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Joint manipulations for the thoracic spine. Types of manipulations, manipulations vs. mobilizations of the spine and thoracic spine. Optimal intervention for cervical pain, CTJ, shoulder pain, TMJ, elbow pain, thoracic spine pain, forward head, arms fall, scapula elevates, and epicondylitis (epicondylalgia). The risk of adverse events, accuracy vs sensitivity, screening, reliability, and validity of thoracic spine manips. 

Joint Manipulation: Thoracic Spine

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Integrated Manual Therapist

This course describes joint manipulation techniques for the thoracic spine (mid and upper back manipulation). Various synonyms and definitions have been used to describe the term "manipulation". The Brookbush Institute uses one conventional definition of the term "manipulations;" implying low-amplitude (relatively small motions), high-velocity (quick) techniques, intended to target and reduce the stiffness of specific joints or segments, that exhibit a decrease in passive accessory range of motion (a.k.a. stiffness during arthrokinematic motion and specifically glide or slide). Research does imply that manipulations likely affect multiple joints simultaneously; however, the Brookbush Institute asserts that efforts to target the stiffest joints or segments will increase the likelihood that the stiffest segments are included in the "multiple joints" affected.

The Brookbush Institute has carefully selected manipulation techniques with the intent to increase the probability of practitioner success. That is, techniques have been chosen that are relatively easy to teach, reliably improve outcomes, and are the most commonly used. The Brookbush Institute does not wish to assert that these manipulation techniques are the only techniques that are effective, and/or that these are the best techniques for every outcome measure. It is possible that a highly complex, and/or advanced technique, may result in better outcomes, or that a particular pathology is better addressed with a relatively rarely used technique.

Note, that the term "mobilization" is reserved for low-velocity techniques that are taught in a separate set of courses.

This course includes manipulation techniques that intend to reduce excessive stiffness of the thoracic spine (and cervicothoracic junction), improve spine range of motion (ROM), improve mobility of the rib cage, and potentially reduce scapular dyskinesis (altered shoulder blade motion) and upper extremity dysfunction. For example, research has demonstrated a correlation between thoracic kyphosis, excessive anterior tipping of the scapula, and shoulder impingement syndrome (SIS), and the addition of thoracic manipulations have resulted in improved short-term and long-term outcomes for SIS patients. These techniques may also be used in an integrated approach for cervicothoracic dysfunction and 

 including cervicogenic headache, shoulder instability, lateral epicondylitis (tennis elbow), chronic thoracic pain, T4 syndrome, chronic neck pain, and acromioclavicular dysfunction. Additionally, thoracic manipulations may be beneficial for individuals exhibiting postural dysfunctions including rounded shoulder posture, forward head posture, thoracic kyphosis, or an anterior pelvic tilt.

The techniques in this course are recommended for all clinical human movement professionals (physical therapists, physical therapy assistants, athletic trainers, massage therapists, chiropractors, occupational therapists, etc.) to develop an evidence-based, systematic, integrated, patient-centered, patient-centered, and outcome-driven approach.

Sample Intervention (Cervicothoracic Junction Pain)

Joint Manipulation: Lumbar Spine, Sacroiliac Joint, and Pubic Symphysis

Joint Manipulation: Elbow (Radial Head) and Wrist

Joint Manipulation: Ankle, Midfoot, and Tibiofibular Joint

For an introduction to joint mobilizations and manipulations:

Joint Mobilization and Manipulation: Introduction

Joint Mobilization and Manipulation: Reliability

Joint Mobilizations and Manipulations: Effects

Joint Mobilization and Manipulation: Risk of Adverse Effects

Joint Mobilizations and Manipulations: Evidence-based Teaching and Learning

Course Description: Thoracic Spine Manipulation

Note: Gross movement exams may be beneficial for identifying asymmetry, significant restriction, and pain with movement; however, cervical rotation, flexion, and extension are not reliable goniometric assessments.

Although shoulder flexion and external rotation are not a measure of cervical/thoracic spine motion, optimal thoracic mobility is needed to achieve optimal 

 motion, which is necessary to achieve optimal 

 mobility - assuming the patient/client does not exhibit signs of shoulder hyper-mobility. Although measuring 

 ROM is not a direct measure of thoracic mobility, goniometry of the cervical spine, thoracic spine and scapula is not reliable.

: Weak or With Compensation (cervical protraction)

: Weak or With Compensation (scapular protraction or elevation)

Introduction

 Studies suggest that thoracic manipulation alone may have a positive effect on cervical pain, ROM, 

, and disability, especially when cervical dysfunction includes limited ROM, low to moderate levels of pain, and thoracic hypomobility.

Further studies demonstrate that integrating thoracic manipulation with cervical manipulation, massage, exercise, and other conventional modalities is likely to result in superior outcomes.

Cervicothoracic junction (CTJ) manipulation:

 may have a therapeutic effect on dysfunctions of the 

, may have beneficial analgesic effects for elbow lateral epicondylalgia, but likely has no direct effect on temporomandibular joint (TMJ) dysfunction.

 Preliminary studies imply thoracic manipulation may be an effective adjunct treatment for thoracic or lumbar spine pain; however, it is likely manipulation will be more beneficial when symptoms have been consistent for longer than 2 weeks and thoracic stiffness is suspected.

