, guidelines, standards, and ethical principals and standards.
The Thoracic Spine and Rib Cage:
Physical Therapy Patient Management
Utilizing Current Evidence
Therefore, clinicians should consider the thoracic spine
as a potential cause of or contributing factor to, patients
with upper quarter region musculoskeletal disorders.
This monograph will review evidence-based examination, diagnosis, and intervention strategies to assist with
management of individuals with both primary and secondary thoracic spine and rib cage disorders.
William Egan, PT, DPT, OCS, FAAOMPT
Temple University
Philadelphia, PA
CLINICAL ANATOMY
Surface Anatomy
The primary or key landmarks used in examination of
the thoracic spine and rib cage are the spinous processes,
the transverse processes, and the rib angles. In manual
therapy and the medical literature, the rule of 3's has often been referred to when describing the location of bony
landmarks. 6 In the thoracic spine, the length of the spinous processes vary by region. According to the rule of
3's, the spinous processes of T1 through T3 are at the same
level as the transverse processes, the spinous processes
of T4 through T6 are one half vertebral level below the
transverse processes, the spinous processes of T7 through
T9 are one full vertebral level below the transverse processes, the spinous processes of T10 through T12 are at
the same vertebral level to which they are attached. 6' 7 A
cadaver study investigated the rule of 3's. Geelhoed and
colleagues, 8 in a study of 5 cadavers, found that the spinous processes of T7 through T12 were, in general, at the
same level as the transverse processes of the next caudal
vertebrae. Above T7, the results were similar but more
variable. There are some limitations to this study, most
notable that it was carried out on cadavers in a prone position. In summary, the thoracic transverse processes are
frequently found above the spinous process and could
also be located at the level of the spinous process. Based
on this research, the transverse processes are not found
below the spinous process. The rib angles, a prominent
area where the posterior rib orients laterally and anteriorly, are key landmarks that are helpful for identifying rib
cage dysfunction. These serve as the site for the attachment of the iliocostalis muscle and are located on the
posterolateral aspect of the rib cage. In the authors' clinical experience, in patients with mechanical rib dysfunction, the rib angle will frequently be tender to palpation
with accompanying soft tissue hypertonicity.
Scott Burns, PT, DPT, OCS, FAAOMPT
Temple University
Philadelphia, PA
Timothy W. Flynn, PT, PhD, OCS, FAAOMPT
Regis University
Denver, CO
Heidi Ojha, PT, DPT, OCS, FAAOMPT
Temple University
Philadelphia, PA
LEARNING OBJECTIVES
Upon completion of this monograph, the course participant will be able to:
1. Describe the relevant clinical anatomy of the thoracic
spine and rib cage to allow for accurate clinical examination.
2. Understand the clinical biomechanics of the thoracic spine and rib cage and its relation to forming an
impairment-based diagnosis and treatment program.
3. Screen for possible sources of thoracic spine pain that
require medical referral.
4. Perform an evidence-based examination of the thoracic spine with an emphasis on tests that guide the
selection of treatment procedures.
5. Understand and be able to carry out manual therapy
and exercise interventions guided by available evidence and the clinical examination.
6. Understand and apply the concept of regional interdependence and how examination and treatment of
the thoracic spine can assist with treatment of other
related areas.
7. Use and interpret appropriate outcome measures and
scales associated with thoracic spine pathology.
INTRODUCTION
Compared to the cervical spine and lumbopelvic regions, the thoracic spine receives little attention in the
medical and orthopaedic literature. Linton and colleagues' estimated that the prevalence of spinal pain in
the general population is 66%, but only 15% reported
thoracic pain compared to 44% reporting neck pain and
56% reporting low back pain. However, primary thoracic and chest wall dysfunction can be equally as painful
and disabling. 2'3 Thoracic spine and rib cage dysfunction
influence pain, motion, and posture of the entire spine.
Furthermore, there is evidence that treatment of the thoracic spine and rib cage can affect pain and motion restriction in related spinal and peripheral joint regions. 45
Osseous and Ligamentous Anatomy
The thoracic vertebrae vary by region, with the superior segments sharing commonalities with the cervical
spine, and the inferior segments becoming more like the
lumbar spine. Hence, the vertebral bodies become larger
and denser from superior to inferior to support increasing
loads superimposed by body mass.' The anterior to posterior and transverse dimensions of the vertebral bodies
are uniform. 9 Their height is slightly higher posteriorly,
and this contributes to the dorsal kyphosis of the thoracic
spine.' The thoracic facet joints are synovial joints that
are planar in structure. They are primarily oriented in
the frontal plane, with the superior articulations oriented
1
60° from the horizontal plane and 20° from the frontal
plane.' The inferior articulations match the superior articulations and face anteriorly, inferiorly, and slightly medially. The superior facet articulation originates from the
superior vertebrae of the thoracic spine motion segment
while the inferior facet articulation originates from the
inferior vertebrae. The thoracic disks are thinner in relation to the cervical and lumbar spines. The ratio of disk
height to vertebral body height is 1 to 5, compared to 2
to 5 in the cervical spine and 1 to 3 in the lumbar spine.'
This, among other factors, is thought to contribute to the
relatively lower mobility of the thoracic spine compared
to the cervical and lumbar regions.
The ribs are long, elastic, curved bones made of
highly vascular spongy bone encased in a thin layer of
compact bone.' The ribs are classified into true and
false and typical and atypical.' Ribs 1 through 7 are true
ribs because they directly attach to the sternum. Ribs 8
through 12 are false ribs because they attach distally to
the costochondral cartilage of the superior rib or in the
case of ribs 11 and 12, have no anterior attachment at
all. The heads of ribs 3 through 9, the typical ribs, have
2 facets for attachment to the corresponding demifacets
on the vertebral bodies. The superior rib facets attach
to the superior vertebral body, and the inferior facet attaches to the numerically corresponding vertebral body
forming the costovertebral joint. Between the 2 facets on
the rib head is a crest that attaches to the intervertebral
disk. The atypical 1st, 10th, 11th, and 12th ribs attach
to only 1 facet on the corresponding vertebral body. The
second rib attaches to T1 and T2, and it is considered
atypical because of its attachment to the junction of the
manubrium and sternum. Ribs 1 through 10 attach to the
corresponding thoracic transverse process forming the
costotransverse joint. Ribs 11 and 12 do not attach to the
transverse processes and do not have a costotransverse
joint. In the upper thoracic spine down to T5 or T6, the
rib portion of the joint is concave and the transverse process portion is convex. In the lower thoracic spine, the
costotransverse joints are planar. This shape appears to
allow for more rotation or torsional movement above rib
7 and more planar gliding movement below that level.
Thus, during inspiration the upper rib cage rises (flexes)
in the sagittal plane while the lower ribs widen (abduct)
in the frontal plane.
cends to the angles of ribs 1 through 6 and the transverse
process of C7. The iliocostalis lumborum originates on
the posterior aspect of sacrum and thoracolumbar fascia and ascends to the angles of ribs 6 through 12. Tissue texture changes of these muscles at the rib angle are
thought to indicate rib cage dysfunction. 6,1 °
The serratus anterior arises from the outer surface and
superior border of the upper 8th through 10th ribs and
the fascia of the associated external intercostal muscles.
It courses close to the chest wall to attach to the anterior
surface of the vertebral border of the scapula. Its action
is to protract the scapula and it also assists with the force
coupling for normal scapular upward rotation and posterior tipping. When the scapula is fixed, it is thought that
the serratus anterior will pull the ribs posteriorly.'
The pectoral is major is a thick muscle with 3 proximal
attachments, from the clavicle, the sternum, and the costal cartilages of ribs 1-6. The distal attachment is into the
lateral lip of the bicipital groove. The general action of
the muscle is to adduct and internally rotate the humerus.
The clavicular portion of the pectoralis can also assist the
coracobrachialis and anterior deltoid with glenohumeral
flexion. When the distal attachment is fixed with the humerus flexed, the pectoralis muscle will tend to pull the
rib cage anteriorly, superiorly, and laterally. The pectoralis
minor arises from the anterior and superior surfaces of ribs
3 through 5 and attaches to the medial superior coracoid
process of the scapula. Shortening or hypertonicity of this
muscle can lead to protraction and anterior tipping of the
scapula and this can potentially affect the normal scapular
motion during elevation of the arm."
The anterior scalene arises from the anterior tubercle
of the transverse processes of C3 through C6 and attaches
to the scalene tubercle on the inner border of the first rib.
The middle scalene arises from the transverse processes
of C2 through C7 and attaches on the first rib medial to
the anterior scalene. The anterior and middle scalenes are
potentially relevant contributing factors to dysfunction of
the first rib because they both can elevate the first rib when
the cervical spine is fixed.' The posterior scalene arises
from the posterior tubercle of the transverse processes of
C4 through C6 and attaches to the outer surface of the
second rib. Given its origin and insertion, the posterior
scalene can potentially elevate the second rib when the
cervical spine is fixed. The diaphragm is the primary muscle of inspiration and has broad musculoskeletal attachments to the ribs and spine. The muscles of the diaphragm
are grouped into 3 parts: sternal, costal, and lumbar. The
sternal portion arises from the back of the xiphoid process,
the costal from the internal surfaces of the costal cartilages
and adjacent parts of the lower 6 ribs, and the lumbar from
the first two or 3 lumbar vertebrae.'
Key Muscles
The thoracic spine and rib cage serve as the attachment site for numerous muscles. The authors will discuss
the muscles relevant to the examination, intervention,
and diagnosis of thoracic spine and rib cage dysfunction.
The trapezius muscle originates from all the thoracic spinous processes, the external occipital protuberance, the
ligamentum nuchae, and the spinous process of C7. It
has an important role in assisting with the force coupling
to allow for normal scapular upward rotation and posterior tipping during elevation of the humerus. The iliocostal
thoracis starts at the angle of ribs 7 through 12 and as-
N eu rovascu I ar Structures
The 12 thoracic spinal nerves are divided into anterior
and posterior primary rami. Each thoracic spinal nerve
exits below its respective intervertebral disk.' The cutaneous branches of the anterior and posterior thoracic rami
2
spinal nerve form each thoracic dermatome. The thoracic
dermatomes run in a circumferential pattern just inferior to
the corresponding thoracic vertebrae from posterior midline to anterior midline. The posterior rami are divided
into medial and lateral branches. The medial branch of the
upper 6 segments supplies the semispinalis and multifidus
muscles and the skin of the upper back. The medial branch
of the lower 6 thoracic segments supplies the transversospinalis and longissimus muscles. Each medial branch has
ascending and descending branches to the zygapophyseal
joints above and below." The lateral branch of the posterior rami supply the longissimus and iliocostalis muscles,
and the costotransverse joints. The lower 6 segments
eventually emerge from the iliocostalis lumborum muscles
to become cutaneous. 12 The anterior rami travel anteriorly
in the intercostal space and are known as the intercostal
nerves. The 12th anterior rami forms the subcostal nerve
as it travels below the 12th rib. Each thoracic spinal nerve
contributes preganglionic sympathetic fibers to the sympathetic chain. The sympathetic chain is just anterior to the
rib head and is lateral to the costovertebral joint. 12
The muscular branches of the typical intercostal
nerves supply the innermost intercostal, internal intercostal, external intercostal, subcostal, and serratus posterior
muscles. The cutaneous branches supply the skin on the
lateral and anterior aspect of the thorax and abdomen.
The muscular branches of the 7th through 11th intercostals and the subcostal innervate the abdominal muscles.
The subcostal nerve supplies the skin of the abdominal
wall, the lateral hip region, and over the iliac crest." This
is one avenue through which dysfunction of the thoracolumbar junction can produce pain in the hip region."
The superior part of the first intercostal nerve (T1) forms
part of the brachial plexus. The lateral cutaneous branch
of the second intercostal nerve is known as the intercostobrachial nerve." The intercostobrachial nerve supplies
the floor of the axilla and joins the medial brachial cutaneous nerve to supply the medial side of the arm as far
distal as the elbow region. This connection allows for
dysfunction of the upper thoracic spine to contribute to
symptoms in the arm." The sinuvertebral nerve is a recurrent branch of the spinal nerve and the anterior rami.
The sinuvertebral nerve consists of both somatic and autonomic fibers and supplies the dura, the outer fibers of
the intervertebral disk, medial aspect of the zygapophyseal joint, and the posterior longitudinal ligament. 12
The spinal canal within the thoracic spine is notably narrower than in other regions. The region from T4
through T9 is known as the critical zone due to the small
diameter of the spinal canal and reduced blood supply in
comparison to other regions of the spine.' The clinical
significance of this is that significant pathology such as a
large herniated disk has the potential to cause central spinal cord compression. Anecdotally, less serious pathology such as segmental stiffness in this region can have
widespread effects on the neurodynamics in the spine
and periphery. Often, treatment aimed at improving the
segmental motion restrictions in this area results in clini-
cally meaningful pain reduction and functional improv6t
ments in distal regions including symptoms associated
with adverse neural dynamics.
Thoracic Pain Referral Patterns
Regional examination of the thoracic spine and rib
cage is indicated for patients whose symptoms originate
from this anatomical region or are referred to areas segmentally innervated by these levels. Identification of appropriate patients is based on the location and nature of
their symptoms or symptoms provoked during the upper
or lower quarter screening examination. The pain referral pattern of the thoracic spine and rib cage articulations, and also what other somatic structures can refer
pain to the thoracic spine, has implications for conducting and interpreting the physical examination. The pain
referral patterns of the thoracic zygapophyseal or facet
joints have been investigated in two studies.
Dreyfuss et ale have provided preliminary evidence in
the asymptomatic population that the thoracic zygapophyseal joints can cause both local and referred pain. The zygapophyseal joints from T3-4 through T10-11 were studied.
The authors reported that in all subjects the most intense
area of evoked pain occurred one segment inferior and
slightly lateral to the joint injected. Furthermore, no joints
referred pain more superior than one half of the vertical
height of that vertebral segment; however, distal referral
was up to 2.5 segments below the injected level. In addition, two subjects had anterior chest wall and sternal pain
when the T3-T4 and the T4-T5 segments were injected.
To complete the pain-referral map of the thoracic facet
joints, Fukui et aP injected the C7-T1 through T2-T3 and
T11-T12 segments in a group of 15 patients complaining
of thoracic spine pain. Pain referral from the C7-T1 to T2T3 segments overlapped extensively, with pain reported
over the paravertebral region, inferior toward the superior
angle of the scapula, and the interscapular region toward
the inferior angle of the scapula. The T11-T12 segment
produced pain localized to the paravertebral region of
the segment, and in one patient over the ipsilateral iliac
crest. Across all subjects, only unilateral pain was reproduced and no radiating pain, including anterior or lateral
chest wall pain, was reported.
