Thoracic Spine Manipulation, Anyone?
Vladimir Camurungan, PT, FAAOMPT
One of the most effective treatment techniques in manual physical therapy is manipulation. Many studies published throughout the years have pointed to the efficacy of manipulation in treating musculoskeletal disorder. However, a 2014 study published by Boissonault and Bryan in JOSPT about the utilization of manipulation as treatment in musculoskeletal disorders in orthopedic outpatient settings showed this to be within the vicinity of 1.8% to 5% of cases. This level of use was much lower than other interventions such as heat, flexibility exercises, strengthening exercises, electrical stimulation, and massage. Yet if you look at history of manual therapy, manipulation is an integral part of the practice guide for physical therapy. If this is the case then why are most physical therapists not manipulating?
There are several reasons why this came about, from the belief that it is not an entry-level skill (57%), a lack of qualified staff (53%), liability concerns (46%), and that students not being academically prepared for it (41%). However I submit that the chief reason is fear of the side effects of manipulation. According to the recent statistics though, this is an unfounded fear. The risk of serious adverse reactions to lumbar manipulation is estimated at less than 1 in 10,000,000. In the cervical spine the risk chance is anywhere between 1 and 100,000 to 1 in 1,000,000. The most common were headache, stiffness, local discomfort, radiating discomfort, and fatigue. The most serious of the recorded reactions were strokes, and these were miniscule in number. Most of the common reactions began within 4 hours and generally disappeared within the next 24 hours. The question then, is manipulation that dangerous? Putting this in perspective, NSAID related death from gastrointestinal bleeding is around 16,500 cases every year. This is nearly the same number of deaths from AIDS related complication and slightly lower than leukemia related deaths (20,000 cases every year). Individuals have a higher chance of dying from taking over the counter drugs such as Advil, Naproxen and Aspirin than having complications from manipulation.
One of the safest areas of the human body that physical therapists can start learning manipulation, or to continue practicing manipulation, is the thoracic spine area. There are no studies that cite any adverse side effects of thoracic spine manipulation or TSM. There is the risk of fracture but if you look at the anatomical make up of the thoracic spine it is inherently a stable area with 8 zygapophysial joints per spinal level. Caution still needs to be taken, for not all physical therapy patients are candidates for thoracic spine manipulation. It is best to start with reviewing patients that may have conditions that make manipulation impractical. The following are contraindications for manipulation of the thoracic spine: recent spinal fracture, osteoporosis, pain during the pre-manipulative hold, upper motor neuron lesion sign such as bilateral or quadrilateral paresthesia, constant pain or night pain and lack of consent.
That being said, patients who are able to undergo manipulation are able to experience its many benefits. These benefits have been studied extensively is the use of TSM as an adjunct for shoulder treatment. In a study done by Muth, and Barber, showed TSM as an effective component of physical therapy treatment to improve pain and function of the shoulder with patients having rotator cuff tendinopathy. Another study done by McCormack in 2012 showed significant improvement of 25 degrees elevation in patients with shoulder adhesive capsulitis after manipulation of the thoracic spine. The most likely explanation is that TSM improve thoracic mobility, which is an essential component of shoulder complex movement.
TSM can also be used as an adjunct treatment for cervical spine musculoskeletal disorder. In a study done by Cleland, Childs et al, presented in the Manual Therapy Journal, subjects showed a significant decrease in cervical pain following thoracic spine manipulation. Mumford wrote another article regarding an evidence-based review of randomized controlled trials on the effectiveness of thoracic spine manipulation for patients with neck pain. It showed that TSM is effective in decreasing pain and disability in patients with neck pain in both the short and long-term and is more effective than alternate treatments. What is the explanation for such an effect? A study done by Norlander et al and Nordgren had found a significant relationship between decreased mobility of the thoracic spine and the presence of cervical pain. It has been postulated that disruptions of the normal biomechanical link between the cervical and the thoracic spine can lead to abnormal distribution of forces in the cervical spine. It has been implied that TSM can restore the normal biomechanics between the neck and the thoracic spine, which in turn lowers the mechanical stresses and improves the distribution of forces in the neck area. So if a patient is very sensitive to pressure applied to the cervical spine and treatment of the cervical spine is not an option, or if a treating therapist is opposed in performing direct manual therapy of the cervical spine, then treatment of the thoracic spine can present as an avenue to start indirect treatment to the cervical area. Manipulation of the thoracic spine can have the same effect as directly manipulating the cervical spine but has fewer complications.
Another benefit of TSM is significant reduction in headache symptoms. As we all know, one of the many causes of headache is neck biomechanical disorder or lesion. This is classified as cervicogenic in nature. TSM to the upper and midthoracic spine have been found to help a great deal in reduction of symptoms. In a case report published in JOSPT in 2014 by Salvatori et al showed an immediate reduction of cervical region pain and headache in a 46-year-old female patient with multiple level anterior cervical spine discectomy and fusion after thoracic spine manipulation. Another case report done by Paris, SJ, published in JMMT, showed how thrust manipulation in the upper thoracic spine was effective in reducing symptoms in a 29-year-old female patient who complained of an occipital headache.
Another cause of prolonged musculoskeletal symptoms in the cervical and lumbar spine is a dysfunctional breathing pattern. This type of breathing pattern has also been associated with persistent headache. One of the ways to address this is teaching our patients to breathe properly. But most often times when we teach proper breathing first, we tend to put the cart before the horse. It will be very hard for patients to learn the proper breathing techniques if they do not have proper mobility of the thoracic and the costovertebral joints. Restoration of proper rib and thoracic mobility patterns is an essential component prior to teaching proper breathing patterns. TSM is believed to restore the proper motions of the aforementioned joints.
As you can see from the preceding discussions, TSM is a very effective tool in addressing musculoskeletal dysfunctions in the cervical, shoulder and lumbar areas either as a direct or as an adjunct treatment. We at Midatlantic Manual Therapy Consultants offers a cervicothoracic manipulation course to learn how to safely manipulate the thoracic spine area. We have several courses scheduled in 2015 all over the US. One can find this under the selection titled “Our Courses” on the homepage of our website http://www.manualtherapyconsultants.com. Remember know your tools and know them very well!