 - Thoracic spine mobility and shoulder function are correlated; however, the effect of thoracic manipulation alone on thoracic spine and scapular kinematics may be relatively small compared to improvements in shoulder pain, ROM and function in shoulder pain patients.

Research suggests that the combination of thoracic manipulation(s) and exercise for the treatment of shoulder pain results in superior outcomes when compared to manipulation or exercise alone. Further, injections and/or NSAIDs may be beneficial early on, however, the addition of thoracic manipulation or thoracic manipulation and physical therapy may be necessary to achieve long-term success.

 Studies imply that patients exhibiting symptoms of lateral epicondylalgia also commonly have cervical/thoracic dysfunction; further, thoracic manipulation may only improve elbow dysfunction when cervical/thoracic dysfunction is also present.

 Studies have suggested that thoracic manipulation is more beneficial than acupuncture, physician care, and self-directed exercise in both the short-term and long-term, and more effective than conventional physiotherapy in the short-term.

 Whether integrated with heat, electrotherapy, infrared radiation (IRR) therapy, exercise, injections, NSAIDS, educational materials, or physician care, research ubiquitously supports the addition of manipulation, demonstrating superior outcomes both short-term and long-term.

 Studies imply that the longer duration impulse of mobilizations has a larger effect on pain pressure threshold, the high velocity and high force of manipulations have a larger effect on EMG activity pain and fear-avoidance behavior, and both techniques have similar effects on ROM. Further, manipulations appear to have a larger effect in the short-term; however, the long-term effects of manipulation and mobilization are similar.

 Studies suggest that supine and prone thoracic manipulation (like taught in this course) may be more effective than sitting variations, direction specificity may not matter, and sing pull on the skin to "hook" spinous process likely does not matter.

 - These studies suggest that the thoracic spine is likely the least vulnerable spinal segment, that injury rates are incredibly low; however, manual practitioners should be aware of complications resulting from intradural hematoma.

 - Studies suggest that the analgesic effects of thoracic manipulation may be specific to inhibition of neuromodulators related to symptoms of dysfunction. That is, the analgesic reflexes, perhaps supraspinal, may only be capable of inhibiting specific afferent information associated with the pain experience that results from injury and dysfunction.

 The mixed sympathoexcitatory response following thoracic manipulation suggests that the effects are either small and not easily detected, do not occur in all individuals (e.g. only occurs in symptomatic individuals), or are the result of factors other than the thoracic manipulation (apprehension, physical contact, thoracic pressure).

Note: Cervical manipulations have a significant effect on sympathoexcitatory outcomes measures, and one study compared cervical and thoracic manipulations confirming cervical manipulation has a large effect and thoracic manipulation do not.

 Thoracic manipulation may reduce cortisol levels and testosterone/cortisol ratio, elevate neutrophils density, and increase circulating substance P. Thoracic manipulation does not have an effect on epinephrine or norepinephrine.

 Studies suggest that the largest decreases in 

 activity can be expected following high-velocity thoracic manipulation in individuals experiencing relatively constant symptoms. Further, thoracic manipulation may affect both proximal and relatively distal musculature, resulting in changes that normalize the altered muscle activity associated with dysfunction.

 Early studies suggest that thoracic manipulation may reduce thoracic cage stiffness, but likely only has an impact on pulmonary function when pulmonary function is impaired. Research investigating the effect on cardiovascular and sports performance is recommended.

Research Summary

Cervical Pain and Dysfunction

Cervicothoracic Junction (CTJ) Manipulation:

Shoulder Pain and Dysfunction

Research Corner: Cervical Spine

Temperomandibular Joint (TMJ) and Thoracic Manipulation

Thoracic Spine Manipulation and the Elbow

Thoracic Spine Pain

Comparing Thoracic Manipulation to Other Modalities:

Thoracic Manipulation in Combination with Other Modalities:

Comparing Thoracic Manipulation Techniques

Research Corner: Thoracic Spine

Several studies have compared high-velocity (thrust) manipulations to low-velocity (non-thrust) mobilizations. An RCT by Cleland et al demonstrated that thoracic manipulation had a significantly larger effect than thoracic mobilization on mechanical neck pain immediately after treatment (76). An RCT by Suvarnnato et al. also demonstrated that thoracic manipulation had a larger effect than thoracic mobilization on pain and cervical ROM immediately post-treatment, and during 24-hour follow-up (77). An RCT by Salom-Moreno et al. demonstrated that both thrust manipulation and non-thrust mobilization resulted in widespread analgesic changes in pain pressure threshold; however, again thoracic manipulation resulted in larger effect sizes (78). However, the RCT by Sung et al. mentioned above, demonstrated that thoracic manipulation resulted in larger improvements than mobilizations for fear-avoidance behavior in low back pain patients (127). Hartstein et al. demonstrated that upper limb neurodynamic mobility improved more with manipulation than mobilization; however, there was also a significant interaction between positive perception and effect magnitude (79). This study may suggest that despite the larger effect size normally expected by manipulations, mobilizations may be the better option for patients who fear thoracic manipulations. A multi-centered RCT by Dunning et al. compared mobilization and manipulation for either the thoracic or cervical spine for the treatment of mechanical neck pain, demonstrating that manipulations for either the thoracic or cervical spine resulted in larger improvements (80). Interestingly, tw0 RCTs by Griswold et al. demonstrated no significant difference between mobilization or manipulation for patients with neck pain, including cervical active ROM, 

