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Figure 3.
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Hooking Maneuver for Slipping Rib
Syndrome
or manipulation of the ribs can be considered. Descriptions of
manual therapy techniques directed toward the ribs will follow.
Additionally, in the subacute to chronic stages, strengthening
exercises loading the muscles supporting the rib cage are added
with consideration of return to sport or work.
Upper Rib Syndromes
Musculoskeletal disorders involving the upper ribs can
result in a variety of symptoms in and around the shoulder girdle
and cervical region. Injury or strain to the first rib can cause
pain in the supraclavicular region with or without neurological
symptoms. Individuals may present with symptoms involved
with movement and loading of either or both the neck
and shoulder. e first rib can be associated with TOS and
readers are referred to additional sources for assessment and
106
management of TOS.
Palpation and springing of the first rib
for reproduction of the patient’s primary complaint in addition
to the previously mentioned CRLF test can assist with diagnosis
of first rib syndrome. e reader is cautioned that the first rib is
often tender and may appear elevated in the presence of a variety
of cervical and shoulder injuries. e clinician should assess the
cervical spine and shoulder prior to the first rib to reduce the
possibility of a false positive first rib diagnosis in the presence
of a cervical or shoulder disorder. e second and third ribs
have been implicated as potential cause of shoulder pain in a
published case series. In this report, the patients’ symptoms of
posterior shoulder girdle pain were reproduced with springing
over the posterior second or third rib region after testing
107
ruled out primary shoulder pain.
Management of upper rib
syndromes often involves manual therapy with an attempt to
improve mobility and reduce pain in the involved thoracic and
rib region. See the section below for manual therapy techniques
targeting the upper ribs. Exercise to address thoracic spine and
rib cage mobility impairments are then paired with manual
therapy.
Manual Therapy Procedures for the
Thoracic Spine and Rib Cage
Individuals with thoracic and rib cage movement
impairments may benefit from a range of manual therapy
techniques. Current evidence suggest that side effects and
adverse events related to manual therapy to the thoracic spine
108
are rare.
ere is no definitive research evidence to suggest the
superiority of one technique compared to another. e decision
of technique selection should be made in conjunction with
the patient and based on the provider’s skills and experience.
Provider factors, which can influence technique selection,
include skill, experience, and expectations based on prior
experience or the level of enthusiasm for a particular technique.
In a study of 306 physiotherapists in the United Kingdom, 61%
preferred the thoracic thrust joint technique with the patient
lying in prone and approximately 30% preferred the supine
technique (both described later).
109
Patient factors include medical conditions or age, which
could preclude certain techniques, patient size and body type,
condition irritability, and patient preferences and expectations.
Rib conditions may be particularly painful or irritable, so as
a general rule, the clinician may opt to perform a manual
therapy technique directed at the thoracic spine prior to the
rib. Manual therapy is thought to mostly provide short-term
110
reduction in pain through neurophysiological mechanisms.
is short-term pain relief, although not a panacea or a standalone treatment, can provide the patient with reassurance of a
favorable recovery and facilitate active management strategies.
e manual therapy techniques discussed in this section
will include both thrust and nonthrust procedures. e
nonthrust procedures will be contract-relax techniques and
graded joint movement at varying speeds and amplitudes also
known as joint mobilization. rust manipulation techniques
are, by definition, high-velocity and low-amplitude procedures.
Based on the evidence for superior effects of manual therapy
when combined with exercise for patients with neck disorders,
103
manual therapy is rarely performed in isolation.
e clinician
will often provide specific exercise and movement reeducation
procedures immediately following the manual therapy
interventions.
e risks and adverse events associated with manipulation
in the thoracic spine are extremely low, provided trained
therapists properly select and assess patients prior to performing
the technique. e estimated rate of occurrence of cauda equina
syndrome as a complication of lumbar spinal manipulation is
111,112
estimated to be less than 1 per 100 million manipulations.
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For personal use only. No other uses without permission.
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27
Overall, serious or severe complications of lumbar spinal
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112
manipulation are extremely rare.
