Should We Be Performing Thoracic Manipulation for Shoulder Pain?

There is belief among the manual therapy-trained that thoracic manipulation may be beneficial for almost any condition due to its effect on the nervous system. With the nervous system being connected from head to toe physically and the input to the central system, a manipulation to the thoracic spine may potentially impact the patient peripherally and/or centrally. Take any individual and measure their SLR ROM. Perform a thoracic manipulation and then remeasure the SLR mobility. Often, you will see a change that appears like we are facilitating.

There have been many studies showing that thoracic manipulation does not show any difference between sham manipulation in improving shoulder pain and muscle activation (Bizzarri et al, 2018 & Grimes et al, 2019). Studies like these contribute to the heavy anti-manual therapy rhetoric by some practitioners and academians. However, can/should we ignore the fact that we can get some sore of change in something like SLR mobility with the technique? Maybe we should consider that the manual contact or verbiage we use in the sham manipulation to get the change as there is no difference compared to thoracic manipulation. 

While some are completely against incorporating manual therapy in treatment and others are heavy manual therapy-biased, I try to fall somewhere in the middle. It's clear that manipulation doesn't have the biomechanical effect we once thought it had. However, it is not clear that manual therapy, placebo or not, doesn't have some sort of impact on the nervous system. The contact of the hand is still an input to the system. It would appear that further research is needed to determine what exactly that impact is.

​-Dr. Fox, PT, DPT, OCS

References:
Bizzarri P1, Buzzatti L2, Cattrysse E3, Scafoglieri A4.  Thoracic manual therapy is not more effective than placebo thoracic manual therapy in patients with shoulder dysfunctions: A systematic review with meta-analysis.  Musculoskelet Sci Pract. 2018 Feb;33:1-10.

Grimes JK1,2, Puentedura E2,3, Cheng MS2, Seitz AL4. The Comparative Effects of Upper Thoracic Spine Thrust Manipulation Techniques in Individuals With Subacromial Pain Syndrome: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2019 Mar 12:1-28.

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