, numerical pain rating scale, neck disability index scores, the patient-specific functional scale, or the global rating change scale (81, 82). Considering the previously discussed studies, it may be that manipulation has larger short-term effect; however, the long-term effects of manipulation and mobilization are similar. Additional studies may suggest that the mechanism of effect are distinctly different between these two modalities. In an RCT by Fryer et al., thoracic region pain pressure threshold increased more in asymptomatic individuals following thoracic mobilization than manipulation (83). Pagé et al. demonstrated that there was a direct relationship between impulse speed and displacement of neighboring vertebrae (i.e. manipulation resulted in more displacement of neighboring vertebrae than mobilization), and an inverse relationship between impulse length and EMG activity (i.e. manipulations had a larger effect on muscle activity than mobilizations) (84). Supporting these findings in a simpler study, Herzog demonstrated that thoracic manipulation resulted in a reflexive change in EMG activity, while slow velocity mobilizations did not (107). These studies may imply that the longer duration impulse of mobilizations has a larger effect on pain pressure threshold, the high velocity and high force of manipulations have a larger effect on EMG activity, pain, and fear-avoidance behavior, and both techniques have similar effects on ROM. Further, manipulations appear to have a larger effect in the short-term; however, the long-term effects of manipulation and mobilization are similar.

Comparing Mobilizations and Manipulations

The effects of thoracic manipulation include systemic responses that may contribute to, or may occur in addition to the mechanical effects associated with this technique. Some, but not all studies have demonstrated a reflexive reduction in pain (analgesia). A study by Martínez-Segura et al. demonstrated that both cervical and thoracic thrust manipulation resulted in similar changes in pain pressure threshold in individuals with bilateral chronic neck pain (85). Terret et al. demonstrated a significant increase in pain tolerance over the 

 following thoracic manipulation (86). Yang et al. demonstrated that instrument-assisted spinal manipulation resulted in widespread decrease in pain pressure threshold and a decrease in local muscle activity in asymptomatic individuals (126). Bishop et al. demonstrated asymptomatic individuals exhibited a reduction temporal sensory summation following thoracic manipulation, note this outcome measure is different than pain pressure threshold (87). A study by Sparks et al., used functional MRI to compare cerebral activity and pain intensity via a standardized stimulus at the bed of the fingernail pre- and post-thoracic manipulation (88). The study demonstrated that thoracic manipulation resulted in a reduction in cerebral blood flow to areas associated with the pain matrix, including a significant correlation between reduced activation in the insular cortex and decreased subjective pain ratings scale. This study suggests that the analgesia experienced post manipulation is at least in part due to supraspinal mechanisms; however, further research including a control group should be performed to confirm findings. This notion is reinforced when reviewing studies investigating manipulation and pain pressure threshold in asymptomatic individuals. A study by McIver et al. demonstrated that thoracic manipulation did not result in an increase in pain pressure threshold when compared to sham treatment ("laser acupuncture") in asymptomatic individuals (89). An RCT by Jordon et al. demonstrated that thoracic manipulation did not have a significant effect on pain pressure threshold over the 

 or lateral humeral epicondyle in asymptomatic individuals (90). An RCT by de Araujo et al. demonstrated that two different thoracic manipulation techniques did not result in a significant change in heart rate variability or tibialis anterior pain pressure threshold (91). Further, O'Neill et al. demonstrated that thoracic manipulation did not have an effect on experimentally induced (saline injection), deep muscle pain (92). These studies suggest that the analgesic effects may be specific to inhibition of the neuromodulators related to symptoms of dysfunction that have persisted for a period of time, and not inhibition of the pain stimuli arising from new, acute or immediate injury.

There is some evidence of sympathoexcitatory changes resulting from thoracic manipulations; however, most research suggests these findings are either small or inconsistent. An RCT by Minarini et al. demonstrated a small but significant change in heart rate variability following thoracic manipulation of an arbitrarily chosen level in asymptomatic individuals (93). In a controlled, cross-over trial by Budgell et al., it was demonstrated that thoracic manipulation had a significant effect on heart rate variability when compared to a sham procedure (94). Ward et al. small changes in atria and ventricle activity in hypertensive patients post thoracic thrust manipulation that were transient and not clinically relevant (97). In another study, Ward et al. demonstrated that thoracic manipulation had no effect on heart rate variability, pulse ox (oxygen saturation), or blood pressure following thoracic manipulation in young normotensive individuals (95). An RCT by Sampath et al. demonstrated that thoracic manipulations did not have an effect on sympathoexcitatory outcome measures in asymptomatic individuals, including heart rate variability and changes in oxyhemoglobin concentration of the right calf muscle (96). In the RCT by de Araujo et al. mentioned above, two different thoracic manipulation techniques exhibited no significant effect on heart rate variability (91). The mixed findings of these studies suggest that changes in heart rate variability are either small and not easily detected, do not occur in all individuals (e.g. only occurs in symptomatic individuals), or are the result of factors other than the thoracic manipulation (apprehension, physical contact, thoracic pressure, etc.). Further studies have investigated other cardiovascular variables. A pilot RCT by Plaugher et al. demonstrated that 2 months of chiropractic manipulation did not significantly alter resting blood pressure in hypertensive patients (98). da Silva et al. demonstrated that thoracic manipulation did not alter respiratory rate or heart rate more than a placebo manipulation in patients with rotator cuff tendinopathy; however, both manipulation and placebo groups exhibited differences when compared to asymptomatic individuals who exhibited no change in outcome measures (99). Again, the mixed results of these studies suggest that thoracic manipulation may have an effect hypertensive individuals; however, it may also be likely that the small changes in blood pressure are the result of confounding variables like apprehension, touch, etc. Further studies have demonstrated that additional sympathoexcitatory markers are also not affected. Packer et al. demonstrated that thoracic spine manipulation of the T3 vertebral segment did not result in skin surface temperature change in the region manipulated in asymptomatic individuals (100). And, An RCT by Sillevis et al. suggests that thoracic manipulation has no effect on pupil size (an attempt to measure sympathetic response), and did not alter pain pressure threshold in neck pain patients (101). These studies suggest that thoracic manipulations have little if any sympathoexcitatory effect. This is a puzzling finding as research covered in "

