Thoracic Spine Interventions: Mobilization and Exercise

Thoracic Spine Interventions Objectives

• Goals are to understand techniques, demonstrate the ability to perform thoracic spine joint mobilizations, high-velocity, low-amplitude thrust manipulations, and coach exercise interventions for the thoracic spine.

Overview of Interventions

• Includes thoracic mobilization, HVLAT manipulation, and exercises.
• Thoracic exercises can address mobility, motor control/graded exposure and strengthening.

Thoracic Mobilization

• Indications include pain modulation, hypomobility, and limited ROM.
• Mobilization can be performed with the patient seated or prone.
• Seated mobilization includes lateral glide and PA extension techniques.
• Prone mobilization includes CPA and UPA techniques.
• Included is 1st rib mobilization.

Seated Lateral Glide Mobilization

• The patient is seated with legs straddling the plinth, all the way to the edge
• The therapist stands on the ipsilateral side
• For example, perform on the patient's right side to improve right sidebending
• Reach over ipsilateral shoulder and across the chest to the opposite scapula
• Contact is made with the mobilizing hand on the ipsilateral side of the spinous process
• A lateral force is applied through the mobilizing hand and into sidebend through the ipsilateral shoulder.

Seated Central PA Mobilization

• Patient seated in a chair, therapist standing to the side with another chair or plinth in front.
• Patient crosses arms and places forehead on forearms, rests on the therapist's leg
• Contact is made on the spinous process with the hypothenar eminence.
• Force is applied anteriorly with additional extension provided through the opposite arm.

Prone Central PA Mobilization

• The setup mirrors a CPA assessment.
• Contact is made through the hypothenar eminence or with a "peace sign" hand position.
• Force is directed anteriorly.

Prone Unilateral PA Mobilization

• Setup is the same as a UPA assessment.
• Use either dummy thumb or hypothenar eminence for contact.
• The force is directed anteriorly.

1st Rib Inferior Mobilization

• Patient seated, and the therapist stands behind.
• The therapist’s forearm contacts the contralateral side of the patient’s head/face, inducing slight ipsilateral lateral flexion to reduce soft tissue tension.
• 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.

Thoracic HVLAT Manipulation

• Indications include pain modulation, hypomobility, and limited ROM.
• Contraindications include osteoporosis and fracture.
• Can be performed with the patient prone, supine, or seated.

Prone HVLAT Manipulation

• Patient is prone and the therapist stands to the side facing perpendicularly to the patient.
• Bed height is knee level or lower.
• Contact the facet joint on each side with the hypothenar eminence, with fingers pointing in opposite directions.
• Take up skin slack by shearing hands in opposite directions, lock elbows, and sink down to take up joint slack.
• Apply a rapid force directly anterior.
• Best for mid-thoracic.

Supine HVLAT Manipulation

• Patient is supine, hugging their chest or a rolled towel, with the therapist to one side.
• Ensure the opposite arm is on top (e.g., you're standing on the patient's right and their left arm is on top)
• Roll the patient to the side and place the contact hand on the desired level using a firm, flat fist.
• Place the spinous process between fingers and thenar eminence (TLJ manip).
• Tuck the patient's elbows to your stomach and deliver force directly posterior into the table.
• Best for the upper thoracic spine, but can target the mid-thoracic area as well.

Seated HVLAT Manipulation

• Patient is seated and hugging their chest. The therapist stands behind.
• Use a rolled towel between you and the patient to 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.

Thoracic Exercise

• Indications include pain modulation, limited ROM, weakness, and endurance deficits.
• Categories include mobility, motor control/graded exposure, and strengthening.

Exercise for Mobility

• Self soft tissue mobilization/trigger point "release."
• Includes bow and arrow, thread the needle, extension, and Cat-Cow/Camel stretch exercises.

Exercise for Motor Control/Graded Exposure

• Exercises include quadruped band-assisted and resisted rotation, resisted bow and arrow, and banded wall slide with lift off.

Exercises for Strengthening

• Exercises include scapulothoracic rows
• Exercises include Ts and Ys
• Exercises include snow angels
• Exercises include lat pull downs

Patient Case Example

• A 43-year-old presenting with mid-thoracic pain (T6).
• The patient is a desk worker, but exercises three times per week with CrossFit-type exercises.
• Limited rotation, extension, and lateral flexion.
• Tender to palpation(TTP) of the middle trapezius and rhomboids.
• Strong but painful muscle testing.
• Experiences pain at the end of the workday, which is relieved by movement and exercise.

Interventions for Patient Case

• Thoracic HVLAT manipulation in prone or supine position.
• Seated thoracic extension with a rolled towel, 10 reps at lower, mid, and upper thoracic levels.
• Side-lying bow and arrow stretch, 15 reps each side.
• Thera-band snow angels, 3 sets of 8-12 reps with 2-3 reps in reserve.
• Retest limited motions after manipulation and again after mobility exercises.