In a prospective case series of 46 patients with chronic
thoracic spine pain, 48% responded to a medial branch
block performed on 2 separate occasions.'s Manch i kanti
et al's state that this indicates a 48% prevalence rate of
zygapophyseal joint pain in patients with chronic thoracic pain. This is in comparison to the reported 15%
to 45% prevalence of facet joint pain in patients with
chronic lumbar pain and 54% to 60% in patients with
chronic cervical pain. This study took place in one private pain management practice and there was no placebo intervention, so the applicability of the results to the
general patient population is speculative.
Due to their innervation, the costovertebral and costotransverse joints both have the potential to generate
pain. Young et a1 16 performed a pain mapping study of
the costovertebral joints with 8 asymptomatic volunteers.
Using video fluoroscopic guidance, the T2-T7 costovertebral joints were injected. Subjects reported symptoms
ipsilateral to and directly over the joint injected. Only
with injection to the T2 costotransverse joint did subjects
report pain 2 vertebral levels above the region injected.
In a clinical case series, Benhamou et al 17 reported on 28
patients who had pseudovisceral pain that was relieved by
injection into the costovertebral joint. In a cadaver dissection study, Nathan" noted a 60% incidence of osteophytes at the costovertebral articulation that appeared to
encroach on the thoracic sympathetic chain. This could
potentially explain the findings of pseudovisceral pain being relieved by injection of the costovertebral joint.
Similar to the cervical and lumbar regions, the thoracic
disk is capable of producing pain. Thoracic disk pathology is often seen on imaging studies such as x-ray film
or magnetic resonance innaging.' 9 The presence of disk
pathology on imaging studies, however, does not automatically implicate the disk as a source of pain. Wood
and colleagues" have demonstrated that the incidence of
asymptomatic thoracic disk protrusions is approximately
37%. Furthermore, a two-year follow-up by Wood et a1 2°
reported that there was little change in the size of the
protrusions, suggesting that these disk abnormalities exist
in a state of relative flux. Therefore, the authors advised
that clinicians should interpret thoracic magnetic resonance imaging with caution. Although descriptive in nature, the literature suggests a link between thoracic disk
herniations and thoracic and chest wall pain. However,
there are no studies reporting the pain referral pattern
for the thoracic disk. A thoracic disk protrusion could
potentially create thoracic nerve root compression and
a radiculopathy. In this instance the clinician may find
decreased sensation in the corresponding thoracic dermatome and the patient may report lancinating pain in a
similar region. A recent case in the literature highlighted
the potential for a lower thoracic disk herniation could
be the source of referred abdominal pain. The patient
in this case reported vague abdominal pain. Diagnostic
work up for visceral causes including gastrointestinal was
negative. The patient was subsequently diagnosed with
a T12-L1 disk herniation and underwent decompression
surgery that relieved her symptoms. 2 '
The lower cervical spine has the potential to refer pain
into the upper to middle thoracic spine. In particular, the
facet joints and intervertebral disks of the C5-C6 and C6C7 segments can refer pain into the upper thoracic spine
and interscapular region. 22,23 For patients with upper thoracic and interscapular region pain, clinical examination
is required to differentiate the thoracic spine versus the
cervical spine or other structures as the source of the patient's symptoms.
addition of the rib cage and rib articulations. The thoracic spine can be thought of as 3 units. The upper thoracic spine and cervicothoracic junction function more
similar to the cervical spine. The middle thoracic spine
functions independently and has significant influence
from the rib cage. The lower thoracic spine and thoracolumbar junction more closely resemble the lumbar spine.
Although the addition of the rib cage does certainly limit
the range of motion and increases the stability of the thoracic spine, the thoracic segments are capable of moving
independently of the rib cage. 24
Flexion and extension
Due to the morphology of the facet joints, motion in
the sagittal plane gradually increases from T1 2 to T1 1 1 2
as the facets become more oriented in the sagittal plane.
With forward flexion, the superior vertebra translates forward in the transverse plane and rotates forward in the
sagittal plane. 25 The articular facets of the superior vertebrae glide upward and forward on the superior facets of
the inferior vertebrae. In a clinical model proposed by
Lee, 25 flexion of the thoracic spine results in concomitant forward rotation of the rib head at the costovertebral
joint. The hypothesis is that the anterior translation of the
superior vertebrae of the motion segment pushes the superior demifacet of the rib head. The concave tubercle of
the rib glides superiorly on the convex facet on the thoracic transverse process at the costotransverse joint. Recall that this motion is more rotational in the upper 6 ribs
and more planar below rib 6 due to the costotransverse
joint configuration. Extension results in posterior translation of the superior vertebrae and backward rotation in
the sagittal plane. 25 The inferior facets of the superior
thoracic vertebrae glide down and back on the superior
facets of the inferior vertebrae at the zygapophyseal joint.
In the clinical model proposed by Lee, 25 thoracic extension produces a concomitant posterior rotation of the rib
head at the costovertebral joint and inferior glide at the
costotransverse joint.
-
-
Side bending
Side bending of the thoracic vertebrae in the frontal
plane is accompanied by a small ipsilateral lateral translatory movement of the superior vertebrae in the horizontal plane. 25 Side bending in the thoracic spine gradually
increases from T1 -2 to Ti 1-12. In right side bending, the
right inferior facet of the superior vertebrae glides inferolaterally and the left inferior facet glides superomedially. 25 Controversy exists as to whether thoracic rotation
couples contralaterally or ipsilaterally during side bending. The thoracic spine coupling pattern was the subject of a systematic review involving 8 different studies. 26
The reviewed studies included both in vitro and in-vivo
designs. Across the 8 studies there was no consistent
coupling pattern reported. The authors concluded that
methodological study design differences could account
for the reported variability and that more research is
needed. In an in vivo study by Willems et a1 27 using FAS-
CLINICAL BIOMECHANICS AND PATHOMECHANICS
Thoracic and Rib Cage Motion
Motion in the thoracic spine is affected by the unique
morphology of the thoracic functional spinal unit and the
4
•
•
TRAK motion analysis, rotation was found to couple to
the ipsilateral side with primary side bending. There was
some variability within and between subjects, and the
ipsilateral coupling pattern was not as consistent in the
upper thoracic spine. A study analyzing the T2 through
T7 segments in asymptomatic individuals found that the
thoracic spine extended, rotated, and side bent to the ipsilateral side during elevation of the arm." In the clinical
model developed by Lee, 25 side bending of the thoracic
spine leads to approximation of the ribs on the ipsilateral
side and separation of the ribs on the contralateral side.
Rotation
Thoracic spine rotation is greatest in the upper segments and significantly reduced in the lower segments."
Thoracic spine rotation is accompanied by slight translation of the superior motion segment to the contralateral
side. 25 In the in vivo study by Willems et a1, 27 ipsilateral coupling of side flexion with primary rotation predominated, but there was variability within and between
subjects. In the clinical model proposed by Lee, 25 right
thoracic rotation results in posterior rotation of the right
rib and anterior rotation of the left rib. In the osteopathic
biomechanical model, the posterior rotation of the rib is
referred to as external torsion and the anterior rotation of
the rib is called internal torsion. 6,1 °
Inspiration and expiration
Clinical models of rib cage motion during respiration
postulate that the ribs follow a pump-handle and buckethandle motion." During inspiration, as the anterior-posterior diameter of the thorax expands and the intercostal
muscles contract, the ribs move through the axes of their
necks at the costovertebral and costotransverse joints
and the anterior ends of the rib rise with the sternum.
This anterior superior motion is referred to as the pump
handle motion. Concurrently during inspiration, as the
transverse diameter of the thorax expands and intercostal
muscles contract, the ribs move laterally and superiorly.
This movement is referred to as a bucket handle motion
because it is similar to a bucket handle moving away
from its attachments when the handle is raised. During
expiration, the rib moves inferiorly in both the anterior
and lateral aspects. Due to the axis of motion through
the costovertebral and costotransverse joints, the pumphandle motion is thought to predominate in the upper
ribs, whereas the bucket-handle motion predominates in
the lower ribs. An in vivo study, however, determined
that rib cage motion was similar at all levels in terms of
the relative anterior and lateral expansion of each rib during inspiration. 30 The 11th and 12th ribs, due to the lack
of anterior attachments and costotransverse joints, are
thought to move in a caliper-type motion. In the caliper motion, the ribs move posterior and lateral during
inspiration and anterior and medial during expiration.
Of note is that during inspiration the thoracic segments
extend, and during expiration the segments return to their
neutral position. 3 '
Neural Dynamics
The concept of neural tissue dynamics has been reported in clinical orthopaedic physical therapy literature. 32,33
Evaluation and treatment of neural tissue is supported by
basic science research and clinical case reports. 34-36 In
the thoracic spine, two areas deserve mentioning in relation to neural dynamics. The sympathetic chain lies
anteriorly along the rib heads and costovertebral joints."
Theoretically, the thoracic sympathetic chain is tensioned
during flexion, contralateral rotation, and contralateral
side bending of the thoracic spine. 32 Further stretching
could be accomplished by performing thoracic flexion
and contralateral side bending in a slump long-sitting position. As stated previously, the area from T4 through T9
is known as the critical zone due to the small diameter
of the vertebral canal. In addition, the T6 spinal cord
segment is reported to be a tension point. 32 This is an
area where the motion of the spinal cord relative to the
spinal canal converges in different directions. Butler 32
postulates that during flexion of the cervical and thoracic
spine, similar to the slump position, the cord, in relation
to the spinal canal, moves cranially toward the cervical
spine and caudally toward the lumbar spine. Segmental
stiffness of this middle thoracic region could contribute
to signs and symptoms associated with adverse neural tissue dynamics. Anecdotally symptoms and range of motion associated with a positive slump test can be altered
after spinal manipulative treatment of the middle thoracic
region. Manipulation of the thoracic spine could produce an increase in thoracic spine segmental mobility
allowing for increased thoracic flexion range of motion
and improved neural dynamics of the spinal cord.
A clinical syndrome referred to as the T4 syndrome,
has been described as a constellation of signs and symptoms associated with stiffness of the upper to middle
thoracic region." Typical signs and symptoms include
headaches, neck pain, upper extremity pain, and bilateral "stocking glove" paresthesias. It is thought that these
signs and symptoms could be resulting in part from the
dysfunction of the thoracic spine and its resulting influence on the sympathetic nervous system. A published
case report described a decrease in symptoms in a patient with upper extremity complex regional pain syndrome after a thrust manipulation directed to the upper
thoracic spine. 38 An experimental study found that grade
3 posterior to anterior nonthrust mobilization applied to
the T4 segment produced sympathoexcitatory effects in
both hands of asymptomatic subjects." Sympathetic nervous system activity was measured via skin conductance
that the authors report as a valid and reliable measure of
sympathetic nervous system activity in the hand. The authors reported that manipulation of the T4 thoracic region
produced an increase in skin conductance in the hands.
However this study does not provide direct evidence
into the mechanism of how manipulation of the thoracic
region can provide a reduction in symptoms in patients
with T4 syndrome. Further research is required to elucidate the etiology of T4 syndrome and the mechanisms
behind how manipulation of the thoracic spine produces
beneficial effects.
plane, unilateral rib joint dysfunction, and unilateral
adverse neural tissue, including the sympathetic chain
mobility. A unilateral thoracic spine flexion impairment
could be evident during combined motion testing of flexion, contralateral rotation, and contralateral sidebending.
Extension impairments are the opposite of flexion impairments and reflect the inability of the thoracic motion
segment to rotate backward in the sagittal plane. Extension impairments are thought to more commonly occur
in the upper thoracic spine and cervicothoracic junction
(C7 through T2), where an increased posterior thoracic
kyphosis is often present.'° The lower thoracic spine is
also thought to be more commonly restricted in extension, as observed by an increased middle to lower thoracic kyphosis. Age-related structural changes of the
thoracic spine including disk height degeneration and
anterior wedging of the vertebral body can also contribute to extension impairments." A unilateral extension
impairment of a thoracic spine could theoretically occur
when the ipsilateral facet joint is restricted in its inferior
glide, ipsilateral rib joint dysfunction, or a space-occupying lesion (eg, a disk protrusion or osteophytes) creating
painful closing down of the neurovascular structures in
the intervertebral foramina. A unilateral extension impairment can be observed by a lack of combined motion
into extension, ipsilateral rotation, and ipsilateral side
bending.
Pathomechanics
To the authors' knowledge, there are no studies analyzing the motion of the thoracic spine and costal cage
in subjects with primary or secondary thoracic spine disorders. As a result, the pathomechanics of the thoracic
spine are based largely on applied anatomy and biomechanics, expert opinion, and clinical models. In the absence of evidence, a clinical model enables clinicians to
categorize movement impairments and can be useful to
direct treatment and interventions.
In most clinical texts, pathomechanical models of
motion restriction usually make reference to motion impairments of specific joint articulations. 6,10,40,41 In the thoracic spinal segments, motion impairments are usually
made in reference to the motion of the facet joints. Recall
that during flexion, the inferior facet of the superior vertebrae glides superiorly on the superior facet of its caudal neighbor. Restriction of a thoracic functional spinal
unit can involve the facet joints, the intervertebral disk
articulation; the costovertebral joints; the costotransverse
joints; and associated muscular, neural, fascia!, and ligamentous structures. Because of the varied clinical terms
used to describe these motion impairments, a common
language to describe these various impairments does not
exist. As a result, universal clinical and scholarly communication among spine practitioners is lacking. A proposed common language for movement impairments in
the thoracic spine is presented below.
Flexion movement impairments reflect the inability of
the thoracic spinal unit to rotate forward in the sagittal
plane. This could be due to impaired superior gliding
of the facet joints, reduced anterior translation of the superior vertebral body on the inferior vertebral body, restricted anterior rotation of the rib joints, and segmental
or multisegmental soft tissue restrictions. The cause of
these perceived movement impairments is unknown at
this time. In isolation, their relevance and contribution
to a patient's complaints of pain and functional limitation
is uncertain. In the thoracic spine, flexion impairments
appear to most commonly occur in the upper to middle
thoracic spine regions, approximately T3-4 through T67.6,10,40 This may be observed by a relative straightening
or a reduction of the normal posterior thoracic kyphosis.