" clearly demonstrates that cervical manipulations result in significant sympathoexcitatory effects. It would seem unlikely that these effects are segment specific, and not technique specific; however, one study clearly highlights this counter-intuitive relationship. Welch et al. demonstrated a significant decrease in diastolic pressure and increase in pulse pressure following cervical manipulation, but thoracic manipulation did not have the same effect (102).

Some studies have demonstrated endocrine changes resulting from thoracic manipulations. An RCT by Sampath et al. (mentioned above) demonstrated that despite not having an effect on cardiovascular outcome measures in asymptomatic individuals, thoracic manipulation resulted in a reduction in salivary cortisol, and changes in the testosterone/cortisol ratio for at least 6 hours after intervention (96). Two RCTs by Brennan et al. demonstrated that thoracic manipulation resulted in a burst of blood-born neutrophils primed for enhanced endotoxin-stimulated tumor necrosis factor production, and a significant increase in levels of Substance P (103, 104). And, a study by Puhl et al. demonstrated that thoracic manipulation directed at a hypomobile segment in the upper thoracic spine of asymptomatic subjects did not have a measurable effect on the plasma concentrations of norepinephrine or epinephrine (105). These studies suggest that although sympathoexcitatory changes may not be observed post thoracic manipulation, a significant endocrine response is noted, including a reduction in cortisol, elevation in neutrophils, and elevation in substance P. More research is needed to determine if norepinephrine or epinephrine levels would be altered by thoracic manipulation in symptomatic individuals.

Several studies have demonstrated a change in muscle EMG activity following manipulation. Colloca et al. demonstrated that individuals experiencing constant low back pain exhibited more spinal stiffness, and manipulations resulted in larger decreases in stiffness and 

 activity when compared to those individuals experiencing intermittent low back pain (106). Herzog et al. demonstrated that the timing, intensity, and duration of EMG activity peak change following cervical, thoracic, lumbar, and sacroiliac joint manipulations, matched the changes expected for a reflex response (107). DeVocht et al. demonstrated that spinal manipulation resulted in at least a 25% decrease in resting EMG activity of 24 f 31 sites monitored of the 

 in a group of low back patients (108). Herzog et al. compared thoracic manipulation to 

, noting that reflexive changes in EMG activity only occurred after higher velocity manipulations (109). Similarly, Nougarou et al. demonstrated that the largest changes in mid-thoracic muscle EMG resulted from the largest amount of peak force, suggesting higher velocity manipulations may result in the largest changes (110). These studies suggest that the largest decreases in 

 EMG activity can be expected following the high-velocity thoracic manipulation in individuals experiencing relatively constant symptoms. Further, studies have investigated the effect on other muscles. Sueki et al. demonstrated that mid-thoracic manipulations significantly increased straight leg raise ROM in asymptomatic individuals; however, results were lost by the 1-week follow-up (111). This study may imply that thoracic manipulation can reduce 

 over-activity. Pires et al demonstrated that thoracic manipulation decreased sternocleidomastoid activity during arm elevation immediately post-treatment in women with chronic neck pain (112). Further, Cleland et al. demonstrated short-term increases in 

 strength following thoracic manipulation in asymptomatic individuals (113). These changes in activity suggest that manipulation effects both proximal and relatively distal musculature, and further, that the changes may represent a normalization of activity - a decrease for typically over-active muscles like the 

, and an increase for typically under-active muscles like the 

Several studies were found that suggest thoracic manipulation may have an effect on pulmonary function. A placebo-controlled RCT by Shin et al. demonstrated that forced vital capacity and forced expiratory volume increased after thoracic manipulation in young, healthy individuals (114). An RCT by da Silva et al. demonstrated manipulation of C3 alone, or manipulation of C3 combined with T12 increased maximum inspiratory and expiratory pressure in a group of healthy adults (115). An RCT by Jung et al. demonstrated that thoracic manipulation improved chest wall expansion, but not pulmonary function in healthy individuals (116). And a study by Joo et al. demonstrated that thoracic manipulation improved pulmonary function in stroke patients without a significant improvement in voluntary ventilation or residual volume (117). These studies allude to thoracic manipulation having an effect on thoracic cage stiffness. This results in an improvement in maximal respiratory values in healthy individuals, but not resting pulmonary function. It may be interesting to investigate whether the increase in maximal pulmonary values had an effect on cardiovascular or anaerobic threshold performance. The study by Joo et al. investigating stroke patients demonstrates that a compromised pulmonary system may benefit from any increase in efficiency, and should inspire further research into manual therapy techniques that could be beneficial for this patient population.

