Thoracic Manipulations have received a good amount of attention in the literature in recent years. Whether you are treating a shoulder, cervical spine, or lumbar spine, the thoracic manipulation has been shown to have positive effects on all of these regions. 

The exact science as to why a manipulation is beneficial is not yet understood, but the most recent evidence suggests that it is multi-factorial. Some proposed effects include:
1) Mechanical- breaking up intra-articular lesions
2) Neurological- stimulates mechanoreceptors & "resets" nocioceptive pathways
3) Hydraulic- change the viscosity of synovial fluid
4) Relaxation- decrease in muscle tone & restore normal blood flow
5) Psychological- both laying hands on the patient & hearing a "pop" are strong influences 

Below is a quick video on how to perform the the Thoracic Manipulation in Supine. With the supine technique you are flexing the thoracic spine, which makes it a facet gapping technique. The thoracic manipulation can also be performed in prone and seated positions, which can be utilized based on the patient's restriction and position of comfort.  

As with all manual therapy, it is important to reinforce the treatment with corrective exercises to maintain the positive effects gained from the manual technique.

We are all guilty at one time or another of prescribing a hamstring stretch prematurely. You saw a patient bend forward to touch their toes and they abruptly stop short. This must be their hamstrings stopping their motion! Well unfortunately it is not that simple anymore. Modern literature tells us the reason they cannot touch their toes may be due to an array of possibilities: tight posterior chain muscles, adverse neural tensioning, or poor stability/motor control of the core musculature just to name a few. For the sake of this post we want to address hamstring tightness vs. adverse neural tension. 

To begin this conversation, let's take that same patient above and place him/her in long sitting to reduce the effects of spinal loading. Now, postural demands are less than that in standing. We can focus specifically on muscle tightness vs. neural tension. The patient leans forward to touch their toes, but again nothing changes. We are no closer to finding our solution than we were in standing. Now, we bring the patient into supine, and the therapist performs a passive straight leg raise (PSLR). The patient cannot raise beyond 60 degrees of hip flexion. We still do not know, but we are getting close to the answer. Is it muscle tightness that is stopping this patient at 60 degrees or is the act of passively straightening the leg causing strain on the neural tissues. To answer this question, simply palpate the ASIS as you perform the PSLR. If you notice that hip flexion stops prior to movement at the ASIS, the answer is Neural Tension. If the ASIS begins to move prior to resistance, then hamstring tightness is the answer. 

Since the hamstrings attach to the Ischial Tuberosity, the body will naturally begin to posterior pelvic tilt once all the available range is taken up in the hamstring muscles. This posterior pelvic tilt will cause movement at the ASIS, letting you know the hamstring muscles have reached their end range. If no movement was noted at the ASIS, you can shift your hypothesis towards adverse neural tension. An additional component you can consider is the use of cervical flexion/extension to change the tension of the nerves and thus potentially alter SLR ROM.

Just like any examination test, it is important to cluster your findings with other tests and measures. For example, if you suspect adverse neural tension, perform a SLUMP test as well. Additionally, always check side to side symmetry. 

This study was released in the March 2013 edition of JOSPT. 

Anyone who has worked in a physical therapy clinic understands that neck pain is a very common problem. Researchers estimate that as many as 1 in 4 patients in an outpatient PT clinic are referred for neck pain. This specific study by Masaracchio et al assessed the short-term (1 week follow up) effects of adding thoracic spine thrust manipulation in addition to cervical spine Grade III non-thrust P-A mobilizations. 66 participants were randomly selected to either the experimental or control group. Subjects were excluded if they had symptoms distal to the shoulder, pain for >3 months, or a Neck Disability Index score <20%. The subjects in the experimental group who received both the thoracic spine and cervical spine manual therapy had statistically significant changes in their pain as indicated by decreased scores on the Numeric Pain Rating Scale and significantly lower scores on the Neck Disability Index.

These results add to the body of literature suggesting the benefits of manual therapy in patients with mechanical neck pain. Different theories exist as to why the thoracic spine manipulation group showed greater improvements. First, there is a clear biomechanical link between the C-spine and T-spine. By moving the thoracic spine, the cervical spine pain generators experience decrease stress. Another explanation discusses changes in mechanoreceptor sensitivity when a thoracic spine thrust manipulation is performed. While thoracic spine manipulation may not have high specificity, several studies have demonstrated that "regardless of the manual therapy intervention chosen, individuals experienced a reduction in pain levels following manual therapy interventions."

Some people may argue that this study only assessed patients at 1-week follow up, and it did not investigate long term reductions in pain. With that said, by having the capability to significantly reduce a patients pain in 1-weeks time, you have much more freedom with your intervention selection. Lowering the significance of pain and disability will greatly improve patient satisfaction, patient buy-in, and your ability to prescribe the necessary exercises. To view the full article click here.  

References: 
Masaracchio M, Cleland JA, Hellman M, Hagins M. (2013). Short-Term combined effects of Thoracic spine thrust Manipulation and Cervical spine nonthrust Manipulation in Individuals with Mechanical Neck pan: A Randomized control trial..JOSPT. 2013 March; 43(3): 118-127. Web. 20 September 2013. 

