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Picture

Another Reason for Using Thoracic Manipulation with Cervical Dysfunction

1/12/2015

11 Comments

 
Picture
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.

-Chris

References:

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).
11 Comments
Alfred
1/12/2015 01:29:20 am

Completely agree! I just took an SMFA course too, they emphasize especially that thoracic spine mobilization trumps cervical and lumbar mobilizations. Is there clear evidence why? Other than the fact that joints seem to alternate through the body - shoulder mobile, elbow stable, hand mobile, etc.

Reply
Chris link
1/13/2015 11:31:57 am

Hi Alfred,

The SFMA is an excellent source for picking up contributing dysfunctions. The research says that cervical mobilization is greater for cervical dysfunction, but thoracic treatment can enhance your treatment to the c-spine or possibly allow you to do something you otherwise wouldn't be able to treat.

Reply
Rebecca
1/12/2015 06:46:42 am

Great post. I am a new PT and have had chronic headaches for upwards of 5 years of which no doctor could give an explanation or any advice that helped decrease the frequency or intensity of my headaches. Finally, during PT school, I realized it was like due to musculoskeletal impairments, both thoracic and cervical. Since it's impossible to do manual work on your own neck, I saw a PT for the manual aspect of my therapy program. Although she noted areas where cervical manipulations would be beneficial, she was able to achieve great results with thoracic manipulations/mobilizations, cervical mobilizations, and neck musculature strengthening and proprioceptive training.

Reply
Chris link
1/13/2015 11:33:16 am

Hi Rebecca,

Thanks for your comment! Glad to hear you were able to find some successful treatment after those 5 years. You make an excellent point that manual therapy alone is not the answer. It is essential to include exercise and education components as well.

Reply
Vince
1/13/2015 09:11:54 am

Great post on Tspine manipulations for cervical benefit. I also find that I do not adjust the cervical spine in that really acute phase as there is so much inflammation and protective muscle guarding. Acute necks really respond well to MET.

Vince

Reply
Chris link
1/13/2015 11:34:58 am

Hi Vince,

You make a great point. People cannot always tolerate (nor is just anyone appropriate) cervical manipulations/mobilizations. There are many ways to get the job done. It is here where we must assess our patient's end-range and level of irritation to determine the appropriate course of action.

Reply
Steve
1/19/2015 11:08:17 am

The clinical prediction rule you reference has been show NOT to be valid, so I would not, nor does Cleland, advise using it.
Puentedura has a curious design. He manips a specific cervical segment after proper assessment, yet when he treats the thoracic spine, he does a very general nonskilled manipulation.
The design should use appropriate specific assessment and treatment techniques. IMO. Why do one and not the other. I would look hard at that research before accepting the conclusions.

Reply
Chris link
1/19/2015 11:26:48 pm

Hi Steve,

Thanks for your comments on the updated status on that CPR. Regardless of the lack of validation, in clinical practice, I have seen significant reductions in neck pain using a thoracic manipulation and there are studies that support that as well. Just because the CPR was not validated does not mean we should throw thoracic manips out the window for patients with neck pain. Some will still benefit from it. Hopefully in the future a better CPR will be developed. In regards to the development of the study by Puentedura, there have been studies that have shown we cannot be specific with our manipulations anyway. Many manual therapists will disagree with this of course. There is significant debate about why a manipulation to the thoracic spine (or anywhere) has the effects that it does. Remember, don't get hung up on what the evidence says or doesn't say. It's often 10 years behind clinical practice.

-Chris

Reply
Steve
1/20/2015 03:52:17 am

1. I agree on the evidence. I was making a point about an invalid CPR being used in the study. Affects the N.
2. Agree on the inability to agree on specificity. I would suggest that RCT's that assess and compare specific and general manips may tell is it matters. Why LP did a specific cervical and nonspecific thoracic with an invalid CPR makes me give less consideration to the results. The design, IMO, has flaws. Not saying its not good research, but this is one where you have to consider the methods!
Thank You.

Steve
1/19/2015 11:10:11 am

You say: "While cervical manipulations have been shown to be more effective than thoracic manipulations for those with neck pain..." Care to reference this? More effective how? Pain, ROM, outcomes....????

Reply
Chris link
1/19/2015 11:21:01 pm

Hi Steve,

The last study in my references is the study that determined this. Here is the link below reference below as well:

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)

-Chris

Reply



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