Systemic Response

Severe adverse reactions from thoracic manipulation are exceedingly rare but do occur. Rydell et al. searched claims from three separate insurance companies to assemble 54 cases over a two-year period. Of the 54 cases, only 6 involved the thoracic spine, suggesting the thoracic spine may be the least vulnerable segment of the spine (118). A systematic review by Puentedura et al., included available literature published between 1950 and 2015, and only 7 cases of severe adverse reactions from thoracic spine manipulation were identified (119). Ruelle et al. reported a case of thoracic epidural hematoma following manipulation, noting it was only the 3rd reported case, and further that surgical evacuation resulted in a complete recovery (120). An additional case was identified and published by Hdeib et al. in 2016, documenting hemorrhage of a thoracic schwannoma (nerve sheath tumor) post thoracic manipulation, resulting in intradural hematoma and paraplegia (121). Obviously, this was the unfortunate collision of several incredibly rare events. Senstad et al. performed a prospective clinic-based survey of 4712 treatments performed by 102 chiropractors in Norway, finding that less severe adverse reactions occurred more during the first treatment sessions, when more than one spinal region was treated, or when the thoracic spine was treated alone. Note, the study calls these events "uncommon", and could not find a correlation between adverse reactions and any useful prognostic indicators (122). The rarity of these events may be in part due to the inherent stability of the thoracic spine. A study by Sran et al. demonstrated that the mean failure load of a cadaver spine (resulting in micro-fracture of cervical vertebrae) was 479 N (SD 162 N), and the amount of posterior to anterior force applied by a clinician reached a mean of 145 N (SD 38 N); suggesting there is a considerable buffer between manipulation force and the amount of force necessary to result in tissue failure (123). Further, Stemper et al. demonstrated that maximum chest compression during a typical maximum effort by a chiropractor during a thoracic manipulation was 1.8% - 4.5% of total chest depth. Based on previous data correlating the amount of chest compression and injury, and defined using the 

 (AIS), this study suggests chiropractors use 1/5th the force needed to achieve a 10% chance of the lowest-rated compression injury (124). These studies suggest that the thoracic spine is likely the least vulnerable spinal segment, that injury rates are incredibly low; however, manual practitioners should be aware of complications resulting from intradural hematoma.

Risk of Adverse Events

Cervicothoracic Junction Manipulation

Thoracic Spine Manipulation

Thoracic Screw Manipulation

Video Demonstration

Cleland, J. A., Childs, M. J. D., McRae, M., Palmer, J. A., & Stowell, T. (2005). Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. 

Ferreira, L. A. B., Santos, L. C. F., Pereira, W. M., Neto, H. P., Christovão, T. C. L., & Oliveira, C. S. (2013). Analysis of thoracic spine thrust manipulation for reducing neck pain. 

Young, I. A., Pozzi, F., Dunning, J., Linkonis, R., & Michener, L. A. (2019). Immediate and Short-term Effects of Thoracic Spine Manipulation in Patients With Cervical Radiculopathy: A Randomized Controlled Trial. 

journal of orthopaedic & sports physical therapy

Cleland, J. A., Mintken, P. E., Carpenter, K., Fritz, J. M., Glynn, P., Whitman, J., & Childs, J. D. (2010). 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. 

Yang, J., Lee, B., & Kim, C. (2015). Changes in proprioception and pain in patients with neck pain after upper thoracic manipulation. 

González-Iglesias, J., Fernandez-De-Las-Penas, C., Cleland, J. A., & del Rosario Gutiérrez-Vega, M. (2009). Thoracic spine manipulation for the management of patients with neck pain: a randomized clinical trial. 

González-Iglesias, J., Fernández-de-las-Peñas, C., Cleland, J. A., Alburquerque-Sendín, F., Palomeque-del-Cerro, L., & Méndez-Sánchez, R. (2009). Inclusion of thoracic spine thrust manipulation into an electro-therapy/thermal program for the management of patients with acute mechanical neck pain: a randomized clinical trial. 

Lau, H. M. C., Chiu, T. T. W., & Lam, T. H. (2011). The effectiveness of thoracic manipulation on patients with chronic mechanical neck pain–a randomized controlled trial. 

Puntumetakul, R., Pithak, R., Namwongsa, S., Saiklang, P., & Boucaut, R. (2019). The effect of massage technique plus thoracic manipulation versus thoracic manipulation on pain and neural tension in mechanical neck pain: a randomized controlled trial. 

Masaracchio, M., Cleland, J., Hellman, M., & Hagins, M. (2013). Short-term combined effects of thoracic spine thrust manipulation and cervical spine nonthrust manipulation in individuals with mechanical neck pain: a randomized clinical trial. 

Lee, K. W., & Kim, W. H. (2016). Effect of thoracic manipulation and deep craniocervical flexor training on pain, mobility, strength, and disability of the neck of patients with chronic nonspecific neck pain: a randomized clinical trial. 

Muralidharan, C. K., Selvi, P., Kalaivani, T., Nandhakumar, R., & Sivakumar, C. (2018). The effectiveness of thoracic manipulation combined with conventional therapy for mechanical neck pain. 