A flexion movement impairment of the upper thoracic
spine is thought to occur after a whiplash-type injury as
a result of a rear-impact collision. It is thought that the
upper thoracic segments become jammed into extension
when the upper trunk is thrust forward and upward during the initial impact. 42,43 A unilateral flexion impairment
may exist, whereby a thoracic spinal motion segment has
decreased flexion, contralateral (to the side of the restriction) rotation, and side bending. This could be due to
the inability of the facet on the ipsilateral side to glide
forward, soft tissue restriction reduced ipsilateral lateral
translation of the superior vertebrae in the horizontal
Rib joint pathomechanics
Upper ribs
The upper rib joints could theoretically become dysfunctional at either the costovertebral or costotransverse
joint articulations. Several authors describe a condition
where the first rib becomes subluxed cranially at the costotransverse joint with a limited caudal glide. 6,10,45 This is
thought to commonly occur with traumatic injuries such
as during whiplash and with repetitive overuse of the extremity. The first rib joint is thought to be vulnerable to
subluxation due to the lack of a superior reinforcing ligament at the costotransverse joint. 45 Impaired mobility of
the first rib during inspiration and expiration has been
demonstrated cineradiographically in patients suffering
from thoracic outlet syndrome. 46
Middle and lower ribs
Middle and lower rib movement impairments can occur either in isolation or concurrently with thoracic spine
impairments. Reduced motion at costovertebral joint,
costotransverse joint, or costosternal joint can contribute
to rib joint impairments.
Two other common rib joint dysfunctions have been
observed clinically. 6,10 During a traumatic injury with a
blow to the posterior chest wall, a rib can become subluxed anteriorly. This is usually indicated by a prominence of the rib anteriorly, a concavity of the rib posteriorly, and reduced motion during inspiration and expiration. Similarly, a posterior rib subluxation can occur after
blunt trauma to the anterior chest wall. It is unknown
6
where the actual subluxation occurs anteriorly at the costochondral or sternocostal joint or posteriorly at the costotransverse or costovertebral joint. Furthermore these
dysfunctions are purely anecdotal, are based on a biomechanical mode1, 6,1 ° and may not actually represent true
joint subluxations. However, the authors have found that
manual therapy interventions directed toward reducing
these theoretical joint and related soft tissue dysfunctions
can lead to decreased pain and functional limitations in
patients with chest wall pain.
tion requiring emergent care due to the high likelihood of
mortality if this condition proceeds untreated. Pain from
myocardial ischemia is accompanied by anterior chest
pain or heaviness, occasional nausea, and sometimes
pain radiating to the back." Patients presenting acutely
with this condition obviously require immediate medical attention. Thoracic or chest pain may also be from
exertional or variant myocardial ischemia, also known
as stable or unstable angina. In stable angina, pain is
related to exertion and relieved with rest." Unstable angina occurs in random or unpredictable fashion, and is
not related to activity. Unstable angina is usually a progression of stable angina and is a risk factor for pending
myocardial infarction.
A clinical prediction rule was developed and validated to rule out coronary artery disease in primary care. 5°
Subjects were included in the study if the patient was
greater than 35 years old and reported anterior chest pain.
The predictor variables in the rule are: age/sex (female
65, male 55), known clinical vascular disease (includes
coronary artery, occlusive vascular, and cerebrovascular
diseases), pain worse during exercise, pain not reproducible by palpation, and patient assumes pain is of cardiac
origin. Sensitivity was 0.98 if two predictor variables
were met, which would be a reasonable cut off for ruling out cardiac disease. The best overall discrimination,
balancing sensitivity and specificity, was presence of 3
predictor variables with a sensitivity of 0.87 and specificity of 0.80, with a positive likelihood ratio of 4.52.
A peptic ulcer of the posterior wall of the stomach
or duodenum can cause boring pain from the epigastric
area to the middle thoracic spine. Thoracic pain either
triggered or relieved by eating is a sign of peptic ulcer
disease." Peptic ulcer disease can result from prolonged
use of nonsteroidal anti-inflammatory drugs (NSAIDs).
A history of extensive NSAID use should raise suspicion
for a peptic ulcer. 49 Pain from an inflamed gall bladder
(cholecystitis) is usually experienced in the right upper
quadrant and right infrascapular region." The pain is often accompanied by a moderate fever, nausea, and vomiting. Symptoms often occur one to two hours after the
ingestion of a heavy meal. The Murphy sign is performed
by palpating the right subcostal region and asking the
patient to take a deep breath. The sign is positive if the
patient reports pain with inhalation. 5 ' Patients with acute
inflammation of the pancreas (pancreatitis) can experience pain around the thoracolumbar junction. Kidney
or renal pain caused by pyelonephritis (kidney infection)
and renal stones is usually referred to the costovertebral
angle or flank area. 49 The flank refers to the lateral region
of the trunk between the rib cage and iliac crest. Pain
originating from the kidneys is typically accompanied by
fever, nausea, vomiting, and renal colic. Renal colic is
flank pain accompanied by lower abdominal pain that
spreads into the labia in women and into the testicles in
men. Those at risk for kidney infection either have a history of urinary tract infections or currently have an ongoing urinary tract infection.
PATHOLOGIC CONDITIONS
Nonmusculoskeletal Thoracic Pain
The first concern in managing a patient with thoracic
spine pain, especially in an era of the physical therapist
becoming a direct access care provider, is to rule out
a serious pathological or visceral cause that requires a
medical referral. Because the presence of primary thoracic pain is relatively uncommon (only an estimated
15% of all spinal pain), clinicians should be suspicious of
nonmechanical causes in patients presenting with a primary complaint of thoracic spine and chest wall pain. 47
A medical screening form, which the patient completes
prior to the clinician conducting an examination, is a
useful first step in the medical screening process. Positive responses to questions on the medical screening
form will then cue the therapist to probe further in order
to ascertain the possibility of serious pathology or disease. Potentially, conditions that would require a medical referral can be divided into visceral conditions that
refer pain to the thoracic spine and serious conditions of
the thoracic spine."
Visceral causes of thoracic spine pain
Visceral causes of thoracic spine pain should be considered when there are no clear mechanical features to a
patient's pain. Visceral conditions that can refer pain to
the thoracic spine include myocardial ischemia, dissecting thoracic aortic aneurysm, peptic ulcer, acute cholecystitis, renal colic, and acute pyelonephritis. Referred
pain is pain perceived in a region separate from the location of the primary source of the pain. 12 The mechanism
of referred pain is not completely clear. The most accepted theory is that referred pain is due to the convergence of primary afferent neurons to the same second-order neuron in the spinal cord. Pain elicited by a visceral
structure can be misperceived as arising from a somatic
structure that has a primary afferent neuron converging
onto the same second-order neuron. 12 The majority of
the visceral organs are innervated by the thoracic spinal
nerves. Therefore, there is a potential for a host of visceral diseases to refer pain to the thoracic spine and rib
cage.
Pain from a dissecting thoracic aneurysm is usually
felt in the chest and can radiate to the back if the descending aorta is involved." Pain is usually of sudden
onset, often is unrelenting, and is not relieved by position change. A dissecting aortic aneurysm is a condi-
7
osteomyelitis, diskitis, and epidural infections. Fever is
usually a hallmark sign in cases of spinal infection.
Serious causes of thoracic spine pain
Pain from serious conditions emanating from the thoracic spine includes infection, fractures and neoplasms,
and inflammatory disorders. Spinal metastases, usually
secondary to a primary breast, lung, or colon cancer, are
the most common forms of cancer in the thoracic spine. 52
Primary thoracic spine tumors are less common. Ozaki
et a1 52 reported on 22 cases of spinal osteoid osteoma
or osteoblastoma of which 6 were in the thoracic spine.
Among the common findings in these 6 cases were a
painful scoliosis, long-tract neurological signs, and leg
pain. Deyo and Diehl" reported on 1975 patients in an
outpatient primary care setting with spinal pain of which
316 (16%) had thoracic spine pain. Two (0.63%) of these
patients had cancer as the cause of the thoracic pain.
This was similar to the 0.66% of cancer-related pain for
patients with low back pain. Historical findings that carried the most accurate diagnostic information for predicting cancer were as follows: age over 50 (sensitivity
0.77, specificity 0.71, positive likelihood ratio 2.7, negative likelihood ratio 0.32), history of cancer (sensitivity
0.31, specificity 0.98, positive likelihood ratio 15.5), unexplained weight loss (sensitivity 0.15, specificity 0.94,
positive likelihood ratio 2.5), and failure of conservative
therapy (sensitivity 0.31, specificity 0.90, positive likelihood ratio 2.6). Therefore, the greatest shift in probability
of cancer (positive likelihood ratio 15.5) occurs when the
patient reports a history of cancer.
Ankylosing spondylitis is an inflammatory disease
that can affect the thoracic spine and rib joints. Information from the patient history can assist in guiding diagnosis. An initial diagnostic criteria set was proposed with
the following predictor variables: stiffness of > 30 minutes duration, improvement in back pain with exercise
but not with rest, awakening because of back pain during
the second half of the night only, and alternating buttock pain. 54 This set has reasonable diagnostic accuracy.
If two of the 4 parameters were fulfilled, the sensitivity
was 0.70 and specificity is 0.81. If 3 parameters were
fulfilled, the sensitivity was 0.33 and the specificity was
0.94. The key physical examination finding implicating
ankylosing spondylitis is limited chest expansion." The
normal expansion of the rib cage measured at the nipple
line is 5 centimeters. Chest expansion of less than 2.5
centimeters is considered pathologic. Other signs alerting the clinician to the possibility of ankylosing spondylitis include sacroiliitis, morning pain and stiffness, and
peripheral joint involvement. The ratio of those affected
by the disease is 3 to 1 for men to women, and age of
onset is between 15 and 40 years." Ninety percent of
patients with ankylosing spondylitis are HLA-B27 positive. However, only 10% to 20% of individuals who are
HLA-B27 positive develop ankylosing spondylitis; therefore, the false positive rate for this test is high.
Infection is an uncommon cause of thoracic spine
pain. The pretest probability of infection as the cause
of back pain in general in the primary care setting is less
than 0.01%." Causes of thoracic spine infection include
Thoracic Vertebral Fractures
Fractures as a serious cause of thoracic spine pain
can be divided into traumatic fractures and osteoporotic
fractures. Traumatic fractures are usually a result of blunt
trauma or injury. Osteoporotic fractures represent an increasingly common serious cause of thoracic spine pain
in our aging patient population. Osteoporosis is an agerelated disorder characterized by decreased bone mass
and increased susceptibility to fracture. Osteopenia is a
generalized decrease in bone mineral density appearing
as excessive radiolucency on radiographs. Risk factors
for osteoporosis include Caucasian race, history of smoking, early menopause, thin body build, sedentary lifestyle,
steroid treatment, and excessive consumption of caffeine
or alcohol." In a large study in the Finnish population,
the prevalence of thoracic vertebral fracture was 6.2 per
1000 in men and 3.9 per 1000 in women." The prevalence in men gradually increased with age, and in women
it greatly increased over the age of 65. The majority of
those with fractures in this study were asymptomatic. A
hospital-based study found that the majority of thoracolumbar compression fractures occurred spontaneously or
as a result of a trivial strain. 57 The clinical implication is
that in men or women age 60 or older presenting with
acute thoracic spine pain, osteoporotic fracture must be
considered.
Vertebroplasty and kyphoplasty are minimally invasive
and commonly used surgeries to manage vertebral compression fractures. Previously, it was thought that vertebroplasty had at least short-term effectiveness in reducing
pain and improving function but recent double blind placebo controlled trials concluded that there was no significant difference between vertebroplasty compared with a
sham procedure in pain, function, disability, quality of life,
and perceived improvement at one- to 6-month followup 58,59 These results indicate that there is no benefit of vertebroplasty over passage of time. Two editorials have criticized these randomized trials stating that the population
in both studies was chronic (> 12 months post-fracture)
whereas vertebroplasty may be effective for a more acute
population. 6°,61 There are no randomized controlled trials
to date comparing kyphoplasty to sham or conservative
care. Although no studies have directly compared surgery
with physical therapy, it is likely that physical therapy can
serve as a low-cost alternative to more invasive management, with little to no risk of serious complications. A pilot randomized trial compared the effects of a multimodal
physical therapy program to a control group in 20 patients
with an osteoporotic vertebral compression fracture. 62 All
patients were older than 50 and had sustained at least one
vertebral compression fracture between the past 3 months
and two years. The physical therapy program took place
once a week for 10 weeks. The program consisted of education, postural taping, manual therapy, range of motion
exercises, and back extensor strengthening. Manual ther-
8
apy included soft tissue massage and nonthrust posterior
to anterior manipulation directed to the thoracic spine.
At the completion of the study the physical therapy group
reported decreased pain, improved physical functioning,
and displayed improvement in physical impairments compared to the control group. No serious adverse events
were reported in the physical therapy group.
EXAMINATION PROCEDURES
Diagnostic Imaging
Although the ordering of imaging studies is not currently a standard part of most physical therapists' practice,
physical therapists should be knowledgeable of when an
imaging study is indicated. In the absence of trauma, imaging of the thoracic spine is indicated when investigating
a serious cause of thoracic spine pain. Individuals with
acute thoracic pain who are at risk for an osteoporotic
fracture should have plain radiographs to assess for the
presence of a fracture. 47 In cases where cancer or infection are suspected, magnetic resonance imaging and bone
scans are typically the preferred initial imaging modalities
due to their high sensitivity in detecting these conditions.
In the presence of trauma, one guideline recommends
plain radiographs for patients with positive or equivocal
clinical findings, such as spinal tenderness and neurologic signs, and for those with altered consciousness. 47 For
those patients who are awake and alert, and have no clinical findings, radiographs are not indicated. In the absence
of trauma or indications of serious causes of thoracic spine
pain, imaging studies, including magnetic resonance imaging and radiographs, are not useful in determining the
source of a patient's pain.
Physical Examination
Inspection
At the stage of inspection in the examination, the therapist is interested in the global visual presentation of the
patient including the posture of the thoracic spine. The reliability of postural assessment in the cervicothoracic spine
has been studied by Griegel-Morris and colleagues. 63 They
visually assessed for the presence of a forward head posture, the rounding of the right and left shoulders, and degree of thoracic kyphosis against a plumb line. Using this
method, the intrarater reliability across 3 therapists was
= 0.825, and the interrater reliability across the 3 therapists
was x = 0.611. The primary purpose of the study was to
assess the association of postural abnormality and a history of pain. In 88 asymptomatic subjects aged 20 to 50, a
relationship between pain frequency and severity and the
severity of postural abnormalities was not found. However, chi-square analysis did reveal a significant increase
in the incidence of pain, including interscapular pain, in
individuals with the most severe postural abnormalities.