However, to the authors’
knowledge, similar data regarding the thoracic spine do not exist
114
in the literature. Senstad
reported on symptoms following
manipulation in more than 100 patients. Manipulation was
performed for the cervical, thoracic, and lumbar spine. e
authors reported that muscle and joint soreness following
manipulation was common but rarely led to even short-term
impairment in functional status.
114
erapists 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
115
therapies. Tannenbaum et al,
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
116
be attributed to NSAIDs.
A contraindication to manipulation
in the thoracic spine is the presence of osteoporosis. Supporting
clinical data are lacking, but manipulation and mobilization
have the potential to cause vertebral or rib fracture in an
117
individual with osteoporosis.
A survey of therapists in a
Canadian city found that about half used manual therapy in
patients with osteoporosis, although more than 90% had
118
some concerns about using these techniques.
Bone mineral
density is most accurately measured with dual-energy x-ray
119
absorptiometry, or a DXA test.
Patients who have a t-score
of 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 and
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. e reader is cautioned to use judgment
and sound clinical reasoning when selecting patients appropriate
for thoracic spine manipulation.
ere is currently a lack of evidence, in terms of high-quality
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
120
ultrasound.
ere were 15 patients in each group who had
responded to a newspaper article for individuals with middle
back pain. e authors found a significant reduction in pain
on the Numeric Pain Rating Scale (NPRS) at the completion
of 6 treatment sessions and at 1 month follow-up for the
manipulation group compared to the placebo group. In a case
121
report, Kelley and Whitney
described the immediate relief of
right lower chest wall pain following a nonthrust manipulation
of the middle thoracic spine in an adolescent athlete. In a
retrospective review of 73 patients reporting to a rheumatology
clinic with a primary complaint of thoracic spine pain, Bruckner
122
reported that the majority of patients were either pain free
et al
(77%) or noted some improvement (15%) after postural advice
and manipulative treatment of the thoracic spine. e 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 based on
a model of spinal movement impairments. It is useful to follow
a model to have a basis from which to make clinical decisions
about the selection of techniques. But, there is currently no
evidence showing that following a particular model is necessary
to achieve the desired outcome. While the authors have focused
on identifying spinal movement impairments, there is evidence
that shows that manual therapy procedures produce a regional
neuromodulatory effect. For example, nonthrust manipulations
of the cervical spine have been shown to lead to a decrease
in pain-pressure threshold over the area of application of the
manipulation and also at sites distal to the application such as
111, 123
the ipsilateral lateral elbow.
is effect has been coined
manipulation-induced analgesia. ere is indirect evidence that
this effect comes from stimulating endogenous nonopioid
central descending pain-inhibiting systems located in the
110
periaqueductal gray region of the midbrain.
Due to the nonspecific neuromodulatory effect of
manipulation, targeting motion impairments with specific
manipulation techniques may not always be necessary to
achieve a positive outcome in a patient with thoracic spine
124
pain. Haas et al,
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 2 similar studies involving
nonthrust manipulation of the cervical spine at targeted versus
random segments, the authors reported similar findings.
125,126
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
127
thrust manipulation, Ross et al
reported that cavitations
occurred up to 4 levels above and below the targeted joint.
e conclusion was that manipulation likely produces forces
to a region of the spine as opposed to only the specific targeted
segment.
Merging this recent evidence with a model of mechanical
motion restriction, the authors continue to use and recommend
using palpation examination and mobility testing to direct
manual therapy interventions. However, less emphasis is
placed on correcting perceived motion restriction and more on
28
Academy of Orthopaedic Physical erapy, APTA.
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For personal use only. No other uses without permission.
patient centered outcomes such as decreasing pain, improving
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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, quite often,
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.
Patients’ expectations about treatment interventions can
128
have an effect on clinical outcome.
It then becomes important
for the provider to manage those expectations through
discussion, education, and establishing a therapeutic alliance.
For example, if a provider determines that a patient may benefit
from a thoracic spine manipulation, the clinician should first
discuss the intervention with the patient using simple, unbiased,
and non-threatening language and avoid technical jargon that
the patient may not understand. e provider should respect
the patient’s preferences and only proceed with manipulation,
or any other intervention, after an agreed upon plan of care.