International Journal of Research in Pharmaceutical Sciences

MPTh, S. N., & Ramteke, G. J. (2016). Effect of Mobilization/Manipulation Directed At Cervical Spine & Thoracic Spine in Patients with Mechanical Neck Pain. 

International Journal of Therapies and Rehabilitation Research

Fernández-de-las-Peñas, C., Fernandez-Carnero, J., Fernández, A. P., Lomas-Vega, R., & Miangolarra-Page, J. C. (2004). Dorsal manipulation in whiplash injury treatment: a randomized controlled trial. 

Cleland, J. A., Childs, J. D., Fritz, J. M., Whitman, J. M., & Eberhart, S. L. (2007). 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. 

Ssavedra-Hernández, M., Castro-Sánchez, A. M., Fernández-de-las-Peñas, C., Cleland, J. A., Ortega-Santiago, R., & Arroyo-Morales, M. (2011). Predictors for identifying patients with mechanical neck pain who are likely to achieve short-term success with manipulative interventions directed at the cervical and thoracic spine. 

Journal of manipulative and physiological therapeutics

Norlander, S., Aste-Norlander, U., Nordgren, B., & Sahlstedt, B. (1996). Mobility in the cervico-thoracic motion segment: an indicative factor of musculo-skeletal neck-shoulder pain. 

Scandinavian journal of rehabilitation medicine

Norlander, S., & Nordgren, B. (1998). Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine. 

Norlander, S., Gustavsson, B. A., Lindell, J., & Nordgren, B. (1997). Reduced mobility in the cervico-thoracic motion segment--a risk factor for musculoskeletal neck-shoulder pain: a two-year prospective follow-up study. 

Krauss, J., Creighton, D., Ely, J. D., & Podlewska-Ely, J. (2008). The immediate effects of upper thoracic translatoric spinal manipulation on cervical pain and range of motion: a randomized clinical trial. 

Fernández-de-las-Peñas, C., Alonso-Blanco, C., Cleland, J. A., Rodríguez-Blanco, C., & Alburquerque-Sendín, F. (2008). Changes in pressure pain thresholds over C5-C6 zygapophyseal joint after a cervicothoracic junction manipulation in healthy subjects. 

Jayaseelan, D. J., & Tow, N. S. (2016). Cervicothoracic junction thrust manipulation in the multimodal management of a patient with temporomandibular disorder. 

Packer, A. C., Pires, P. F., Dibai-Filho, A. V., & Rodrigues-Bigaton, D. (2015). Effect of upper thoracic manipulation on mouth opening and electromyographic activity of masticatory muscles in women with temporomandibular disorder: a randomized clinical trial. 

Packer, A. C., Pires, P. F., Dibai-Filho, A. V., & Rodrigues-Bigaton, D. (2014). Effects of upper thoracic manipulation on pressure pain sensitivity in women with temporomandibular disorder: a randomized, double-blind, clinical trial. 

American journal of physical medicine & rehabilitation

Vinuesa-Montoya, S., Aguilar-Ferrándiz, M. E., Matarán-Peñarrocha, G. A., Fernández-Sánchez, M., Fernández-Espinar, E. M., & Castro-Sánchez, A. M. (2017). A preliminary randomized clinical trial on the effect of cervicothoracic manipulation plus supervised exercises vs a home exercise program for the treatment of shoulder impingement. 

Cleland, J. A., Flynn, T. W., & Palmer, J. A. (2005). Incorporation of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylalgia: a pilot clinical trial. 

Mintken, P. E., Cleland, J. A., Carpenter, K. J., Bieniek, M. L., Keirns, M., & Whitman, J. M. (2010). Some factors predict successful short-term outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: a single-arm trial. 

Mintken, P. E., McDevitt, A. W., Michener, L. A., Boyles, R. E., Beardslee, A. R., Burns, S. A., … & Cleland, J. A. (2017). Examination of the validity of a clinical prediction rule to identify patients with shoulder pain likely to benefit from cervicothoracic manipulation. 

Journal of Orthopaedic & Sports Physical Therapy

Edmondston, S., Ferguson, A., Ippersiel, P., Ronningen, L., Sodeland, S., & Barclay, L. (2012). Clinical and radiological investigation of thoracic spine extension motion during bilateral arm elevation. 

Kanlayanaphotporn, Rotsalai. "Changes in sitting posture affect shoulder range of motion." 

Journal of bodywork and movement therapies

Theisen, C., van Wagensveld, A., Timmesfeld, N., Efe, T., Heyse, T. J., Fuchs-Winkelmann, S., & Schofer, M. D. (2010). Co-occurrence of outlet impingement syndrome of the shoulder and restricted range of motion in the thoracic spine-a prospective study with ultrasound-based motion analysis. 

Imagama, S., Hasegawa, Y., Wakao, N., Hirano, K., Muramoto, A., & Ishiguro, N. (2014). Impact of spinal alignment and back muscle strength on shoulder range of motion in middle-aged and elderly people in a prospective cohort study. 

Muth, S., Barbe, M. F., Lauer, R., & McClure, P. (2012). The effects of thoracic spine manipulation in subjects with signs of rotator cuff tendinopathy. 

Journal of orthopaedic & sports physical therapy

Haik, M. N., Alburquerque-Sendín, F., & Camargo, P. R. (2017). Short-Term Effects of Thoracic Spine Manipulation on Shoulder Impingement Syndrome: A Randomized Controlled Trial. 