The majority of subjects displayed posture that is traditionally considered abnormal, including forward head = 66%,
kyphosis = 38%, right rounded shoulder = 73%, and left
rounded shoulder = 66%. In a smaller study, Refshauge et
al 64 did not find an association between cervicothoracic
posture and pain. In isolation, postural abnormalities have
uncertain relevance to the patient's symptoms. However,
their presence can alert the clinician to areas of potential
movement impairment. For instance, areas of increased
kyphosis suggest an extension restriction, whereas areas of
decreased kyphosis or flatness suggest a flexion restriction.
Active range of motion
Patterns of active range of motion impairments and
pain provocation at end range are helpful in determining
treatment classifications. Active range of motion of the
thoracic spine is performed with the patient seated with
the arms crossed in front over the chest. In performing
these procedures, the clinician will attempt to determine
the range of motion present in each direction and the behavior of the patient's symptoms during and immediately
following the evaluated movement. The patient forward
bends, backward bends, side bends to the right and to
the left, and rotates to the left and right. The patient may
require verbal or manual cueing in order to emphasize
motion in the thoracic spine versus the lumbar spine and
pelvis. If the patient reports no pain with the active range
of motion, the clinician can provide passive overpressure
at end range to assess for both symptom response and end
feel. In addition to cardinal plane range of motion, the
clinician can also use quadrant positions or combined
range of motion. Combined motions are used when the
clinician is unable to reproduce the patient's symptoms
with cardinal plane ranges of motion. Combined motion
quadrants include flexion or extension with combined
right or left rotation and side bending. The patient actively
performs these motions with guidance from the clinician
and the clinician may provide overpressure at end range as
needed. The clinician should also consider using a combined motion if the position is similar to a functional position during which the patient reports pain. For example,
if the patient is a right-handed tennis player and reports
middle thoracic pain while reaching for an overhead shot,
the clinician could assess combined thoracic extension
with right rotation and right side bending.
Measuring thoracic range of motion
Moderate reliability for the quantification of forward
bending and right and left side bending with inclinometry
has been reported. 65 Thoracic rotation is difficult to quantify with inclinometry but it is important to assess given
the requirements of trunk rotation for various functional
activities. Thoracic rotation range of motion is commonly
estimated with visual inspection. When using inclinometry, the examiner locates and marks the T1 spinous process and places the inclinometer at the mark and zeros it.
The T1 spinous process is located inferior to the vertebral
prominens C7. To distinguish T1 from C7, the C7 spinous
process will move away from the palpating finger during
active cervical extension while Ti will remain relatively
prominent. The examiner can also attempt to locate T1
by palpating the posterior aspect of the shaft of the first rib
and following it medially to the T1 spinous process. The
of motion testing and accessory mobility testing such as
posterior to anterior spring testing over the cervical spinous processes and articular pillars. If the patient's upper
thoracic or scapular symptoms are reproduced with cervical range of motion and accessory mobility testing, the
symptoms are likely originating from the cervical spine.
The reader is referred to the cervical spine monograph for
further information on evaluation of the cervical spine. Patients with upper thoracic and interscapular pain can also
have a cervical radiculopathy. Wainner et a1 69 developed a
test-item cluster that can assist the clinician in determining
the presence of a cervical radiculopathy. The 4 items in
the test-item cluster include cervical rotation range of motion to the painful side of less than 60°, positive Spurling A
test, positive upper limb tension test-A (median nerve bias),
and positive cervical distraction test. Positive findings on
all 4 tests produce a positive likelihood ratio of 30.3 for
the presence of a cervical radiculopathy as determined by
positive electrodiagnostic testing. Three of 4 positive tests
produce a positive likelihood ratio of 6.1. Furthermore,
the upper limb tension test-A was the single most sensitive test (0.97), with a resultant negative likelihood ratio
of 0.12. Therefore, a negative upper limb tension test-A
effectively rules out the disorder.
examiner stabilizes the inclinometer against the patient's
trunk with the thumb and index finger while his remaining fingers rest on the upper trunk. The range of motion
is measured for forward bending, backward bending, and
right and left side bending. The therapist can determine
the range of motion and note any change in the patient's
symptoms as a result of the movement. The sequence is
repeated with the inclinometer at the T12 segment. To locate the T12 spinous process, the clinician can find the
12th rib on the posterior lateral aspect and palpate superiorly until he feels the spinous process of T12. Normative
values for thoracic spine motion using inclinometry do not
exist. Measuring thoracic range of motion at baseline and
then after intervention can alert the clinician to objective
changes in range of motion and the potential success of
the intervention. Although not studied for the thoracic
spine, clinical research has shown that increases in cervical range of motion within a treatment session predict an
increase in cervical range of motion between treatment
sessions. 66
Assessing for centralization
In addition to recording the range of motion, it is important to ascertain the effect of each movement on the
patient's status. The patient's status change with movement is assessed using the following terms: peripheralizes, a neurological sign or paresthesia is produced or the
patient's paresthesia or pain moves distal to the thoracic
spine, and the pain can radiate into the upper or lower extremity, or wrap around the rib cage to the anterior aspect;
centralizes, a neurological sign is improved, or paresthesia
or pain is abolished or moves from the periphery toward
the thoracic spine; status quo, symptoms may increase or
decrease in intensity but do not centralize or peripheralize
and remain unchanged from the baseline assessment. The
judgment of a status change with movement testing may
be an important component for classifying patients. The
presence of centralization is a positive prognostic indicator
in low back pain and is used in the cervical spine region as
we ll .67,68 This phenomenon is less common in the thoracic
spine but can be useful in certain situations. More often,
in the thoracic spine, symptoms fall in the category of status quo. However, the therapist should carefully evaluate
the provocation of symptoms with movement even if they
rapidly return to baseline. After an intervention, the same
motions that previously produced symptoms can then be
reassessed. A useful, quick screening of the thoracic spine
for symptom provocation is seated rotation. During this
test, the patient is seated with arms crossed over the chest.
The patient then rotates the trunk to the right and left, and
the therapist assesses for symptoms and range of motion.
Segmental examination of the thoracic spine
The physical therapist has a number of proposed examination systems and models to consider when assessing
restricted segmental motion or segmental dysfunction in
the thoracic spine. It should be noted that in general, spinal segmental motion palpation procedures have poor to
fair reliability. Christensen et a1 7° assessed the reliability of
a manual examination of the upper thoracic spine by two
experienced chiropractors. Subjects included 29 patients
with stable angina pectoris and 27 control subjects. Palpatory assessment, including seated and prone accessory
motion restriction and palpation for segmental paraspinal
tenderness, was carried out from T1 through T8. Intrarater
reliability was superior to interrater reliability, and reliability for assessment of tenderness was superior to motion
palpation. For tenderness, kappa scores for intrarater reliability were 0.63 to 0.77 and for interrater reliability were
0.67 to 0.70. Kappa scores for motion palpation were
0.24 and 0.22 for the seated and prone examination interrater reliability, and ranged from 0.59 to 0.68 for intrarater
reliability. Cleland et al 71 reported that segmental mobility testing of the thoracic spine, using posterior to anterior
spring testing with the patient prone, has poor to fair interrater reliability for both pain and mobility assessment
in patients with neck pain. Because this study involved
patients with primary neck pain, the results may not be
generalizable to patients with primary thoracic spine pain.
Previous research has shown that clinicians can be fairly
reliable in detecting painful motion segments in the cervical spine in patients with neck pain. Further research is
required to determine the reliability of detecting painful
motion segments in patients with a primary complaint of
thoracic spine pain. In a study involving subjects with-
Cervical spine screening
Symptoms in the upper to middle thoracic spine may
be caused by cervical irritation. It can be difficult to differentiate between the lower cervical and upper thoracic
spine as the source of the patient's symptoms. The clinician should screen the cervical spine with active range
10
out symptoms, reliability of segmental mobility testing of
the thoracic spine and ribs improved when an expanded
definition of agreement was used." The authors of this
study reported that most of the errors in measurement
came from accurately identifying the same thoracic vertebral segment. In the expanded definition of agreement,
the authors allowed for agreement within and between raters to within ±1 thoracic vertebral level. More research
is required; however, one could conclude that reliability
within and between raters for thoracic segmental mobility
testing is improved when assessment is based on a region
of the thoracic spine rather than a specific segment. In
other words, clinicians could consider mobility testing of
various thoracic regions (upper, middle, lower) divided
into 4 segments when assessing thoracic spine mobility.
The poor to fair reliability of the segmental examination does not necessarily make these procedures obsolete
or not useful. Models or systems of segmental examination allow the therapist to assess individual segmental levels or spinal regions and, when coupled with the history,
form the basis of a movement—impairment-based diagnosis. The authors caution the reader that the diagnosis of
movement impairments is based on a model. The model
allows physical therapists to think about restriction of motion in the thoracic spine and chest wall. The joints, in
fact, may have all or nothing to do with the loss of perceived motion. The therapist must be cautious of what
Blomberg73 terms systematic palpatory illusions. In other
words, the therapist should understand that when identifying a hypomobile segment, the actual structural position of
the segment is unlikely to be significantly altered. However, these serve as markers of dysfunction, guiding the
therapist toward both a particular targeted spinal region
and treatment technique. The therapist should assess the
effectiveness of the intervention by reassessing the markers
of dysfunction, the aggravating factors, and the outcomes
instruments.
During the first step in the thoracic spine segmental
examination, the therapist assesses for tenderness and tissue reactivity by running the fingers down the patient's
spine in the medial gutter between the spinous process
and the transverse process. Segmental mobility testing of
the thoracic spine is then performed with posterior to anterior spring testing, conducted with the patient prone. The
clinician screens the thoracic spine for mobility and pain
by applying his hypothenar eminence to the thoracic spinous process and producing a graded posterior to anterior
force. The examiner records the presence or absence of
pain and notes whether the mobility is normal, hypomobile, or hypermobile for each thoracic segment/ 1,72 The
clinician can spring unilaterally over the region of the thoracic transverse processes in a similar fashion.
Segmental examination of the chest wall
Chest wall range of motion
Thoracic spine range of motion as described above also
involves rib cage motion. In addition to those tests, the
clinician can also assess rib cage range of motion visually
and manually as the patient is breathing. Assess the first
rib by sitting at the head of the table with the patient lying supine. The therapist's palpating fingers should be just
inferior to the sternoclavicular joint. Instruct the patient
to take a deep breath and then exhale completely. Monitor the motion for right to left symmetry and also for the
presence of pain. Perform a similar assessment on the remaining rib segments by standing at the side of the patient
and testing the remaining ribs in groups: upper (ribs 2-5),
middle (ribs 6-10), and lower (ribs 11-12). For the upper
and middle ribs, the examiner can assess both the bucket
handle and pump handle motions. This is accomplished
by placing his finger tips on the lateral aspect of the ribs for
the former and the anterior aspects for the latter, while the
patient fully inspires and then expires. Recall that ribs 11
and 12 move in a caliper fashion. To assess range of motion of these ribs, the examiner palpates the lateral aspects
while the patient fully inspires and expires.
Rib cage static positioning and segmental mobility
Loss of rib cage mobility results from a variety of factors including poor postural habits, myofascial shortening,
and joint dysfunction. 1 ° Following the general assessment
of overall rib cage range of motion, the ribs are palpated
for tenderness and symmetry. The ribs are palpated for
symmetry and tenderness anteriorly at the costochondral
junction and posteriorly at the rib angle and the intercostal
spaces. Rib cage dysfunction frequently presents with tenderness at the rib angle, and therefore this is a key palpatory landmark. The ribs are for segmental mobility and pain
using posterior to anterior spring testing with the patient
prone. Using a crossed handed technique, the clinician
stabilizes the opposite side of the thoracic spine with his
hypothenar eminence lateral to the spinous process and
springs over each rib, just lateral to the transverse process,
using the hypothenar eminence of his opposite hand. The
clinician can also perform passive accessory mobility of
the anterior ribs by springing in an anterior to posterior
direction over the costosternal joints using his thumbs.'"
The clinician records the presence or absence of pain and
notes whether the mobility is normal, hypomobile, or hypermobile for each rib."
First rib testing using the cervical rotation lateral flexion
test
First rib dysfunction can be present in a number of
upper quarter clinical syndromes. The cervical rotation
lateral flexion test is an additional method that has been
reported to assess for the presence of an elevated first rib
in patients with brachialgia. The test is performed with the
patient in a sitting position. The cervical spine is rotated
passively and maximally away from the side being tested
(eg, rotation to the right to test the left side) (Figure 1). In
this position, the cervical spine is gently side bent as far as
possible, moving the ear toward the chest. A test is positive
when the side bending movement is limited or blocked. A
reduction in sidebending mobility is suggestive of an elevated first rib on the side opposite from which the cervi-
endurance, and motor control particularly of the scapular
stabilizing muscles.
Figure 1. The Cervical Rotation Lateral Flexion Test
Assessing the Left First Rib
INTERVENTION TECHNIQUES
Joint Manipulation Techniques
The manual joint manipulation techniques discussed
in this section will include both thrust and nonthrust procedures. The nonthrust procedures demonstrated will be
contract-relax techniques and graded joint movement at
varying speeds and amplitudes also known as joint mobilization. Thrust manipulation techniques are by definition
high-velocity and low-amplitude procedures. The reader
should be aware that the majority of the thrust manipulation
procedures described in this section could be performed in
a graded mobilization fashion. 75 In the authors' experience,
thrust manipulation is used more frequently than other manual therapy techniques when treating the thoracic spine.
However, nonthrust techniques are still employed but frequently in a preparatory manner or after thrust manipulation
to assist with muscle re-education. Based on the evidence
for superior effects of manipulation when combined with
exercise for patients with neck disorders, manipulation is
rarely performed in isolation. 76 The therapist provides specific exercise and postural corrective instructions immediately following the manual therapy procedures.
The risks of manipulation in the thoracic spine are extremely low, provided trained therapists properly select
and assess patients and perform the technique. The estimated rate of occurrence of cauda equine syndrome as a
complication of lumbar spinal manipulation is estimated
to be less than one case per 100 million manipulations!'
Overall, serious or severe complications of lumbar spinal manipulation are extremely rare. 78 However, to the
authors' knowledge, similar data regarding the thoracic
spine are not present in the literature. Senstac 79 reported
on symptoms following manipulation in more than 100
patients. Manipulation was included for the cervical,
thoracic, and lumbar spine. The authors reported that
muscle and joint soreness following manipulation was
common but rarely led to even short-term impairment in
functional status.