We recently came across this manual therapy resource from OPTIMPT. They have hundreds of manual therapy videos with explanation on why to perform certain techniques. The techniques are performed by fellow trained manual therapists. Enjoy! 

OPTIMPhysTher   

Ankle Dorsiflexion: The What, Why, and How is a recent post from Adam Kelly, ATC at www.eatrunrehabiliate.com.

 I like this post for a number of reasons: First, I recently had an ankle sprain myself and like a true physical therapist, failed to take the necessary and appropriate rehab measures. I am now dealing with the chronic side-effects of an ankles sprain and am constantly working on my ankle ROM and mechanics. Second, Adam does an excellent job reviewing the anatomy, kinesiology, and mechanics of the ankle. He incorporates the importance of assessing the whole lower chain as well identifying proximal and distal impairments in his patients. Third, he presents a case scenario explaining how deficits at the talocrural joint could affect the average person. Finally, Adam references other professional links and videos, allowing the reader to have a much more comprehensive understanding of evaluation and treatment of the ankle. 

Some take home points from the the post:  
1) When a person lacks ankle mobility, you may not see an immediate decline in functional mobility. The human body has an amazing ability to compensate. It is our ability as practitioners to find these subtle substitutions. 
2) When it comes to increasing ankle mobility with manual interventions, a multi-faceted approach is important. We must be dynamic during our treatment sessions. What is successful for one patient may not be appropriate for another patient with similar impairments.
3) Do not forget the above and below. Regional interdependence is so important. As competent clinicians, evaluating tibial torsions, hip mechanics, and mobility of the rearfoot and midfoot must all be considered as contributing impairments. 

Thanks for the post Adam! 

-Jim 

After reading these articles, it would appear that, while there are many hypotheses to the changes in shoulder impairments following thoracic spine manipulation, we still are uncertain about the mechanism. Strunce et al looked at the effect of thoracic and rib manipulations had on shoulder pain in general. The authors found both an increase in shoulder ROM and a decrease in pain. This study, like many others related to this topic, had several methodological errors. There was no blinding, randomization, or control. That doesn't mean the results of this study should be disregarded. It at least should bring the idea of regional interdependence to consideration in your differential diagnosis. Walser et al performed a systematic review for the effect of thoracic manipulations on various musculoskeletal conditions. The authors reported that significant differences were found between those who had a thoracic manipulation and those who did not, in the short-term. In the long-term, there was no difference.

Scapular upward rotation is one of the usual suspects in regards to causes of subacromial impingement and rotator cuff tendinopathy. Interestingly, the literature varies on findings of decreased upward rotation to increased upward rotation in these patients (Muth et al, 2012). This study found that thoracic manipulation resulted in minimal decreases in scapular upward rotation, along with little to no change in EMG activity of the shoulder musculature. On the other hand, t-spine manipulation was found to increase shoulder elevation force production and improve both level of function and pain. While no change in shoulder elevation ROM was found, this may have been due to the fact that ROM was measured with weighted glenohumeral elevation. Strunce et al, however, did find an increase in glenohumeral motion following thoracic manipulation.

Boyles et al performed an exploratory study on the effects of a single thoracic spine manipulation on subacromial impingement syndrome. While no additional treatment was performed, the authors were able to find statistically significant changes in both pain and disability scores in just 48 hours; however, these results were not found to be clinically significant, based on the established minimal change for clinical significance. The methods of this study were lacking in several areas: low participant number, no randomization, no control group, and more. The authors realized this and emphasized the fact that this study should be used as a launching point for further studies. The fact that significant changes were created after one treatment alone in just 48 hours suggests the potential for a component of care in dealing with patient suffering from subacromial impingement syndrome. Just as manual therapy + exercise was found to be greater than exercise alone for cervical pain, maybe the same applies to these conditions. Additionally, when using thoracic manipulations for cervical pain or lumbar manipulations for low back pain, there exists specific inclusion criteria in order to have the desired results. Again, maybe the same applies to thoracic manipulation for subacromial impingement (or other should pathologies) and we just need to discover the criteria. Sounds like a perfect research opportunity! Obviously, solid evidence on this topic is still lacking, but we hope that this research has at least opened your mind to the possibility of regional interdependence in your patients and maybe treating either the cervical or thoracic spine (or both) the next time you have a patient with a shoulder pathology.

References:
Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moore JH, Koppenhaver SL, Wainner RS. (2009). The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther. 2009 Aug;14(4):375-80. Web. 15 May 2013.

Muth S, Barbe MF, Lauer R, McClure PW. (2012). The effects of thoracic spine manipulation in subjects with signs of rotator cuff tendinopathy. J Orthop Sports Phys Ther. 2012 Dec;42(12):1005-16. Web. 15 May 2013.

Strunce JB, Walker MJ, Boyles RE, Young BA. (2009). The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. J Man Manip Ther. 2009;17(4):230-6. Web. 15 May 2013.

Walser RF, Meserve BB, Boucher TR. (2009). The effectiveness of thoracic spine manipulation for the management of musculoskeletal conditions: a systematic review and meta-analysis of randomized clinical trials. J Man Manip Ther. 2009;17(4):237-46. Web. 15 May 2013.