Archives of physical medicine and rehabilitation

Haik, M. N., Alburquerque-Sendín, F., Silva, C. Z., Siqueira-Junior, A. L., Ribeiro, I. L., & Camargo, P. R. (2014). Scapular kinematics pre–and post–thoracic thrust manipulation in individuals with and without shoulder impingement symptoms: a randomized controlled study. 

Kardouni, J. R., Pidcoe, P. E., Shaffer, S. W., Finucane, S. D., Cheatham, S. A., Sousa, C. O., & Michener, L. A. (2015). Thoracic spine manipulation in individuals with subacromial impingement syndrome does not immediately alter thoracic spine kinematics, thoracic excursion, or scapular kinematics: a randomized controlled trial. 

Rosa, D. P., Alburquerque-Sendín, F., Salvini, T. F., & Camargo, P. R. (2013). Effect of seated thoracic manipulation on changes in scapular kinematics and scapulohumeral rhythm in young asymptomatic participants: a randomized study. 

Boyles, R. E., Ritland, B. M., Miracle, B. M., Barclay, D. M., Faul, M. S., Moore, J. H., … & Wainner, R. S. (2009). The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. 

Dunning, J., Mourad, F., Giovannico, G., Maselli, F., Perreault, T., & Fernández-de-las-Peñas, C. (2015). Changes in shoulder pain and disability after thrust manipulation in subjects presenting with second and third rib syndrome. 

Strunce, J. B., Walker, M. J., Boyles, R. E., & Young, B. A. (2009). The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. 

da Silva, A. C., Santos, G. M., de Godoy Marques, C. M., & Marques, J. L. B. (2019). Immediate Effects of Spinal Manipulation on Shoulder Motion Range and Pain in Individuals With Shoulder Pain: A Randomized Trial. 

Wassinger, C. A., Rich, D., Cameron, N., Clark, S., Davenport, S., Lingelbach, M., … & Davidson, J. (2016). Cervical & thoracic manipulations: acute effects upon pain pressure threshold and self-reported pain in experimentally induced shoulder pain. 

Munday, S. L., Jones, A., Brantingham, J. W., Globe, G., Jensen, M., & Price, J. L. (2007). A Randomized, Single-Blinded, Placebo-Controlled Clinical Trial to Evaluate the Efficacy of Chiropractic Shoulder Girdle Adjustment in the Treatment of Shoulder Impingement Syndrome. 

Journal of the American Chiropractic Association

Belón-Perez, P., & Cuesta-Vargas, A. I. (2018). Immediate Effects of Thoracic Spine Manipulation Upon Shoulder Functionality in Patients With Sutured Rotator Cuff Repair: A Prospective Study. 

Kardouni, J. R., Shaffer, S. W., Pidcoe, P. E., Finucane, S. D., Cheatham, S. A., & Michener, L. A. (2015). Immediate changes in pressure pain sensitivity after thoracic spinal manipulative therapy in patients with subacromial impingement syndrome: a randomized controlled study. 

Coronado, R. A., Bialosky, J. E., Bishop, M. D., Riley 3rd, J. L., Robinson, M. E., Michener, L. A., & George, S. Z. (2015). The comparative effects of spinal and peripheral thrust manipulation and exercise on pain sensitivity and the relation to clinical outcome: a mechanistic trial using a shoulder pain model. 

Rainbow, D. M., Weston, J. P., Brantingham, J. W., Globe, G., & Lee, F. (2008). A Prospective Clinical Trial Comparing Chiropractic Manipulation and Exercise Therapy vs. Chiropractic Mobilization and Exercise Therapy for Treatment of Patients Suffering from Adhesive Capsulitis/Frozen Shoulder. 

Mintken, P. E., McDevitt, A. W., Cleland, J. A., Boyles, R. E., Beardslee, A. R., Burns, S. A., … & Michener, L. A. (2016). Cervicothoracic manual therapy plus exercise therapy versus exercise therapy alone in the management of individuals with shoulder pain: a multicenter randomized controlled trial. 

Winters, J. C., Sobel, J. S., Groenier, K. H., Arendzen, H. J., & Meyboom-de Jong, B. (1997). Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: randomised, single blind study. 

Winters, J. C., Jorritsma, W., Groenier, K. H., Sobel, J. S., Meyboom-de Jong, B., & Arendzen, H. J. (1999). Treatment of shoulder complaints in general practice: long term results of a randomised, single blind study comparing physiotherapy, manipulation, and corticosteroid injection. 

Bergman, G. J., Winters, J. C., Groenier, K. H., Meyboom-de Jong, B., Postema, K., & van der Heijden, G. J. (2010). Manipulative therapy in addition to usual care for patients with shoulder complaints: results of physical examination outcomes in a randomized controlled trial. 

Bergman, G. J., Winters, J. C., Groenier, K. H., Pool, J. J., Meyboom-de Jong, B., Postema, K., & van der Heijden, G. J. (2004). Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain: a randomized, controlled trial. 

The immediate effect of lumbar spine manipulation, thoracic spine manipulation, combination lumbar and thoracic spine manipulation and sham laser on bowling speed in action cricket fast bowlers

González-Iglesias, J., Cleland, J. A., Neto, F., Hall, T., & Fernandez-de-las-Penas, C. (2013). Mobilization with movement, thoracic spine manipulation, and dry needling for the management of temporomandibular disorder: a prospective case series. 