Therapists should always do everything within their
power to limit risk of patient harm. However, it is helpful to put the risk of harm from manipulation into context
with competing therapies. Tannenbaum et a1, 8° reporting
on the major side effects from NSAIDs, noted that 1% to
3% of users are thought to develop gastrointestinal bleeding. Furthermore, each year in the United States, 7600
deaths and 76,000 hospitalizations may be attributed to
NSAIDs. 81 One contraindication to manipulation in the
thoracic spine is the presence of osteoporosis. Supporting
clinical data is lacking, but manipulation and mobilization have the potential to cause vertebral or rib fracture in
an individual with osteoporosis." A survey of therapists
in one Canadian city found that about half used manual
therapy in patients with osteoporosis, although over 90%
had some concerns about using it." Bone mineral density is most accurately measured with dual-energy x-ray
cal spine was rotated. Lindgren and colleagues 74 reported
excellent interrater reliability (lc = 1.0) and good agreement with cineradiographic findings (lc = 0.84). Lindgren 74
reports that the cervical side bending movement during
this test is limited due to the transverse process of T1, on
the contralateral side, contacting and being blocked by the
superiorly subluxed rib. However, additional research is
required to substantiate this claim.
Mechanical Movement Impairments Diagnosis
After excluding red flags or serious causes of thoracic
spine pain, there is no reliable or valid clinical examination scheme for diagnosis of specific pathoanatomical
causes of a patient's thoracic spine pain. Therefore, a
pathoanatomical diagnosis is not appropriate for most
patients with thoracic spine and rib cage pain. They are
often considered a homogeneous group and labeled as
nonspecific mechanical thoracic pain, thoracic pain of
unknown origin, or somatic thoracic spinal pain. 47 Such
terms, however, are not useful in guiding the therapist's
selection of treatments appropriate for specific patients.
Instead of focusing on a pathoanatomical diagnosis, the
therapist can focus on clusters of signs, symptoms, and
impairments identified during the examination that will
assist in determination of the most appropriate treatment approach. Interventions are then used that address
the specific impairments found during the examination.
Common impairments in patients with thoracic spine or
rib cage pain include limited joint mobility of the thoracic vertebral joints and ribs; impaired posture; soft
tissue mobility restrictions involving shortened and hypertonic muscles; and impairments in muscle strength,
12
•
absorptiometry, or a DXA test." Patients who have a tscore 2.5 or more standard deviations below the reference standard are considered to have osteoporosis and
are at risk for vertebral and other fractures. Individuals
with t-scores between 1 to 2.5 standard deviations below the reference are considered to have osteopenia.
Individuals with osteopenia are at risk for developing osteoporosis. Further research is warranted, but it seems
prudent to limit manual therapy procedures in individuals with moderate to severe osteoporosis (eg, a patient
with a prior history of compression fracture) to nonthrust
procedures. In the authors' opinion, for patients with osteopenia, the potential for a vertebral fracture from spinal
manipulation is less of a concern given the low risk of
fractures in these individuals. However, it is important
to note that the great majority of research using thoracic
spine manipulation has been performed on patients 60
years old and younger. The reader is cautioned to use
judgment and sound clinical reasoning when selecting
patients appropriate for thoracic spine manipulation.
There is currently a lack of evidence, in terms of highquality clinical trials, concerning the effectiveness of interventions for patients with primary thoracic spine pain.
One small pilot study assessed the effects of manipulation
compared to placebo ultrasound." There were 15 patients
in each group who had responded to a newspaper article
for individuals with middle back pain. The authors found
a significant reduction in pain on the numeric pain rating
scale (NPRS) at the completion of 6 treatments and at 1
month follow-up for the manipulation group compared to
the placebo group. In a case report, Kelley and Whitney 86
described the immediate relief of right lower chest wall pain
following a nonthrust manipulation of the middle thoracic
spine in an adolescent athlete. Fruth 87 reported a case of a
patient with right upper thoracic pain that was resolved after
7 physical therapy visits including nonthrust manipulation
of the ribs, ischemic compression of trigger points, and therapeutic exercise. In a retrospective review of 73 patients
reporting to a rheumatology clinic with a primary complaint
of thoracic spine pain, Bruckner and colleagues" reported
that the majority of the patients were either pain-free (77%)
or noted some improvement (15%) after postural advice
and manipulative treatment of the thoracic spine. The majority of patients (75%) in this retrospective review reported
middle thoracic pain and about half also complained of anterior chest wall pain. Larger high-quality trials are needed
to determine the optimal treatment interventions for patients
with primary thoracic spine pain.
What follows are interventions to improve motion impairments based on a model of mechanical spinal segmental restriction. It is useful to follow a model in order to
have a basis from which to make clinical decisions about
the selection of particular techniques. There is currently no
evidence showing that following a particular model of mechanical spinal segmental restriction is necessary to achieve
the desired outcome. While the authors have focused on
identifying mechanical segmental restrictions, there is evidence that shows that manual therapy procedures produce
a regional neuromodulatory effect. For example, non
manipulation of the cervical spine has been shown to:1
to a decrease in the pain-pressure threshold over the area:
application and also at sites distal to the application such:
the ipsilateral lateral elbow. 89 This effect has been coined')
manipulation-induced analgesia. There is indirect evidence'
that this effect comes from stimulating endogenous nono- .
pioid central descending pain-inhibiting systems located in
the periaqueductal gray region of the midbrain. 89
Due to the nonspecific neuromodulatory effect of manipulation, targeting motion impairments with specific
manipulation techniques may not be necessary to achieve
a positive outcome in a patient with thoracic spine pain.
Haas and colleagues, 9° using cervical manipulation in patients with neck pain, showed an equal short-term reduction
in neck pain after manipulating a segment, based on segmental testing versus a randomly selected segment. In two
recent and similar studies involving nonthrust manipulation
of the cervical spine at targeted versus random segments,
the authors reported similar findings. 91,92 Furthermore, evidence also suggests that clinicians are unable to precisely
limit manipulative forces to a targeted segment. Using microphones to record cavitation sounds during prone thoracic thrust manipulation, Ross and colleagues 93 reported
that cavitations occurred up to 4 levels above and below the
targeted joint. The conclusion was that manipulation likely
produces forces to a region of the spine as opposed to only
at the specific targeted segment.
Merging this recent evidence with a model of mechanical motion restriction, the authors continue to use and
recommend using palpatory examination and mobility
testing to direct manual therapy interventions. However,
less emphasis is placed on correcting perceived motion
restriction and more on patient centered outcomes such
as decreasing pain, improving function, and increasing
the patient's health-related quality of life. Furthermore if a
technique, selected based on a perceived loss of motion to
a targeted region, creates increased pain during the setup,
it is not uncommon for the authors to target regions above
or below or on the opposite side of the painful or irritable
segment. Using a test-retest model, previously painful
functional movements are improved and less painful even
if the specific segment was not addressed. It is also common for a patient to report pain with manual techniques
that takes the patient into the perceived direction of motion loss. In these cases, a manipulation in the opposite or
pain-free direction quite often leads to a decrease in pain
and restoration of motion.
Thoracic spine
Supine upper thoracic thrust manipulation (a high-velocity,
end-range, anterior to posterior force through the elbows
to the upper thoracic spine in a bridged position)
For this technique, the therapist stands at the side of the
patient. The patient crosses the arms with the opposite arm
on top. A rolled towel can be placed underneath the patient's arms to increase patient comfort and to help establish
a firm lever arm. In this example, the therapist is targeting
13
Supine cervical thoracic junction thrust manipulation (A
high-velocity, end-range, caudal to cranial force through
the cervical spine in the supine position)
Prior to initiating the technique, it is useful to relax
any hypertonic soft tissue structures that directly affect
this area. The posterior scalenes are commonly involved.
The manipulative technique begins with the therapist
attempting to take up the soft tissue of the upper thoracic
spine with a wide-based handgrip (Figure 3A). This is
an attempt to securely and comfortably contact the C7
or T1 segment. With the other hand, the clinician then
stabilizes the head and neck with a chin hold. Slack is
taken up, final minor adjustments are made, and a quick
thrust of short amplitude is delivered in a straight, cranial
direction (Figure 3B). If needed, this technique can then
be followed by a more direct technique to gain upper
thoracic spine extension.
the T1-T2 segment. The therapist rolls the patient toward
himself and places his thenar eminence and palmar region of his hand proximal to the second MCP joint on
the inferior vertebrae: T2 (Figure 2A). To establish a firm
contact, the therapist applies a skin lock by ulnarly deviating his hand and pulling caudally. The therapist rolls
the patient back to the supine position. In this technique,
the aim is to restore extension at the T1 -T2 segment. The
therapist lifts the patient to directly place the T1 -T2 segment over his hand to assist with directing the manipulative forces to the targeted segment. While applying
pressure through the patient's crossed arms, the therapist
makes final minor adjustments until a crisp end feel is established. The patient is asked to inhale and then exhale,
and the therapist performs a quick thrust down toward his
underneath hand and the table. It is often useful to have
the patient perform a supine bridge in order to bring the
upper thoracic spine onto the therapist's hand. Once the
patient bridges and the targeted thoracic region is firmly
on the therapist's hand, the thrust is delivered (Figure 2B).
Figure 3. Supine Cervicothoracic Junction Thrust
Manipulation
Figure 2. Supine Upper Thoracic Thrust Manipulation
A, hand placement for supine upper thoracic thrust manipulation. B, position for thrust. A high-velocity, end-range, anterior
to posterior force through the elbows to the upper thoracic spine
in a bridged position.
A, hand position. B, final thrust position. A high-velocity, endrange, caudal to cranial force through the cervical spine in the
supine position.
14
Seated upper thoracic/cervical thoracic junction thrust
manipulation (a high-velocity, end-range, anterior to
posterior force through the elbows to the upper thoracic
spine in a seated position)
The patient sits on a treatment table with his hands
clasped behind the neck as low down on the cervical
spine as possible The therapist stands behind the patient
and loops his hands through the patient's arms and places
the hands clasped over the patient's hands. The patient's
elbows should be allowed to drop forward so as to not
place the shoulders into the vulnerable abducted, externally rotated position. Care should be taken to not force
the patient's neck into flexion by forward pressure from
the therapist's hands (Figure 4). The clinician leans backwards by extending his hips and avoiding hyperextension
of his own back, to take up slack in a superior direction.
A thrust is delivered by the therapist thrusting upwards
towards the ceiling in an attempt to create a distraction
force in the patient's upper thoracic region. The thrust
should be generated by the clinician's legs. Care is taken
with this procedure to not cause strain to the patient's
shoulder girdle. If the patient experiences shoulder discomfort, is unable to attain the position with his arms, or
has a history of anterior shoulder instability, an alternate
technique should be selected.
Figure 5. Seated Middle Thoracic Thrust Manipulation
TM
A high-velocity, end-range, anterior to posterior force through
the elbows to the middle thoracic spine in a seated position.
suggests that the most comfortable position is with the
elbows in parallel and this also allows for the therapist to
attempt the technique on a larger patient. The therapist
applies his sternum to the patient's middle thoracic spine.
Alternately a rolled towel can be placed horizontally on
the caudal vertebra of the segment of interest between
the patient and the clinician in an attempt to be segment
specific. The therapist reaches around the patient and
grasps around the patient's elbows. If possible, the clinician interlocks his hands. The therapist takes up slack
by adducting his arms, retracting his shoulder girdle, and
pushing his chest towards the patient's thoracic spine. A
high velocity thrust is performed by the therapist thrusting
through the patient's arms in an anterior to posterior direction while at the same time keeping the chest pushed
forward. Some therapists attempt to produce a distractive
force by lifting the patient during this procedure. This
could potentially injure the clinician with a larger patient
and this practice should be discouraged. The clinician
should also make sure to direct the manipulative thrust
through the patient's elbows and towards the therapist's
sternum and not through the patient's diaphragm. If the
therapist cannot reasonably reach his arms around the
patient, another technique should be selected.
Figure 4. Seated Upper Thoracic Thrust Manipulation
A high-velocity, end-range, anterior to posterior force through
the elbows to the upper thoracic spine in a seated position.
Prone middle and lower thoracic spine thrust and nonthrust
manipulation (a high or low-velocity, mid- to end-range,
posterior to anterior force to the middle thoracic spine on
the lower thoracic spine in a prone position)
An extension movement impairment with an increased kyphosis can occur commonly in the lower or
middle thoracic spine. In the authors' experience and
based on evidence from two trials, extension movement
Seated middle thoracic spine thrust manipulation (a highvelocity, end-range, anterior to posterior force through the
elbows to the middle thoracic spine in a seated position)
The patient sits on the treatment table with his arms
across the body with the hands grasping the opposite
posterior shoulder region (Figure 5). Clinical experience
15
impairments of the middle to lower thoracic spine are
associated with lower trapezius inhibition. 94,95 This is detected with the patient prone and the arms fully flexed
and resting on the table. The therapist then observes
the lower trapezius while the patient attempts to lift the
arm off the table. In order to improve extension in the
middle-lower thoracic spine, prone techniques are commonly used.
In this example, the T8-T9 segment is targeted. The
patient lies prone with the therapist standing on either
side of the patient. The therapist's hypothenar eminences
will contact the transverse processes of the T8 segment
(Figure 6). It is useful to improve contact with the segment with direct skin contact using a skin lock. In this
example, the therapist would establish skin contact and
twist the right hand in a clockwise fashion while introducing the ventral force, and twist the left hand in a clockwise fashion while introducing the caudal force. Ask the
patient to take a deep breath in and exhale. At the end of
the exhalation effort, the therapist applies either graded
nonthrust mobilizations (I through IV) or a high-velocity,
low-amplitude thrust. The therapist's movement is similar to the compressions used during cardiopulmonary re-
suscitation. This movement introduces extension of the
middle/lower thoracic region. As with other techniques,
excessive force is unnecessary. It is more comfortable,
and achieves a similar goal, if the thrust is not initiated
from the end range position of extension. Allow for some
slack to remain prior to the thrust in order to have a range
in which to thrust through.
Supine middle to lower thoracic spine thrust manipulation
(a high-velocity, end-range, anterior to posterior force
through the elbows to the middle thoracic spine on the
lower thoracic spine in a supine position)
Supine techniques are typically used to improve mobility of the middle and lower thoracic spine into flexion.
Flexion movement impairments are commonly seen at
the T3 through T7 region of the thoracic spine. In this example, a manipulation or high-velocity thrust technique
will be described to target the T4-T5 segment.
The therapist stands at the side of the patient and
crosses the patient's arms with the opposite arm on top.
The key element of this technique is establishing a firm
fulcrum at the segment below the dysfunctional segment,
therefore stabilizing T5, and subsequently moving T4 on
the stabilized T5 segment. Next, the therapist rolls the
patient's opposite shoulder toward himself and reaches
his arm around the patient's trunk. Using the thenar eminence and palmar region of his hand proximal to the
second MCP joint, the therapist creates a skin lock of the
T5 segment by firmly contacting the tissue overlying the
T5 vertebrae and applying an ulnar deviation twisting
movement of the wrist (Figure 7A). A common mistake
with novice therapists is to have the stabilization contact too far laterally. The therapist then rolls the patient's
trunk completely back over onto his stabilizing hand and
places firm pressure through the patient's elbows in the
direction of his stabilizing hand. At this point, flex the
patient's head and neck down to the targeted segment.