Although there is research to support the use of thoracic
manipulation for patients with a variety of conditions, it is not
indicated or appropriate to use with every patient. e provider
should use their best clinical judgment in collaboration with
the patient in deciding whether to employ manipulation. A
clinical example of a patient-centered, collaborative approach
to decision making about the use of thoracic manipulation was
129
reported in a case by Salvatori et al.
In this case, the therapist
or relatively more mobile shoulders. In this example, targeting
the T1-2 segment, the therapist rolls the patient toward them
and places their thenar eminence and palmar region of the
hand proximal to the second metacarpophalangeal joint on the
inferior vertebra: T2. To establish firm contact, the therapist
applies a skin lock by ulnarly deviating the hand and pulling
caudally. e therapist rolls the patient back to the supine
position while at the same time pulling the contact hand in a
caudal direction to put the patient’s upper thoracic spine into a
position of relative extension. While applying pressure through
the patient’s crossed arms, the therapist makes final minor
adjustments, such as side bending the patient’s thoracic spine
toward the therapist and slightly rotating away, until a crisp
end feel is established. e patient is asked to inhale and then
exhale, and the therapist performs a quick thrust down toward
the hand positioned behind the back of the patient and the
table. With this technique, it is often useful to have the patient
perform a supine bridge 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 4).
Figure 4.
Supine Upper oracic rust
Manipulation
anxious about her condition. e therapist showed the patient
pictures of the thoracic spine manipulation techniques that
could be employed. e patient decided which one she was
most comfortable receiving and the therapist subsequently used
the technique selected by the patient.
oracic 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. e patient crosses their arms with the opposite
arm on top and the elbows parallel. e therapist can test for
potential shoulder discomfort by first pushing through the
patient’s arms. If the patient reports shoulder discomfort, a
rolled towel can be placed underneath the patient’s arms to
increase patient comfort and help establish a firm lever arm.
is is usually required for patients who have long, slender arms
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
A, Hand placement. B, rust position.
29
Seated upper thoracic/cervicothoracic junction thrust
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manipulation (a high-velocity, end-range, caudal to cranial
force through the upper thoracic spine in a seated position)
e patient sits on a treatment table with hands clasped
behind their neck as low on the cervical spine as possible.
e therapist stands behind the patient and loops their hands
through the patient’s arms and places their hands clasped over
the patient’s hands. e patient’s elbows should be allowed to
drop forward so as to not place the shoulders into an 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 5). e clinician leans backwards
by extending their hips and avoiding hyperextension of their
own back, to take up slack in a superior direction. A thrust is
delivered by the therapist’s legs, upwards toward the ceiling in
an attempt to create a distraction force to the patient’s upper
thoracic region. 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
their arms, or has a history of anterior shoulder instability, an
alternate technique should be selected.
Prone upper thoracic thrust manipulation (a high-velocity,
end-range, transverse force through the upper thoracic spine
in a prone position)
e patient is prone with the head rotated to the right
and side bent to the left so that they are resting on their left
zygomatic region. e patient’s right arm is elevated with the
shoulder in about 100° of abduction and the elbow in 90° of
flexion. e patient’s left arm is down at their side. e clinician
is standing on the patient’s left side. e clinician places their
right hand along the right side of the patient’s head or face and
their left hand contacts the patient’s left CT region using their
thumb and web space. Slack is taken up moving the head into
left side bending and transversely moving the CT region to the
right. A high velocity thrust is provided with the clinician’s left
hand transversely moving to the right countered by their right
hand into left side bending (Figure 6).
Figure 6.
Prone Upper oracic rust
Manipulation
Figure 5.
Seated Upper oracic rust
Manipulation
30
A, Hand placement. B, rust position.
Academy of Orthopaedic Physical erapy, APTA.
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For personal use only. No other uses without permission.