"What IASTM is, is not, and might be"  is a recent post by Leonard van Gelder via his Dynamic Principles Blog. In this post, he discusses his usage of the EDGE Tool, why he uses it and the controversy surrounding using different instruments in his treatment sessions. First off, it is important to note that there is not a great deal of evidence surrounding IASTM. While major IASTM companies report high levels success, the amount of published articles does not directly correlate with these claims. 

A few of these reported health benefits include regarding IASTM: 
1. Activating the histamine response and triggering localized tissue inflammation
2. Scar Tissue (Type III Collagen) breakdown and "realigning fibers"
                                     3. Promoting collagen synthesis by promoting fibroblast proliferation

Of those reported benefits (above), increasing fibroblast proliferation is the only property that has been consistently demonstrated through various research articles. With that said, the current studies have mainly been performed on rat MCL's with little evidence supporting long term differences in collagen synthesis whether or not IASTM was used. 

In conclusion, it is important to remember that regular mobility of an affected area helps increase lubrication and maintains critical fiber distance. Whether it be from hands on techniques or the use of an instrument, it is important to keep structures mobile. As Goodman and Fuller state, "Immobilization is associated with excessive deposition of connective tissue in associated areas. This is accompanied by a loss of water and subsequent dehydration. The result is an increase in intermolecular cross-linking, which further restricts normal connective tissue flexibility and extensibility." When using Graston tools, the back edge of spoon, or the EDGE Tool, one must remember their intent behind treating with an instrument. In other words, what are you really trying to change or modify? The body of knowledge surrounding IASTM is limited, but being informed about what it is and maybe is a step in the right direction. 

References:
Goodman C, Fuller K. Pathology: Implications for the Physical Therapist. 3rd Edition. St. Louis: Saunders 
     Elsevier, 2009. Print.

Can't get enough ortho? Well, the audio recordings from the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) conference in Canada this year were made available (for free!) to all a couple months ago. These lectures were provided by some of the leading Ortho PTs and contain information from a wide variety of topics. Some of this material provides the latest research and topics that aren't even being presented in school yet. These could be great for listening to during long car rides during your upcoming summer break. We've only listened to a few thus far, but definitely check out the Keynote Speakers!

A 2013 Cochrane review was recently published regarding the effects of Spinal Manipulative Therapy (SMT) for acute low back pain. The review identified 20 randomized control trials with inclusion criteria being adults 18 or older with a mean duration of low back pain of six weeks or less & participants with or without radiating pain. In general the review found that SMT for the outcomes of pain and functional status had low to very low quality evidence. This suggests that there is no difference when treating a patient with SMT vs. another intervention. The conclusion stated that "SMT is no more effective for acute low back pain than inert interventions, sham SMT, or as adjunct therapy. SMT also seems to be no better than other recommended therapies." 

For someone who is entering an Orthopaedic Residency with a strong emphasis in manual therapy, this information was astounding. I have seen the short and long term benefits of manipulation and mobilization first-hand in the clinic. How could the evidence be so contradictory? When discussing this article with an OCS/ fellow trained manual therapist, he had the following comments to make: 

"This review like many others on manipulative therapy have similar pitfalls:
Operational definitions- Spinal manipulative therapy (SMT) includes every hands on intervention: thrust, non-thrust, mobs, etc. I thinking it would make for a more valid study to really try and separate the types of therapies out. Apples and oranges in my book.
SMT alone- we have known that SMT without exercise for low back and neck pain provides very minimal effect. Let’s move on from the thinking that SMT is a panacea and look at what actually happens in the clinic.
Minimal subgrouping of patients- classification of patients is vital. Any physical therapist can perform SMT, regardless of training or expertise.  Whether the patients are sub-grouped based off of a CPR, patient preference, or therapist experience/critical thinking, not all patients will respond from treatment types the same. After all LBP is a symptom and not a diagnosis.
Multiple low quality studies- there is still a void in the literature. Minimal high quality articles regarding SMT are performed by PT’s using the above qualifiers. Therefore, most RCT’s are really just comparing a bunch of low quality research and finding the same conclusions.
This study is helpful in that it adds to the body of literature. However, I don’t think it is clinically useful, because it does not adequately describe practice patterns. Humans are extremely complex and manual therapy will only be THE answer in a small subgroup of patients. Everyone else needs a uniquely tailored solution based on the biopsychosocial state, fitness level, and impairments."

I found all of these points to be true. Additionally, it allowed me to realize that I too often skim to the conclusion and results section of an article without fully interpreting the research process that goes into finding these results. Understanding the operational definitions and the quality of studies that were researched will alter the authors conclusive points and change your ability to translate this information into a practical clinical setting. The biggest battle which stands between us and our research is the complexity of the human being. We are all so unique. While 2 patients may present the same impairments, there are a myriad number of factors that will go into how they respond to your treatment session.  

Reference:
Rubinstein S, et al. "Spinal Manipulative Therapy for Acute Low Back Pain: An Update of the Cochrane Review." SPINE. 2013; 38.3: E158-E177.