It is often easier to not lift the patient's head and create the flexion by placing the patient's head on pillows
or, if available, raising the head piece of the treatment
table. The therapist must not remove any pressure from
the patient's trunk. The therapist then instructs the patient
to take a deep breath in and then exhale. As soon as
the therapist senses the movement nearing the fulcrum, a
high-velocity thrust is given with the therapist's chest wall
through the patient's elbows in a vector toward T5 (Figure 7B). In both the supine upper and middle thoracic
spine thrust techniques the height of the table should be
positioned low enough for the therapist to place his body
over the patient's elbows. Instructing the patient to move
to the side of the table closest to the therapist is also beneficial for this reason.
Figure 6. Prone Middle Thoracic Manipulation, Thrust
and Nonthrust
Seated thoracolumbar thrust manipulation (a high velocity,
end-range, rotational force to the lower thoracic spine on
the upper lumbar spine in the seated position)
The thoracolumbar junction may be a source of dysfunction in patients with lumbar pain, hip pain, and
A high-velocity, end-range, posterior to anterior force to the middle
thoracic spine on the lower thoracic spine in a prone position.
16
the treatment table. The patient folds the arms and the
therapist places his left shoulder, with a pillow placed
on top, underneath the patient's left axilla. The therapist reaches under the patient's folded arms with the left
arm and grasps the posterior aspect of the patient's right
shoulder or rib cage (Figure 8A). The therapist introduces a moderate amount of right trunk side bending using
the left shoulder and by translating the patient's trunk
from right to left. With his right hypothenar eminence,
the therapist contacts the right transverse process of T12
and secures the contact with a skin lock. The therapist
then walks around behind the patient, rotating the patient's trunk to the left with both hands and applying a
traction force with the right hand. Once directly behind the patient, a thrust with the right hand is initiated
in mostly an anterior and superior direction creating a
distractive and rotary force (Figure 8B). To optimize the
speed of the thrust and for safe therapist body mechanics, it is important that therapists use their trunk and legs
to set up the technique and complete the thrust.
Figure 7. Supine Middle Thoracic Thrust Manipulation
Rib cage
Seated upper rib thrust and nonthrust manipulation (a
high or low-velocity, mid- or end-range, infero-medial
force to the first thoracic rib on the lower cervical spine
in a seated position with the head in a laterally flexed
and ipsilaterally rotated position)
Movement restrictions of the first and second ribs
can contribute to loss of thoracic spine motion. If difficulty is experienced in restoring motion of the upper
thorax, the therapist should consider mobilization of
the first and second ribs. An example of treating the
right first rib is provided. The therapist stands behind
the patient and supports the patient's left trunk (Figure
9). The web space of the therapist's right hand contacts the posterior border of the right first rib. The therapist's hand is rolled slightly backward to position the
trapezius muscle out of the way. While the therapist's
left arm supports the patient's head and neck, move T1
through an arc of flexion and extension to locate the
midrange or neutral position. The therapist's right arm
guides a right to left translatory movement at T1 while
the hand maintains contact with the first rib. This will
result in right side bending the patient's neck placing the
cervical soft tissue, including the scalene muscles, on
slack. Ask the patient to take a deep breath and exhale.
During exhalation, the therapist translates further into
the barrier, and at the end range, the therapist provides
a high-velocity, short-amplitude thrust on the posterior
aspect of the first rib (downward and to the left). Immediately re-examine the motion segment. A modification of this technique is applicable for a second rib
restriction. In this instance, the thrust is in an anterior
direction and the thumb of the therapist's right hand is
placed on the shaft of the second rib. The therapist allows slightly greater left rotation of the patient's head to
occur in order to introduce neutral mechanics down to
the T2 segment.
A, hand placement for supine middle thoracic manipulation. B,
position for thrust. A high-velocity, end-range, anterior to posterior force through the elbows to the middle thoracic spine on the
lower thoracic spine in a supine position.
lower thoracic pain. A useful technique to improve the
quality and range of motion in this area is a seated rotational technique. In this example, the T12-L1 segment
will be moved into left rotation. The patient is seated,
straddling the end of the treatment table with the therapist standing on the left side. Straddling the table assists
with stabilization of the pelvis during the technique.
If the patient is unable to straddle the table due to restricted hip range of motion, it is possible to perform
this manipulation with the patient sitting on the side of
17
Figure 8. Seated Thoracolumbar Thrust Manipulation
Figure 9. Seated First Rib Manipulation Thrust and Nonthrust Directed Towards the Right First Rib
A high- or low-velocity, mid- or end-range, infero-medial force to
the first thoracic rib on the lower cervical spine in a seated position
with the head in a laterally flexed and ipsilaterally rotated position.
Supine rib thrust manipulation (A high-velocity, endrange, anterior to posterior force through the elbows to
the rib the thoracic spine in a supine position)
To manipulate the ribs, a technique similar to the thoracic spine supine techniques can be used. In this example, the supine thrust technique is directed to the left
fifth rib. The patient is supine with the therapist standing
on the right side of the patient. The patient's arms are
crossed with the left arm over the right arm. The therapist
rolls the patient toward himself and places a stabilizing
hand on the patient's trunk. It is important that the hand
contact in this technique is slightly more lateral than previously described. The therapist places his thenar eminence
on the fifth rib medial to the rib angle and uses a twisting
motion of the wrist to establish a skin lock. The therapist rolls the patient back onto his hand and places his
abdomen on the patient's elbows and applies a downward
pressure to engage the stabilizing fulcrum. The therapist
then cradles the patient's head and neck and slightly flexes
inferiorly to the region of T4-5 while maintaining firm contact against the therapist's thenar eminence. The therapist
asks the patient to take a deep breath in and exhale. A
A, hand position for seated thoracolumbar rotational manipulation. B, position for thrust into left rotation. A high velocity, endrange, rotational force to the lower thoracic spine on the upper
lumbar spine in the seated position.
18
manipulative thrust through the therapist's chest wall in a
vector toward the fifth rib is introduced.
translation of the rib. In this example, the right sixth rib is
treated. The patient is seated with the right arm across the
chest. A rolled up towel is placed over the costochondral
region of the right sixth rib and the patient's left fisted hand
is placed directly over the towel. The patient's right arm is
crossed over the chest while the therapist's left arm firmly
pulls the patient's arms into the chest wall (Figure 11). This
movement helps with the posterior translation of the right
sixth rib. The patient is then guided into a diagonal slump
position (flexion, left side bending, and left rotation at T6).
This encourages a lateral and posterior glide of the sixth
rib. The therapist's hand can also be placed on the medial
border of the rib angle and palpated to ensure that the
lateral motion is occurring. The technique is performed
by asking the patient to gently lift the right elbow up and
out. This movement facilitates the right serratus anterior
muscle. With the arm fixed, the right serratus anterior will
produce a posterior translatory motion to the right sixth
rib. After 3 to 5 seconds, the patient is told to relax, and
the therapist engages the new barrier by increasing the
slump of the patient and the compression of the patient's
right elbow. This procedure is repeated 3 to 5 times followed by a re-examination of the segment.
Prone rib thrust and nonthrust manipulation (A highor low-velocity, mid- or end-range, postero-medial to
antero-lateral force to the rib on the vertebrae in a prone
position)
The therapist stands at the head of the table with the
patient prone and the arms positioned comfortably at the
sides. Using a cross-handed technique, the therapist stabilizes the opposite side of the thoracic spine using his
hypothenar eminence (Figure 10). With the other hand,
the therapist contacts the shaft of the rib just lateral to the
transverse process with the hypothenar eminence. Using
a slight skin lock, the therapist can apply graded nonthrust or thrust manipulation to the ribs.
Figure 10. Prone Rib Manipulation Thrust and Nonthrust
Directed Towards the Right Fourth Rib
Figure 11. Seated Nonthrust Rib Manipulation Directed
Posteriorly
A high- or low-velocity, mid- or end-range, postero-medial to antero-lateral force to the rib on the vertebrae in a prone position.
Seated rib nonthrust manipulation directed posteriorly
Reprinted from Orthopaedic Manual Physical Therapy Management of the Thoracic Spine and Ribcage. Copyright 2000, with
Trauma can produce a subluxation at the costovertebral, costotransverse, or costochondral joints. An anterior subluxed rib can occur following a blow to the posterior thorax. Treatment of an anterior subluxation employs a contract relax technique to facilitate a posterior
permission of the publisher Evidence in Motion, LLC (www.evi
denceinmotion.com ).
19
Seated rib nonthrust manipulation directed anteriorly
A posterior subluxed rib can occur with a blow to the
anterior chest wall. Treatment of the posterior subluxed
rib uses a contract relax technique to facilitate an anterior
translation of the rib. In this example, treatment will be
directed at the right sixth rib. The patient is seated and
the therapist stands behind the patient. The patient's right
arm is brought across the chest with the patient's hand
resting on the left shoulder. The therapist reaches around
and grabs the patient's right elbow. The patient is told to
gently stick out the stomach to introduce thoracic extension and to drop the right shoulder to introduce right side
bending. This facilitates an anterior glide of the right sixth
rib. The patient is then translated into an extension and
right side bending left rotation position of the T6 segment
(Figure 12). During this maneuver, the therapist should
sense the right sixth rib translating forward. The patient
is then asked to gently pull the right elbow down to the
left. This should facilitate the right pectorals to provide
an anterior translatory force on the right sixth rib. After 3
to 5 seconds, the patient is told to relax, and the therapist
engages the new barrier by increasing the patient's tho-
racic extension and right side bending at that segment.
Additionally, the therapist's right thumb can introduce an
anteromedial glide of the rib. The entire procedure is
repeated for 3 to 5 times followed by re-examination of
the motion segment.
Selected soft tissue techniques
Active assisted pectoral stretching
The purpose of the active assisted pectoral stretch is to
improve scapular retraction and thoracic extension. The
patient is positioned in side lying with the therapist standing behind the patient. The therapist, using a broad hand
contact, compresses the pectoral major and/or minor
muscle and then glides the tissue towards the midline.
The patient's arm is then slowly horizontally abducted
with slight flexion (Figure 13). The patient is asked to
continue the motion to the point of tension, hold for 2 to
3 seconds, relax, and then repeat this motion. The therapist can then reposition the hand contact in an attempt
to segmentally lengthen different portions of the muscle.
Figure 13. Active Assisted Pectoralis Stretch
Figure 12. Seated Nonthrust Rib Manipulation Directed
Anteriorly
Scapulo-thoracic manipulation
The purpose of the scapulo-thoracic manipulation is to
improve scapular mobility particularly retraction and posterior scapular tipping. The patient is positioned in side lying
with the therapist standing behind the patient. The therapist,
using broad hand contacts, grasps the scapula posteriorly
and with the other hand grasps the clavicle and acromioclavicular (AC) joint (Figure 14). The therapist then begins a
slow oscillatory circular motion predominately in the sagittal plane. When increased tension is felt, the therapist can
Reprinted from Orthopaedic Manual Physical Therapy Management of the Thoracic Spine and Ribcage. Copyright 2000, with
permission of the publisher Evidence in Motion, LLC (www.evi
denceinmotion.com ).
20
Figure 14. Scapular Manipulation
Figure 15. Increasing Middle Thoracic Flexion (BarrelHug Stretch) Demonstrating Stretching of the Left Side
patient's thoracic spine. The patient supports his head with
the hands and produces graded mobilization of the targeted
thoracic region by extending and flexing the thoracic spine
over the roll (Figure 16). The mobilization can be enhanced
by having the patient inhale while extending over the roll.
provide a manipulative thrust with both hands in a direction
that increases the posterior scapular tipping.
Selected therapeutic exercise
It is recommended that the clinician instructs the patient
in exercises immediately following manual therapy intervention. The goal of these exercises should be to encourage
movement in the restricted or painful range of motions and
also to re-educate the local musculature involved in stabilization of the segment. Emerging evidence supports that
manual therapy techniques may provide a short window of
opportunity during which an active movement re-education
program is more efficiently accomplished secondary to pain
reduction and reduced muscle guarding. 96
Figure16. Increasing Thoracic Extension Using Foam Roller
Increasing middle thoracic flexion
The purpose of the barrel-hug stretch is to improve or
maintain flexion in the T3 through T7 region. The patient is
asked to imagine that there is a 55-gallon drum on his lap
and that he is trying to get his arms around it. When stretching the left side of the upper back, the patient is asked to
turn slightly to the right and to put more weight on the left
hip (Figure 15). The patient should be bent forward slightly,
and the apex of the curve should be at the area where the
greatest flexion or opening is desired. This exercise is typically given to the patient immediately after the supine manipulation technique to the T3 through T7 region.
Increasing thoracic spine extension
Using either a towel roll or foam roll, the patient lies
supine over the roll that is placed horizontally under the
Lower trapezius muscle re-education
The purpose of the lower trapezius muscle re-education exercise is to improve or maintain extension in the
21
middle to lower thoracic region and to facilitate normal
scapular-thoracic motion. The patient assumes a prone
position with one arm off the side of the table. The therapist directs the patient to flex the arm in the plane of the
scapula with the shoulder in external rotation (thumb
towards the ceiling). The therapist can facilitate the activation of the lower trapezius tapping on the muscle and
directing the patient to bring the shoulder blade into retraction and depression (Figure 1 7). If the patient has difficulty firing the lower trapezius, a manipulation targeting
the middle to lower region can facilitate the muscle firing.
Figure 18. Serratus Anterior Muscle Re-education
Figure 17. Lower Trapezius Muscle Re-education on the
patient reaches forward and maintains contact with the
floor with the palm of the hand (Figure 19A). The patient
is encouraged to let the trunk rotate and stretch while
reaching in a large circle around the body (Figures 19B,
C). Deep breathing and self-mobilization into the restricted ranges is encouraged. In addition, the therapist
can provide a mobilization on the anterior or posterior
rib cage to facilitate motion into the restricted range.