Seated middle thoracic spine thrust manipulation (a high-
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velocity, end-range, anterior to posterior force through the
elbows to the middle thoracic spine in a seated position)
e patient sits on the treatment table with arms across
the body and hands grasping the opposite posterior shoulder
region (Figure 7). Clinical experience 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. e therapist should test for shoulder discomfort by
applying backward pressure through the patient’s arms. If the
patient reports shoulder discomfort, a rolled towel can be placed
underneath the patient’s arms to increase patient comfort and
to help establish a firm lever arm. e therapist applies their
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 more segment specific. e therapist reaches
around the patient and grasps around the patient’s elbows. If
possible, the clinician interlocks their hands. e therapist takes
up slack by adducting their arms, retracting the shoulder girdle,
and pushing their chest toward the patient’s thoracic spine.
A high velocity thrust is performed by the therapist 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. is could potentially injure
the clinician with a larger patient and this practice should be
discouraged. e clinician should also make sure to direct the
manipulative thrust through the patient’s elbows and toward the
therapist’s sternum and not through the patient’s diaphragm.
If the therapist cannot reasonably reach their arms around the
patient, another technique should be selected.
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)
Movement impairments can occur commonly in the
middle and lower thoracic spine. Based on evidence from 2
trials, movement impairments of the middle to lower thoracic
spine can be associated with lower trapezius inhibition.
130,131
is is detected with the patient prone and the arms fully flexed
and resting on the table. e therapist then observes the lower
trapezius while the patient attempts to lift the arm off the table.
To improve mobility in the middle to lower thoracic spine,
prone techniques are commonly used.
In this example, targeting the T8-9 segment, the patient
lies prone with the therapist standing on either side. e
therapist’s hypothenar eminences contact the right and left
transverse processes of T8 (Figure 8). It is useful to improve
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 cranial force.
e patient is asked 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, lowamplitude thrust. e therapist’s movement is similar to the
compressions used during cardiopulmonary resuscitation. is
movement introduces extension of the middle or lower thoracic
Figure 8.
Prone Middle oracic Manipulation,
rust and Nonthrust
Figure 7.
Seated Middle oracic rust
Manipulation
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31
region. As with other techniques, excessive force is unnecessary.
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It is more comfortable, and a similar goal is achieved, if the
thrust is not initiated from the end range position of extension.
Allow for some slack to remain prior to the thrust 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)
e therapist stands at the side of the patient and crosses
the patient’s arms with the opposite arm on top and the elbows
parallel. e therapist can test for potential shoulder discomfort
by first pushing through the patient’s arms. If the patient reports
shoulder discomfort, a rolled towel can be placed underneath the
patient’s arms to increase patient comfort and to help establish
a firm lever arm. is is usually required for patients who have
long, slender arms or relatively more mobile shoulders. Next,
the therapist rolls the patient’s opposite shoulder toward them
and reaches their arm around the patient’s trunk. Using the
thenar eminence and palmar region of the hand proximal to the
second metacarpophalangeal joint, the therapist creates a skin
lock on the targeted thoracic region by firmly contacting the
tissue overlying the vertebra and applying an ulnar deviation
twisting movement of the wrist. A common mistake with novice
therapists is to have the stabilization contact too far laterally.
e therapist then rolls the patient’s trunk completely back over
onto their stabilizing hand and places firm pressure through the
patient’s elbows in the direction of the stabilizing hand. At this
point, the therapist flexes 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. e therapist must not remove any pressure from the
patient’s trunk. e 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 the therapist’s hand (Figure 9). 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 their body over the patient’s elbows. Having
the patient near the side of the table closest to the therapist is
also beneficial for this reason.
Rib cage
Seated upper rib thrust and nonthrust manipulation (a
high- or low-velocity, mid- or end-range, inferomedial force
to the first 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
Figure 9.
Supine Middle oracic rust
Manipulation
A, Hand placement. B, rust position.
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. e
therapist stands behind the patient and supports the patient’s left
trunk (Figure 10). e web space of the therapist’s right hand
contacts the posterior border of the right first rib. e 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, T1 is moved through an arc of flexion
and extension to locate the midrange or neutral position. e
therapist’s right arm guides a right to left translatory movement
at T1 while the hand maintains contact with the first rib. is
will result in right side bending of the patient’s neck, placing
the cervical soft tissue, including the scalene muscles, on slack.
e patient is asked 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). A modification of this technique
32
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Figure 10.