Thoracic Spine Pain and Thoracic Manipulation

Schiller, L. (2001). Effectiveness of spinal manipulative therapy in the treatment of mechanical thoracic spine pain: a pilot randomized clinical trial. 

Journal of Manipulative and Physiological Therapeutics

The effect of thoracic spine manipulation compared to thoracic spine and costovertebral joint manipulation on mechanical mid-back pain at the Durban University of Technology Chiroptractic Day Clinic

Campbell, B. D., & Snodgrass, S. J. (2010). The effects of thoracic manipulation on posteroanterior spinal stiffness. 

Ditcharles, S., Yiou, E., Delafontaine, A., & Hamaoui, A. (2017). Short-term effects of thoracic spine manipulation on the biomechanical organisation of gait initiation: a randomized pilot study. 

Crothers, A. L., French, S. D., Hebert, J. J., & Walker, B. F. (2016). Spinal manipulative therapy, Graston technique® and placebo for non-specific thoracic spine pain: a randomised controlled trial. 

Pagé, I., & Descarreaux, M. (2019). Effects of spinal manipulative therapy biomechanical parameters on clinical and biomechanical outcomes of participants with chronic thoracic pain: a randomized controlled experimental trial. 

Lateral Epicondylagia and Thoracic Manipulation

Berglund, K. M., Persson, B. H., & Denison, E. (2008). Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain. 

Bautista-Aguirre, F., Oliva-Pascual-Vaca, A., Heredia-Rizo, A. M., Bosca-Gandia, J. J., Ricard, F., & Rodriguez-Blanco, C. (2017). Effect of cervical vs. thoracic spinal manipulation on peripheral neural features and grip strength in subjects with chronic mechanical neck pain: a randomized controlled trial. 

European journal of physical and rehabilitation medicine

Fernández-Carnero, J., Cleland, J. A., & Arbizu, R. L. T. (2011). Examination of motor and hypoalgesic effects of cervical vs thoracic spine manipulation in patients with lateral epicondylalgia: a clinical trial. 

Hadler, N. M., Curtis, P., Gillings, D. B., & Stinnett, S. A. N. D. R. A. (1987). A benefit of spinal manipulation as adjunctive therapy for acute low-back pain: a stratified controlled trial. 

Koes, B. W., Bouter, L. M., & van Mameren, H. (1992). The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for nonspecific back and neck complaints. A randomized clinical trial. 

Savolainen, A., Ahlberg, J., Nummila, H., & Nissinen, M. (2004). Active or passive treatment for neck–shoulder pain in occupational health care? A randomized controlled trial. 

Giles, L. G., & Muller, R. (2003). Chronic spinal pain: a randomized clinical trial comparing medication, acupuncture, and spinal manipulation. 

El-Sodany, A. M., Alayat, M. S. M., & Zafer, A. M. I. (2014). Sustained natural apophyseal glides mobilization versus manipulation in the treatment of cervical spine disorders: a randomized controlled trial. 

Muller, R., & Giles, L. G. (2005). Long-term follow-up of a randomized clinical trial assessing the efficacy of medication, acupuncture, and spinal manipulation for chronic mechanical spinal pain syndromes. 

Stochkendahl, M. J., Christensen, H. W., Vach, W., Høilund-Carlsen, P. F., Haghfelt, T., & Hartvigsen, J. (2012). Chiropractic treatment vs self-management in patients with acute chest pain: a randomized controlled trial of patients without acute coronary syndrome. 

Korthals-de Bos, I. B., Müllner, M., Hoving, J. L., van Tulder, M. W., Rutten-van Mölken, M. P., Adèr, H. J., … & Bouter, L. M. (2003). Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. Commentary: Bootstrapping simplifies appreciation of statistical inferences. 

Karas, S., Olson Hunt, M. J., Temes, B., Thiel, M., Swoverland, T., & Windsor, B. (2018). The effect of direction specific thoracic spine manipulation on the cervical spine: a randomized controlled trial. 

Karas, S., & Olson Hunt, M. J. (2014). A randomized clinical trial to compare the immediate effects of seated thoracic manipulation and targeted supine thoracic manipulation on cervical spine flexion range of motion and pain. 

Joint Manipulation: Thoracic Spine

Related Courses:

Course Description: Thoracic Spine Manipulation

Introduction

Research Summary

Research Corner: Cervical Spine
3 Sub Sections

Research Corner: Thoracic Spine
6 Sub Sections

Comparing Mobilizations and Manipulations

Systemic Response

Risk of Adverse Events

Video Demonstration
3 Sub Sections

Bibliography

Related Courses:

Comments

Guest

Joint Manipulation: Thoracic Spine

Related Courses:

Course Description: Thoracic Spine Manipulation

Introduction

Research Summary

Research Corner: Cervical Spine3 Sub Sections

Research Corner: Thoracic Spine6 Sub Sections

Comparing Mobilizations and Manipulations

Systemic Response

Risk of Adverse Events

Video Demonstration3 Sub Sections

Bibliography

Related Courses:

Comments

Guest

Research Corner: Cervical Spine
3 Sub Sections

Research Corner: Thoracic Spine
6 Sub Sections

Video Demonstration
3 Sub Sections