REGIONAL INTERDEPENDENCE
Regional interdependence refers to how impairments
and treatment of a particular body region can affect related
regions. There is evidence that manipulative treatment of the
thoracic spine can improve neck and shoulder conditions. 97
Cervical Spine
Several authors have reported positive results using
thoracic spine manipulation in patients with mechanical
neck pain, cervical radiculopathy, cervical myelopathy,
and post-whiplash injury. In a systematic review, Walser
and colleagues 97 determined there was sufficient evidence to recommend thoracic spine manipulation procedures for individuals with neck pain. In that review, 4
high-quality studies demonstrated significant reductions
in pain for individuals with neck pain who received manipulation to the thoracic spine. In a randomized trial,
Cleland et al' found a 15-mm reduction in the visual
analogue pain scale in patients with mechanical neck
pain immediately following thoracic spine manipulation
when compared to a placebo manipulation. In a high
quality randomized controlled trial, Lau and colleagues 98
found .that thoracic spine manipulation was superior to
electrothermal modalities in reducing pain and disability
Serratus anterior muscle re-education
The patient assumes a quadruped position. From this
position, he is instructed to protract the scapulas and flex
the upper to middle thoracic spine to activate the serratus
anterior muscle and facilitate thoracic flexion (Figure 18).
Shoulder circle or sweep
The purpose of the shoulder circle or sweep exercise
is to mobilize the chest wall and integrate upper extremity function with thoracic spine and rib cage motion. The
patient lies on the floor with the hips and knees bent to
90°. A small pillow can be placed under the head. The
22
cal neck pain. Gonzdlez-Iglesias et a1 10° reported that
the addition of thoracic spine manipulation to an electrotherapy/thermal modality regimen resulted in significant
reductions in pain and disability, and increases in active
cervical range of motion compared to modalities alone.
In a prospective case series, Flynn and colleagues 101 noted immediate improvement in flexion, extension, total
rotation, and total side bending in patients with mechanical neck pain or cervical radiculopathy following thoracic spine manipulation. In a case series of 7 patients with
cervical myelopathy, Browder et ar 02 used a combination
of thoracic spine manipulation and intermittent cervical
traction. They reported reduced pain, improved cervical range of motion, and a reduction in long tract signs
in all patients. In a randomized trial, Fernandez-de-lasPenas et a1 43 reported a significant reduction in a NPRS in
patients with whiplash injury when using a combination
of thoracic spine manipulation and standard physiotherapy including modalities, exercise, and massage when
compared to patients receiving standard therapy alone.
Savolainen et al 103 reported superior 12-month reduction
in the worst pain on a NPRS in Finnish broadcast workers complaining of neck and shoulder pain who received
thoracic manipulation compared to those who received
only home exercise instruction.
Numerous theories abound as to why thoracic manipulation would improve cervical range of motion and decrease pain. At this time, they all remain purely speculative. The clinical bottom line is that there is sufficient evidence to warrant examining the thoracic spine in patients
with cervical dysfunction and to consider using thoracic
spine manipulation. In patients with acute or irritable
cervical conditions such as a radiculopathy or postwhiplash injury, thoracic spine manipulation is well tolerated
and leads to improvement in cervical complaints. Once
the level of irritability has decreased, the cervical spine
can then be directly addressed. A case report by Pho
and Godges 104 provides an example of this treatment approach in a patient after whiplash injury.
Figure 19. Shoulder Circle or Sweeping Exercise on the
Left Side
Shoulder
There is emerging evidence demonstrating the effectiveness of manual therapy directed toward the thoracic
spine and ribs for patients with shoulder pain. In a large
randomized trial, Bergman et al 4 reported decreased pain
and disability in patients with shoulder pain who received
6 treatments of manual therapy to the cervicothoracic
spine and upper ribs as compared to patients receiving
the usual medical care. These patients were prestratified,
having been identified as patients with shoulder pain
and concomitant cervicothoracic dysfunction including
reduced cervical or thoracic range of motion, spinal tenderness, and reduced segmental mobility.
In a study by Winters et a1, 105 symptoms resolved more
quickly in patients with shoulder impingement who received manipulative therapy of the cervicothoracic spine
and upper ribs compared to those receiving physiotherapy consisting of exercise, massage, and modalities. This
A, starting position. B, middle position. C, ending position.
Reprinted from Orthopaedic Manual Physical Therapy Management of the Thoracic Spine and Ribcage. Copyright 2000, with
permission of the publisher Evidence in Motion, LLC (www.evi
denceinmotion.com ).
for patients with chronic neck pain at 3- and 6-month
follow-up. Cleland and colleagues," in a randomized
trial, incorporated thoracic spine manipulation into a
standardized exercise program and found a significant
reduction in disability at 1 week, 4 weeks, and 6 months
compared to exercise alone for patients with mechani-
23
was a prestratified group, identified with pain arising from
the structures of the shoulder girdle compared to of the
glenohumeral joint. In the same study, those identified as
having a synovial disorder, or pain arising from the glenohumeral joint, responded most quickly to a subacromial
injection as compared to manipulation or standard physiotherapy. With longer term follow-up, the differences
in manipulative therapy versus standard physiotherapy
were not nnaintained. 106 Boyles and colleagues 107 performed thrust manipulation procedures directed to the
thoracic spine in individuals with subacromial impingement syndrome. Significant reductions in disability and
pain with provocative testing were observed at 48 hours
postmanipulation. Tate and colleagues'° 8 used a combination of strengthening, manual stretching, thrust and
nonthrust techniques directed to the thoracic spine and
glenohumeral joints in 10 patients with subacromial impingement syndrome. At 12 weeks, 80% of patients reported at least 50% reduction in disability or a perceived
recovery of at least "moderately better."
Strunce and colleagues 109 investigated the immediate effects of thoracic spine and rib manipulation in patients with a primary complaint of shoulder pain. A significant reduction in pain and improvements in active
shoulder range of motion were seen immediately following the intervention. Additionally, 51% of patients
reported feeling "quite a bit better" to "a very great
deal better" following the intervention. Mintken and
colleagues"° identified potential predictor variables for
patients, with a primary complaint of shoulder pain,
whom are likely to respond to manual therapy (thrust
and nonthrust techniques) and exercise to the cervicothoracic region. The potential predictor variables included pain-free shoulder flexion < 127°, glenohumeral
internal rotation < 53° (at 90° abduction), symptoms <
90 days, not taking medications for shoulder pain, and
a negative Neer test. Caution should be used when applying these potential predictor variables to patients as
they have not been validated.
In a prospective case series of 15 patients with shoulder pain, Jensen"' found an immediate improvement in
shoulder flexion range of motion in patients receiving a
seated traction manipulation to the upper thoracic spine.
Boyle 112 reported on 2 cases of shoulder impingement
that completely resolved after mobilization of the second rib. In a randomized trial, Bang and Deylem found
superior short-term outcomes for patients with shoulder
impingement who received 6 sessions of manual therapy and exercise compared to exercise alone. Manual
therapy techniques were selected based on the patients'
individual impairments, but the majority received mobilization of the glenohumeral joint, cervical spine, thoracic spine, and upper rib joints.
Similar to the cervical spine, multiple theories exist
to explain the potential mechanisms by which manipulative therapy of the cervicothoracic spine can lead to decreased shoulder pain. Based on the above-mentioned
studies, there is preliminary evidence to suggest that
patients with a primary complaint of shoulder pain may
benefit from manual therapy directed towards the thoracic spine.
REVIEW OF OUTCOME MEASURES AND SCALES
In relation to outcomes, patient self-reported functional scales are recommended use for both clinical and
research purposes. Clinicians have historically relied
most heavily on physical impairments, such as range of
motion and strength, to track patient outcomes. In many
cases, physical impairment measures account for only a
small portion of a patient's disability. 114,115 No specific
measures for functional loss and disability have been
reported for use in patients with thoracic spine and rib
cage pain. One option is to use a cervical spine-specific scale such as the Neck Disability Index for patients
reporting upper thoracic spine pain above the level of
T4, and to use a lumbar-specific form such as the Oswestry Disability Index for patients complaining of pain
below T4. The Patient-Specific Functional Scale (PSFS)
is another tool that can be used for patients with thoracic spine pain. 115117 Patients list up to 5 important functional activities and rate their ability to complete them
on a numeric rating scale. The average score (from 0 to
10) of these activities is then used. The PSFS has been
shown to be reliable, responsive, and valid in patients
with knee pain, neck pain, and low back pain. 115- " 7 The
PSFS is a generic functional measure that can assist the
clinician and the patient in tracking the progress of the
patient's individual functional limitations. Due to the
individualized nature of the items on the scale, the PSFS
is not designed for use in comparing outcomes across
patients. The PSFS has not been validated for use in
patients with thoracic spine pain. Pain is assessed at
baseline using a NPRS, which is a reliable, responsive,
and appropriate measure of pain for patients with musculoskeletal conditions. 118-12 °
CASE SCENARIOS
Case Scenario 1
A 35-year-old male presents with a chief complaint of
middle thoracic spine pain for the past 3 weeks. The patient is employed as an information technology specialist
and spends 8 to 9 hours per day on his laptop computer.
He reports the symptoms began after a particularly stressful work period during which he was working up to 12
hours per day. He reports that the pain is located in the
center of the middle thoracic region and does not radiate from this area. The patient reports that his symptoms
increase with sitting or working on his computer for > 1
hour. His symptoms are relieved with stretching, exercise, and lying down. The patient reports that his general
health is good with a family history of diabetes. Besides
intermittent neck stiffness associated with prolonged sitting, this is his first episode of thoracic spine pain. The
patient is active recreationally and enjoys golf, tennis,
and running. Current average pain on the NPRS is 6/10,
his Oswestry Disability Index is 24%.
24
. If the patient reports increased pain after the ingestion
of a fatty meal, what diagnosis would be most likely?
a. cholecystitis.
b. peptic ulcer.
c. unstable angina.
d. vertebral metastases.
nipulation of the middle to lower thoracic region
ratus anterior weakness could exist but is more comrn
with a flexion restriction of the upper thoracic regid
Transversus abdominis muscle inhibition is commonly
reported with low back pain. Pectoral is minor shortening
could be present but is more commonly associated with
a protracted shoulder girdle.
The correct answer is a. cholecystis. Gall bladder disease typical refers to pain the right periscapular region and
is often exacerbated after eating a fatty meal. Unstable angina would present more commonly with chest pain and
a history of heart disease. A peptic ulcer could cause thoracic pain but the symptoms are often relieved after eating.
Vertebral metastases is possible but the patient does not
have the key red flags for cancer including age > 50, night
pain, weight loss, and a previous history of cancer.
4. You decide to perform a seated, followed by a prone
thrust manipulation to the middle thoracic region.
Afterwards the patient displays increased thoracic
spine extension and bilateral rotation with less pain.
Which of the following exercises would be the best to
immediately follow?
a. barrel hug.
b. self extension mobilization.
c. serratus anterior re-education.
d. shoulder sweep.
2. Given the patient's current area of symptoms, aggravating factors, and chief complaints what is the most
likely diagnosis?
a. mechanical rib cage dysfunction.
b. mechanical thoracic spine pain.
c. thoracic facet joint inflammation.
d. thoracic spine disk herniation.
The correct answer is b. self extension mobilization.
This most closely matches the patient's presenting impairments in addition to the manipulation techniques. Furthermore the patient could potentially perform this in his
chair during working hours by extending his spine over
the back of his chair. The barrel hug is more directly related to treating flexion restrictions. The shoulder sweep
could be potentially taught; however, the extension exercise is more specific to the patient's impairments. Serratus anterior re-education could be taught; however, a
lower trapezius dysfunction is more commonly associated with middle to lower thoracic spine dysfunction.
The correct answer is b. mechanical thoracic spine
pain. While the source of the patient's pain could be either the thoracic disk or facet joint, it is difficult from the
history and physical examination to determine the pathoanatomical cause of the pain. Furthermore even with diagnostic imaging, perhaps displaying a herniated thoracic disk, it would be difficult to determine that the imaging
findings are the source of the patient's symptoms. This
is due to the frequent finding of thoracic disk herniation
in an asymptomatic population. Rib cage dysfunction is
unlikely due to the location of the patient's symptoms in
the middle thoracic region. Patients with rib dysfunction
often report pain located further laterally in the region of
the costovertebral or costotransverse joints. Patients with
rib dysfunction also often report pain with deep inspiration or expiration.
The patient exhibits an increased middle thoracic kyphosis, hypomobility, and pain in the T6-T9 region with
posterior to anterior spring testing, and restricted and
painful active thoracic extension and bilateral rotation.
Case Scenario 2
The patient is a 42-year-old female with a chief complaint of thoracic spine pain, headaches, and bilateral upper
extremity paraesthesias. She reports an insidious onset of
these symptoms beginning 2 months ago. Her symptoms
are aggravated by sustained postures such as sitting and
driving for longer than 15 minutes and are relieved with
exercise such as walking and stretching. She denies night
pain, chest pain, shortness of breath, or a history of cancer.
During the physical examination, she displays a reduced
thoracic kyphosis in the T3-T6 region and bilateral scapular
winging. During posterior to anterior spring testing applied
to the T4-5 region there is local pain, hypomobility, and her
bilateral upper extremity paraesthesias are reproduced. The
slump test is positive for a reproduction of her thoracic spine
pain and headache that eases with cervical extension. Her
upper quarter sensory motor screening is normal. Her Neck
Disability Index is 34% and her average pain on the Numerical Pain Rating Scale is 6/10.
3. What muscle dysfunction often accompanies middle
to lower thoracic spine extension restriction and hypomobi I ity?
a. lower trapezius weakness.
b. pectoralis minor shortening.
c. serratus anterior weakness.
d. transversus abdominis inhibition.
1. Given the above presentation, which of the following
diagnoses is most likely?
a. cervical myelopathy.
b. thoracic disk herniation.
c. thoracic outlet syndrome.
d. T4 syndrome.
The correct answer is a. lower trapezius weakness.
This is a common finding in patients with a variety of
upper quarter musculoskeletal disorders, and two studies
have found improved lower trapezius strength after ma-
25
The correct answer is d. T4 syndrome. The patient
presents with the constellation of signs and symptoms consistent with this disorder including thoracic spine pain and
stiffness, headaches, and bilateral upper extremity paraesthesias with a normal neurological examination. Cervical
myelopathy is a possibility but less likely due to the normal neurological examination and that cervical extension
eases her symptoms during the slump test. With cervical
myelopathy, symptoms are often worsened during cervical
extension due to the narrowing of the cervical canal in this
position. Thoracic outlet syndrome is another possibility
however the distribution of symptoms with this syndrome
is usually unilateral and located towards the ulnar region
of the distal upper extremity. In addition, involvement of
the thoracic spine is more likely to occur in the upper thoracic spine (T1-T2) and first rib region as opposed to the
T3-T7 region. A thoracic disk herniation could potentially
cause these symptoms but it is difficult to make this diagnosis based on physical examination alone.