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Seated First Rib Manipulation rust
and Nonthrust Directed Toward the Right First Rib
A, Hand placement. B, rust position.
rib angle and uses a twisting motion of the wrist to establish a
skin lock. e therapist rolls the patient back onto their hand
and places their abdomen on the patient’s elbows and applies a
downward force to engage the stabilizing fulcrum. e therapist
places their top hand on the anterior aspect of the patient’s
right second rib. e therapist asks the patient to lift their head
off the table. e manipulative thrust is accomplished by the
therapist applying 3 motions simultaneously: (1) downward
pressure through the patient’s elbows, (2) anterior to posterior
pressure through the anterior aspect of the patient’s second rib,
and (3) a caudal traction force with their bottom hand on the
posterior aspect of the rib (Figure 11).
Supine middle rib thrust manipulation (a high-velocity, endrange, anterior to posterior force through the elbows to the
rib in a supine position)
In this example, the supine thrust technique is directed
to the right 5th rib. e patient is supine with the therapist
standing on the left side of the patient. e patient’s arms are
crossed with the right arm over the left arm. e therapist rolls
the patient toward them 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
(Figure 12). e therapist places their thenar eminence on
the 5th rib medial to the rib angle and uses a twisting motion
of the wrist to establish a skin lock. e therapist rolls the
patient back onto their hand and places their abdomen on the
patient’s elbows and applies a downward pressure to engage
the stabilizing fulcrum. e 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. 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. e
therapist asks the patient to take a deep breath in and exhale. A
manipulative thrust through the therapist’s chest wall in a vector
toward the 5th rib is performed.
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. e therapist
allows slightly greater left rotation of the patient’s head to occur
to introduce neutral mechanics down to the T2 segment.
Supine upper rib thrust manipulation (a high-velocity, endrange, anterior to posterior force through the elbows to the
second rib in a supine position)
In this example, the supine thrust technique is directed to
the right second rib. e patient is supine with the therapist
standing on the left side of the patient. e patient grasps their
opposite elbows to fold their arms across their body. e therapist
places their thenar eminence on the second rib medial to the
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For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
Prone rib thrust and nonthrust manipulation (a high- or lowvelocity, mid- or end-range, posteromedial to anterolateral
force to the rib on the vertebra in a prone position)
e 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 by applying their hypothenar
eminence along the thoracic transverse processes (Figure 13).
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. As with
all techniques directed toward the ribs, the patient should be
cleared for bony insufficiency and the force or amplitude of the
technique should be kept to a minimum.
33
Figure 11.
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Second Rib
Supine Rib Manipulation Targeting
Figure 12.
Supine Rib rust Manipulation
Targeting Middle Ribs
A, Hand position on posterior rib. B, Hand position
on anterior rib. C, rust position.
Selected Therapeutic Exercises
It is recommended that the clinician instructs the
patient in exercises immediately following manual therapy
intervention. e exercises should encourage movement in the
previously restricted or painful ROM and reeducation of the
local musculature of the involved thoracic region. One theory
A, Hand placement. B, rust position.
is that manual therapy techniques may provide a short window
of opportunity during which an active movement reeducation
program is more efficient secondary to pain reduction and
101
reduced muscle guarding.
Increasing middle thoracic flexion
e purpose of the barrel-hug stretch is to improve or
maintain flexion in the upper to middle thoracic spine region.
e patient is asked to imagine that there is a 55-gallon drum
on their lap and that they are trying to get their 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 14). e 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. is exercise is typically given to
Academy of Orthopaedic Physical erapy, APTA.
34
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Figure 13.
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Prone Rib Manipulation rust and
Nonthrust Directed Toward the Left 4th Rib
Figure 15.
oracic Extension Mobilization
exercise may also be performed while sitting using the back of a
chair as the fulcrum for creating thoracic spine extension. is
is often useful for individuals with seated occupations.
Figure 14.
