Jim and I recently had one of our Fellowship courses on the Advanced Cervical Spine. While practicing one of our cervical manipulation techniques, I realized I was having a protective spasm of some of my suboccipital muscles. This prevented Jim from getting my neck to end-range, which can be an important component of manipulations. I suggested trying a thoracic manipulation first to see if it would calm down the protective spasm. After the manipulation to T6, I had significantly less discomfort with the cervical positioning and Jim was easily able to get my neck to end-range. Jim was then able to complete a cervical manipulation with ease.
There are multiple studies suggest thoracic manipulations can improve cervical dysfunction (Cleland et al, 2007) (Cleland et al, 2007) (Dunning et al, 2010). In fact, one of these includes a Clinical Prediction Rule that identifies patients with neck pain more likely to respond positively to thoracic manipulation. While thoracic manipulations are beneficial for neck pain, cervical manipulations can be even more effective (Puentedura et al, 2011) (Puentedura et al, 2012).
While cervical manipulations have been shown to be more effective than thoracic manipulations for those with neck pain, they aren't always easy to perform. If the patient is experiencing acute neck pain, it's possible they cannot attain the position for manipulation in the cervical spine (as was the case for me). What these studies don't discuss quite as much is the benefit of using the two together. Like what happened to me, a thoracic manipulation can be used to possibly lower the pain threshold in order to do a more aggressive technique to the cervical spine. That being said, not every patient needs (or is safe enough for) cervical manipulations. You can also perform cervical mobilizations, MET's, or STM that would otherwise have been too uncomfortable. Some patient's will benefit from a thoracic manipulation alone. The point is treat the dysfunctions that you see as appropriate for your patient, but also consider using certain tricks that will permit you to have more direct approaches that the patient may be protecting again otherwise.
Cleland JA, Childs JD, Fritz JM, Whitman JM, & Eberhart SL. (2007). Development of a Clinical Prediction Rule for Guiding Treatment of a Subgroup of Patients with Neck Pain: Use of Thoracic Spine Manipulation, Exercise, and Patient Education. Physical Therapy. 2007 January;87(1):9-23.
Cleland JA, Glynn P, , Whitman JM, Eberhart SL, MacDonald C, & Childs JD. (2007). Short-Term Effects of Thrust Versus Non-Thrust Mobilization/Manipulation Directed at the Thoracic Spine in Patients with Neck Pain: A Randomized Clinical Trial. Physical Therapy. 2007 April;87(4):431-440.
Dunning JR, Cleland JA, Waldrop MA, Arnot C, Young I, Turner M, & Sigurdsson G. (2010). Upper Cervical and Upper Thoracic Thrust Manipulation vs Non-Thrust Mobilization in Patients with Mechanical Neck Pain: A Randomized Controlled Trial. Journal of Manual & Manipulative Therapy. 2010 December;18(4):175-180.
Puentedura EJ, Cleland JA, Landers MR, Mintken P, Louw A, & Fernandez-de-las-penas C. (2012). Development of a Clinical Prediction Rule to Identify Patients with Neck Pain Likely to Benefit from Thrust Joint Manipulation to the Cervical Spine. JOSPT. 2012 July;42(7):577-592.
Puentedura EJ, Landers MR, Cleland JA, Mintken P, Huijbregts P, & Fernandez-de-las-penas C. (2011). Thoracic Spine Thrust Manipulation Versus Cervical Spine Thrust Manipulation in Patients with Acute Neck Pain: A Randomized Clinical Trial. JOSPT. 2011 April;41(4).
James Heafner PT, DPT, OCS:
Owner and lead physical therapist at Heafner Health, cash-based physical therapy in Boulder, CO. Areas of expertise include orthopedic and manual therapy, functional movement, pain science, and movement science.
In May 2013, I earned my Doctorate in Physical Therapy from Saint Louis University. After graduating from the Harris Health Systems Orthopedic Residency in October 2014, I moved to Boulder, CO. Since living in Boulder, I have started my own cash-based PT practice, earned my OCS certification, and teach for the OPTIM Fellowship and COMT program in Houston TX and Scottsdale, AZ.
Chris Fox PT, DPT, OCS: Physical therapist at Foothills Sports Medicine & Physical Therapy in Scottsdale, AZ and regularly lectures at the Phoenix Campus for NAU's DPT program and for Optim Manual Therapy's COMT program. Completed multiple advanced manual therapy courses implementing aspects of biomechanical analysis. He received his DPT from Saint Louis University in 2013. Completed Scottsdale Healthcare's Orthopaedic Residency (now Honor Health) in July 2014. He became a Board Certified Orthopaedic Specialist in 2015. Level I Expert in FMS and SFMA , Kinetacore FDN Level 1 certification, and IASTM Technique course completion. He would like to pursue further education in McKenzie Technique, Dry Needling, Strength & Conditioning, Orthopaedic and Manual Therapy.
Brian Schwabe PT, DPT, SCS, CSCS:
- Board Certified Sports Physical Therapist (SCS) at Elite OrthoSport in Santa Monica, CA which specializes in treating collegiate/professional athletes and clientele from the Beverly Hills, Hollywood, and Santa Monica areas.
- USC Sports Residency Trained Physical Therapist (<1% of all PT's residency trained)
- DPT from Saint Louis University
- Future plans/interest include:
1. USAW, SFMA & Catapult Systems technology for NBA teams
2. Pursuing a position as a sports physical therapist &/or Strength coach for a Division 1 athletic medicine department or professional sport team.
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