The correct answer is b. serratus anterior re-education. The patient presents with a restriction in thoracic
spine flexion and bilateral scapular winging. Serratus
anterior weakness or inhibition often presents with these
findings. Furthermore during serratus anterior re-education, there is the added benefit of producing a flexion
mobilization to the thoracic spine. Answer "a," lower trapezius re-education, could also be indicated as part of a
comprehensive scapular stabilization program but is not
specific to the patient's presenting impairments. Answer
"d," thoracic extension mobilization, would be indicated
if the patient had a restriction in thoracic spine extension.
Similarly answer "c," the shoulder sweep exercise, is not
specific to the patient's presenting impairments.
4. Which of the following is theorized to cause the constellation of signs and symptoms associated with T4
syndrome?
a. compression of the thoracic spine cord.
b. peripheral neuropathy of thoracic nerve roots.
c. referred mechanical thoracic pain.
d. sympathetic nervous system dysfunction.
2. Given the above presentation which manual therapy
intervention is indicated?
a. prone middle thoracic nonthrust manipulation
b. prone middle thoracic thrust manipulation.
c. seated middle thoracic thrust manipulation.
d. supine middle thoracic thrust manipulation
The correct answer is d. sympathetic nervous system
dysfunction. Due to the proximity of the sympathetic
chain to the thoracic spine, it is thought that mechanical
movement impairment of the thoracic spine could lead
to altered sympathetic nervous system function. Answer
"b" is incorrect because thoracic spine peripheral neuropathy would present with pain or paraesthesias along
the sensory distribution of the thoracic nerve roots in
the chest wall region. Answer "a" is incorrect because
compression of the thoracic spine cord would lead to
symptoms below the level of the compression and the
patient would be more likely to present with neurological signs and symptoms in the lower quarter region.
Answer "c" is incorrect because pain mapping studies
have shown that the thoracic spine refers pain locally or
within one segment above or below and does not typically create widespread symptoms in the upper extremities or headaches.
Following a purely mechanical model, the correct answer is d. supine middle thoracic thrust manipulation. The
patient presents with a reduced thoracic kyphosis indicating
a region of the thoracic spine that is in relative extension or
lacking flexion range of motion. The supine manipulation
with the patient's thoracic spine in flexion most closely targets her presenting impairment. Answers "a" and "b" are
incorrect because the prone technique would theoretically
be used to improve extension range of motion. Answer "c"
is incorrect because the seated technique is not direction
specific. However based on recent evidence, it is also likely
that the type of technique used would not make a difference
in the patient's outcome. A major consideration for technique selection should be selected based on the patient's
comfort level with the technique. It is recommended that
key comparable signs be retested immediately following a
technique to determine if there has been an improvement.
If no improvement has occurred, then an alternate technique could be selected. Recent studies involving thoracic
spine manipulation for patients with neck or shoulder pain
have used multiple techniques to target the same region of
the thoracic spine. At this time, there is no research to guide
what the optimal technique or dosage is for manual therapy
procedures in the thoracic spine.
Case Scenario 3
A 72-year-old female presents to physical therapy
with a chief complaint of middle thoracic spine pain.
The symptoms began after she bent down to pick up a
laundry basket 2 days ago. She was referred by her primary physician who diagnosed her with a thoracic spine
strain. She reports constant pain in the middle thoracic
region that worsens with sitting, standing, and walking.
Her pain eases with lying down. The pain does not radiate and she does not report any neurological complaints.
She has a history of smoking, having smoked 1 pack per
day until 10 years ago. Her health history indicates she
has chronic shortness of breath, hypertension, and she is
postmenopausal. The patient denies a history of cancer
or surgery. Her Oswestry Disability Index is 52% and she
rates her pain on the analog pain scale as an 8/10.
3. Which of the following exercise interventions should
be used immediately following the manipulation?
a. lower trapezius re-education.
b. serratus anterior re-education.
c. shoulder sweep exercise.
d. thoracic extension mobilization.
26
1. Based on the above presentation which of the following is the most likely diagnosis?
a. cardiac ischemia.
b. mechanical thoracic spine pain.
c. thoracic compression fracture.
d. thoracic spine bone metastases.
tebroplasty versus conservative management. 5859 Due
to the decreased costs and risks associated with more
conservative care including physical therapy, this should
be the first treatment option for this patient; therefore,
answers "c," kyphoplasty, and "d," vertebroplasty, are incorrect. If initial conservative care fails to reduce the patient's symptoms and they remain severe and disabling,
then percutaneous procedures such as vertebroplasty are
a viable treatment option. Answer "a" is incorrect as bed
rest would lead to deterioration in overall health from the
effects of inactivity and immobilization.
The correct answer is c. thoracic compression fracture. Given the patient's age, gender, history of smoking, and sudden onset of symptoms after a trivial strain,
a thoracic compression fracture is a high probability.
Answer "d," boney metastasis, is a possibility due to her
history of smoking but usually there are no additional
red flags, the primary being a history of cancer. 47 Answer "a," cardiac ischemia, is possible due to her history of shortness of breath and hypertension; however,
this usually presents with chest pain upon exertion also
known as angina. Mechanical thoracic spine pain or a
thoracic spine strain is possible but given the patient presentation a fracture should be ruled out before making
this diagnosis.
4. What type of physical therapy intervention is indicated for this patient once the fracture has healed and is
less acute?
a. aerobic conditioning.
b. aquatic therapy.
c. progressive spinal extensor muscle strengthening.
d. stretching and range of motion exercises.
The correct answer is c. progressive spinal extensor
muscle strengthening. Several clinical trials have shown
that extensor strengthening improves health-related quality of life and decreases the incidence of future fractures
in women with osteoporotic compression fractures." Answer "b," aquatic therapy, is incorrect as weight bearing
exercise has been shown to be most beneficial for bone
mineral density. Answer "d," stretching and range of motion, is incorrect, while this may be beneficial, it does not
address deficits in bone mineral density. Aerobic conditioning, answer "a," is incorrect because although aerobic conditioning is important for overall health it will not
directly address the bone mineral density.
2. Which of the following is the best plan of treatment
given this patient's presentation?
a. continue physical therapy respecting her pain tolerance.
b. refer her to an orthopaedic surgeon for a surgical
consultation.
c. refer her to the primary physician with a recommendation for magnetic resonance imaging.
d. refer her to the primary physician with a recommendation for radiographs.
The correct answer is d. refer her to the primary physician with a recommendation for radiographs. This
patient should be referred for a radiograph due to the
high likelihood of a thoracic spine compression fracture.
Response "c" is incorrect because a magnetic resonance
imaging is more expensive and is not usually required to
make the diagnosis of a compression fracture. She could
be referred to an orthopaedic surgeon (answer "b") but
only after she's had the radiograph; invasive surgery is always not required for this injury. While physical therapy
could still be indicated, imaging is required in order to
effectively and safely implement a plan of care for this
patient.
Case Scenario 4
The patient is a 23-year-old female who presents to
physical therapy with a chief complaint of right anterior
chest wall pain. The symptoms began about 6 weeks ago
and have progressively increased. The patient is a collegiate rower and believes that the pain is related to her
rowing activities. The patient reports pain located on the
right anterior chest wall in the region of the costosternal junction. Symptoms increased with deep inspiration,
rowing, pushups, and with direct pressure to the region
of pain. Symptoms ease with rest, ice, and ibuprofen.
Treatment by the team trainer has consisted of electrothermal modalities and stretching exercises. This has not
changed the patient's symptoms. Past medical history is
unremarkable. Average pain on the numerical rating of
pain scale is 6/10. And the composite score on the Patient Specific Functional Scale is 5/10.
3. Assuming the patient had a thoracic spine compression fracture what is the best initial treatment option
for this patient?
a. bed rest until the fracture heals.
b. conservative care including physical therapy.
c. kyphoplasty procedure.
d. vertebroplasty procedure.
1. Give the current patient presentation which of the following serious conditions is most likely?
a. cardiac ischemia.
b. gall bladder disease.
c. penetrating ulcer.
d. rib stress fracture.
The correct answer is b. conservative care including
physical therapy. Randomized trials have shown that
medium to long-term outcomes are identical with ver-
27
3. Which of the following exercises is best to now teach
the patient?
a. pectoralis major stretching.
b. serratus anterior strengthening.
c. thoracic extension over a foam roller.
d. thoracic flexion, barrel hug.
The correct answer is d. rib stress fracture. The patient engages in heavy, repetitive activity involving use
of the musculature attached to the rib cage. Rib stress
injuries are common in rowers. Answer "c," penetrating ulcer, is a possibility but the patient's symptoms are
mechanical in nature and there are no other indications
in the history that would suggest an ulcer. Answer "a,"
cardiac ischemia, is a possibility but the patient's younger
age and symptom presentation do not match with this diagnosis. Answer "b," gall bladder disease, usually presents with right-sided periscapular pain that is associated
with ingestion of a fatty meal.
The correct answer is c. thoracic extension over a foam
roller. The patient presents with an increased thoracic kyphosis and is also involved in an activity, rowing, involving
repetitive thoracic flexion. Teaching the patient a thoracic
extension mobilization would address the postural deficits
and the hypomobility found on the examination. Answer
"d," flexion barrel hug stretch, would be more appropriate
for the patient who lacks thoracic flexion. Answers "a"
and "b" could be appropriate but these impairments were
not reported as part of the physical examination.
You decide to refer the patient back for a rib radiograph that was read as negative. The patient returns to
physical therapy and your key examination findings are
as follows:
• Increased thoracic kyphosis.
• Active right thoracic rotation restricted x 25% with
reproduction of the anterior pain.
• Reduced excursion of the right middle ribs during inspiration.
• Thoracic hypomobility with spring testing centrally
from T4 6.
• Rib hypomobility with spring posterior to anterior
testing over the right fifth rib.
• Severe pain and hypomobility with spring testing over
the right fifth rib at the costosternal junction.
Case Scenario 5
A 32-year-old female presents to physical therapy with
a chief compliant of cervical and upper thoracic pain. The
symptoms began one week after she sustained a whiplashtype injury. The patient reports she was in her car stopped at
a light when she was struck from behind by another vehicle
that was traveling approximately 35 miles per hour. The
patient had cervical radiographs taken the day of her injury
that were read as normal. She has been wearing a soft cervical collar prescribed by the emergency department physician. She reports that her cervical pain is severe, constant,
and worsens with active range of motion of the neck, driving, and sitting. She is taking naproxen 500 mg twice per
day that helps to decrease her pain. Her goal is to decrease
her pain and improve her neck range of motion. Average
pain score is 8/10 and her Neck Disability Index is 42%.
During the physical examination, the patient has a
normal upper quarter neurological examination, negative
signs of cervical instability including alar and transverse
ligament stress testing, painful and restricted active cervical range of motion in all planes by 50%, and segmental
hypomobility of the upper thoracic spine.
-
2. Which of the following is the best manual therapy intervention for this patient?
a. nonthrust manipulation to the anterior aspect of
rib 5.
b. nonthrust manipulation to the posterior aspect of
rib 5.
c. thrust manipulation to the posterior aspect of rib 5.
d. thrust manipulation to the T4 T6 region.
-
The best answer is d. thrust manipulation to the T4T6 region. Despite no evidence to support this notion,
manipulation of the thoracic spine in the presence of a
rib dysfunction is recommended first.' Often this can
relieve the pain from the rib dysfunction likely because
the thoracic techniques have a regional effect and the rib
will get mobilized during the techniques. Answer "a"
is incorrect because there is significant pain with spring
testing in an anterior to posterior direction over the costosternal junction and direct mobilization of this area has
the potential to exacerbate the patient's symptoms. Mobilization of the anterior aspect of the rib could be used
later in the course of treatment if there is less pain when
mobilizing this area. Answers "c" and "d" are considerations and could be used after first addressing the thoracic spine hypomobility.
You performed a supine manipulation to the T4-T6
region followed by a prone thrust to the right fifth rib.
The patient now has full, pain-free thoracic rotation and
inspiration.
1. Given the above findings, which of the following interventions is indicated?
a. cervical nonthrust manipulation and active cervical range of motion exercises.
b. cervical thrust manipulation and active cervical
range of motion exercises.
c. electrothermal modalities and advice to rest as
much as possible.
d. thoracic thrust manipulation and active cervical
range of motion exercises.
The correct answer is d. thoracic thrust manipulation
and active cervical range of motion exercises. Research
has shown that patients with whiplash disorders often
have thoracic spine hypomobility, and one clinical trial
has shown that thoracic manipulation is an effective treatment for patients with neck pain from whiplash. 43 There
28
is significant evidence that patients with neck pain benefit
in terms of reduced pain and disability from thoracic spine
thrust manipulation. Answers "a" and "b" are incorrect
because it is likely that direct cervical spine manipulation
could lead to an increase in the patient's symptoms due
to the recent traumatic injury involving the neck and the
patient's presentation of high irritability. As the patient's
symptoms resolve and become less irritable, the patient
may benefit from cervical manipulation to restore full
range of motion. Answer "c" is incorrect as there is currently no evidence for modalities in the treatment of whiplash and the best current evidence supports advice to remain as active as tolerated after a whiplash injury.
volve direct hand pressure to the targeted vertebrae. The prone techniques (answers "a" and "b") are not indicated
at this time because the patient reports increased pain
with lying prone. As there currently is no evidence to
guide the clinician on the optimal manual therapy technique to use for the thoracic spine, patient comfort and
irritability are important treatment considerations.
3. According to research, what type of thoracic spine
restriction is found in patients with whiplash-related
neck pain?
a. extension restriction.
b. flexion restriction.
c. first rib subluxation.
d. rotation restriction.
During the examination, the patient has significant
tenderness with direct pressure to the upper thoracic
spine and reports pain with lying prone.
The correct answer is b. flexion restriction. Answers
"a," "c," and "d" are incorrect as Fernandez-de-las-Penas and colleagues43 reported the highest incidence of
flexion restrictions of the upper thoracic spine found on
physical examination in patients with whiplash disorders.
The authors theorized that this occurs when the patients
cervical and upper thoracic spine is driven into a hyperextended posture during a typical rear-end collision.
However, it is also important to recognize that emerging
research indicates that the predominant mechanism for
manual therapy techniques is a nonspecific neuromodulatory effect and the particular direction of the technique
may not significantly affect the outcome.
2. Which of the following techniques is the best thoracic
spine manipulation for this patient?
a. prone rib thrust.
b. prone thoracic spine thrust.
c. seated thoracic spine thrust.
d. supine thoracic spine thrust.
The correct answer is c. seated thoracic spine thrust.
This technique involves less specific, direct force to the
tender vertebral segments and would likely be better tolerated than the supine techniques (answer "d") that in-
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