Another Reason for Using Thoracic Manipulation with Cervical Dysfunction

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

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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).