Thoracic Manipulation for Neck Pain CPR

With the progression of evidence-based practice, much of the research that is being performed is looking to determine what treatment techniques are most effective for a variety of injuries. Included in that research is the development of clinical prediction rules (CPR's), which are used to take various exam findings and cluster them to determine more effective treatment measures. The below findings for individuals with neck pain were initially found to have significant benefit from thoracic manipulations (Cleland et al, 2007):

-Symptoms < 30 days
-No symptoms distal to the shoulders
-Looking up does not aggravate symptoms
-FABQ Physical Activity Scale < 12
-Diminished upper thoracic kyphosis
-Cervical extension ROM < 30 deg

​-3 positive = +LR of 5.5
​-4 positive = +LR of 12
​-5-6 positive = +LR of > 12

There is an extensive process for developing a CPR that has true utilization and application. After a CPR has been proposed, it must go through a validation procedure. When reviewed, this CPR was unable to be validated (Cleland et al, 2010); however, those in the manipulation group were still found to have improved short- and long-term disability. Just because it didn't have the other original intended effects, doesn't mean it may not have a use.

​Whether thinking about the thoracic spine in an anatomical sense or a neurophysiological one, manipulating the region can be incredibly useful. The T6-7 area has been shown to be a tension point as the vertebral canal is relatively narrow compared to the spinal cord here. Additionally, there is little movement in the spinal core here relative to the adjacent structures. These restrictions can affect nerve irritability and function. With manipulation and mobilization, the biomechanical aspect of nerve mobility can theoretically improve or it may simply be stimulating the nervous system in a novel way (or it may be purely psychological). Either way, manipulating the thoracic spine can be beneficial for many injuries. It's definitely a skill worth practicing and implementing!

​-Dr. Chris Fox, PT, DPT, OCS

​References:
Cleland JA, Childs JD, Fritz JM, Whitman JM, Eberhart SL. "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." Phys Ther. 2007 Jan. Web. 08/18/2012.

Cleland JA, Mintken PE, Carpenter K, Fritz JM, Glynn P, Whitman J, Childs JD. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a general cervical range of motion exercise: multi-center randomized clinical trial.
Phys Ther. 2010 Sep;90(9):1239-50.

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