Barrel-Hug Stretch
Sidelying trunk rotation
e patient lies on the floor with the hips and knees bent to
90°. A small pillow can be placed under the head. e patient’s
top hand is either placed on their rib cage or the upper extremity
is extended by their side. e patient is instructed to rotate the
trunk, head, and shoulder to the opposite side (Figure 16).
Deep breathing and self-mobilization into the restricted ranges
is encouraged.
Lower trapezius muscle reeducation
e purpose of the lower trapezius muscle reeducation
exercise is to improve or maintain extension in the middle to
lower thoracic region and to facilitate normal scapulothoracic
motion. e patient assumes a prone position with one arm
off the side of the table. e therapist directs the patient to
flex the arm in the plane of the scapula with the shoulder in
Figure 16.
Sidelying oracic Rotation
Mobilization
the patient immediately after the supine flexion manipulation
technique.
Increasing thoracic spine extension
Using either a towel roll or foam roll, the patient lies supine
over the roll that is placed horizontally perpendicular under the
patient’s thoracic spine. e patient supports their head with
their hands and produces graded mobilization of the targeted
thoracic region by extending and flexing the thoracic spine
over the roll (Figure 15). e mobilization can be enhanced
by having the patient inhale while extending over the roll. is
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35
external rotation (thumb toward the ceiling). e therapist
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can facilitate the activation of the lower trapezius by tapping
on the muscle and directing the patient to bring the shoulder
blade into retraction and depression (Figure 17). If the patient
has difficulty activating the lower trapezius, a manipulation
targeting the middle to lower region can facilitate the muscle
firing.
clinician can determine if movement impairments involving the
thoracic spine or rib cage region are contributing to a patient’s
condition. Additionally, a clinician may use several factors in
making the decision to provide interventions to the thoracic
spine including tissue irritability of the local area, perceived
contribution of regional impairments, patient expectations, and
previous success with this approach.
Serratus anterior muscle reeducation
e patient assumes a quadruped or pushup position on
a wall. From this position, they are instructed to protract the
scapulae and flex the upper to middle thoracic spine to activate
the serratus anterior muscle and facilitate thoracic flexion
(Figure 18).
Regional Interdependence
Regional interdependence refers to how impairments
and treatment of a particular body region can affect related
regions. Over the last decade, there have been numerous studies
published reporting successful outcomes associated with the use
of manual therapy interventions targeting the thoracic spine
for patients with primary mechanical neck pain and conflicting
evidence for primary shoulder pain.
132,133
While the research has
focused mainly around the effects of thoracic spine manipulation
is typically used in combination with other interventions
and may only provide short-term modulation in symptoms.
Additionally, some research has indicated that treating the local
area of symptoms initially may have greater benefit than using a
134
regional interdependence approach.
Using clinical reasoning
and a detailed history/interview and physical examination, a
Figure 17.
Lower Trapezius Muscle Reeducation
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. Targeting the thoracic spine with manual interventions
may assist in improvement in pain, ROM, and disability. Based
on the current research, there appears to be a short-term benefit
to incorporating thoracic spine manipulation into a plan of care,
but there is no evidence that identifies a particular technique that
135
is most beneficial.
As stated above, thoracic spine manipulation
is offered as part of a multimodal package of interventions
including manual therapy and therapeutic exercise directed
to the cervical spine. An example of this type of intervention
136
package was reported by Masaracchio et al.
ey randomized
64 individuals with mechanical neck pain into 2 groups. One
group received nonthrust manipulation of the cervical spine
plus a home exercise program focusing on active ROM of the
cervical spine. e experimental group received the same set of
interventions with the addition of thoracic spine manipulation.
e results of this study demonstrated 94% of the experimental
group and 35% of the comparison group had significant shortterm improvements in pain, disability, and perceived recovery
137
at 1 week. Young et al
also reported short-term (48-72 hours)
improvements in pain, disability, and cervical ROM following
a single session of thoracic manipulation for individuals with
cervical radiculopathy. Numerous theories abound as to why
36
Figure 18.
Serratus Anterior Muscle Reeducation
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For personal use only. No other uses without permission.
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