Thoracic Spine Interventions

Objectives

• Ability to perform thoracic spine joint mobilizations is important
• Ability to perform high-velocity, low-amplitude thrust manipulations of the thoracic spine is key
• Coaching exercise interventions for the thoracic spine is also part of the objectives

Thoracic Spine Interventions Overview

• The interventions include: thoracic mobilization, HVLAT manipulation, and exercise

Mobilization Overview

• Indications for mobilization include pain modulation, hypomobility, and limited ROM
• Seated mobilization techniques are Lateral glide and PA – extension
• Prone mobilization techniques are CPA and UPA
• First Rib Mobilization also is an intervention

Seated Lateral Glide

• Conduct the seated lateral glide with the patient sitting, legs straddling plinth, all the way to the edge
• The therapist stands on the ipsilateral side
• An example is to work the right side to improve right sidebending
• Reach over the ipsilateral shoulder and across the chest to the opposite scapula
• Contact with mobilizing hand should be on the ipsilateral side of the spinous process
• Force is lateral through the mobilizing hand and into sidebend through the ipsilateral shoulder

Seated Central PA

• Therapy takes place while the patient is seated in chair, and the therapist stands to the side, with another chair or plinth in front of the patient
• The patient crosses arms, then places their forehead on their forearms
• Arms should rest arms on therapist's leg
• Contact is applied to the spinous process with hypothenar eminence, applying force anteriorly

Prone Central PA

• Performed with the same set up as CPA assessment
• Use contact through hypothenar eminence or "peace sign" for pressure
• Force is applied directly anterior

Prone Unilateral PA

• Set up should be the same as UPA assessement
• Apply pressure using either dummy thumb or hyopthenar eminence
• Apply force directly anterior

1st Rib Inferior Mobilization

• The patient is seated while the therapist stands behind
• The therapist contacts the contralateral side of the head and face with the forearm
• Induce slight ipsilateral lateral flexion to reduce soft tissue tension
• Place the lateral aspect of the 2nd MCP of the mobilizing hand is placed just anterior to the upper trapezius
• Drag the upper trapezius backward and apply a downward force through the 1st rib toward the opposite hip

Manipulation Techniques Overview

• Pain modulation, hypomobility, and limited ROM are all indications
• Contraindications are osteoporosis and fracture
• Manipulation can be performed Prone, supine or seated

Prone HVLAT Manipulation

• The patient lies prone as the therapist stans to the side facing perpendicular the patient
• Set the bed height to knee level or lower
• Contact facet joint on each side with hypothenar eminence
• Fingers should be pointing in opposite directions
• Take up skin slack and shear hands in opposite directions
• Elbows locked, sink down to take up joint slack
• Apply rapid force directly anterior
• Best for mid-thoracic

Supine HVLAT manipulation

• The patient should be supine and hugging their chest or rolled towel
• Therapist should stand to one side
• Ensure that the opposite arm is on top
• An example is if the therapist is standing on the right, the patient’s left arm is on top
• Roll the patient to the side and place contact hand by using a firm, flat fist
• Placement should be on the desired level and include the spinous process between fingers and thenar eminence, so the TLJ manip can take place
• Tuck the patient's elbows to your stomach and deliver force directly posterior into the table
• Best for upper thoracic spine but can do mid thoracic as well

Seated HVLAT Manipulation

• The patient is seated and hugging their chest while the therapist stands behind
• A rolled towel may be used between the patient and the provider to help localize forces
• Grab the patient's elbows and apply a rapid posterior and superior force through the patient's arms.
• The patient may come off the table slightly

Exercise Overview

• Indications for exercises include pain modulation, limited ROM, weakness, and endurance deficits
• Includes mobility, motor control/graded exposure, and strengthening

Mobility

• Should include Self soft tissue mobilization/trigger point “release”
• Exercises are bow and arrow, thread the needle, extension, and cat-cow/camel stretch

Motor Control/Graded exposure

• Includes Quadruped Band assisted and resisted rotation; resisted bow and arrow; and banded wall slide with lift off

Strengthening exercises

• Need to focus on Scapulothoracic with exercises like rows, T’s and Y’s, snow angels and the lat pull down

Patient Case Example

• Case Presentation of 43-year-old with mid thoracic pain (T6)
• Patient profile: desk worker that exercises 3 times a week (CrossFit type exercise); limited rotation, extension, lateral flexion; TTP middle trapezius, rhomboids.
• Strong but can be painful when muscle testing; experiences pain at the end of a work day which is relieved by movement and exercise

Patient Care Interventions

• The interventions for included: Thoracic HVLAT manipulation (Prone or Supine); Seated thoracic extension with rolled towel for 10 reps at lower, mid, upper thoracic; side lying bow and arrow stretch 15 reps each side; and Thera-band snow angels 3x8-12 reps with 2-3 reps in reserve
• Retest limited motions after manipulation, then again after mobility exercises