Joint Manipulation: Thoracic Spine

PACE

<h3>Introduction</h3>
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 &quot;manipulation&quot;. The Brookbush Institute uses one conventional definition of the term &quot;manipulations;&quot; implying low-amplitude (relatively small motions), high-velocity (quick) techniques, intended to target and reduce the stiffness of <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> joints or segments, that exhibit a decrease in passive accessory range of motion (a.k.a. stiffness during <a id="arthrokinematics" data-tip="1701" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic motion</a> and specifically <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> or <a id="glide" data-tip="1815" target="_blank" href="/glossary-term/glide" class="glossary">slide</a>). 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 &quot;multiple joints&quot; 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.&#xA0;
Note, that the term &quot;mobilization&quot; is reserved for low-velocity techniques that are taught in a separate set of courses.&#xA0;&#xA0;
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 <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> of the rib cage, and potentially reduce scapular <a id="dyskinesis" data-tip="1693" target="_blank" href="/glossary-term/dyskinesis" class="glossary">dyskinesis</a> (altered shoulder blade motion) and upper extremity dysfunction. For example, research has demonstrated a correlation between thoracic kyphosis, excessive <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> 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 <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> approach for cervicothoracic dysfunction and <a href="https://brookbushinstitute.com/courses/upper-body-dysfunction-ubd" title="Upper Body Dysfunction" target="_blank" rel="noopener">upper body dysfunction (UBD)</a> including cervicogenic headache, shoulder <a id="stability" data-tip="1193" target="_blank" href="/glossary-term/stability" class="glossary">instability</a>, <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylitis (tennis elbow), chronic thoracic pain, T4 syndrome, chronic neck pain, and acromioclavicular dysfunction. Additionally, thoracic manipulations may be beneficial for individuals exhibiting <a id="movement-impairment" data-tip="1578" target="_blank" href="/glossary-term/movement-impairment" class="glossary">postural dysfunctions</a> including rounded shoulder <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>, forward head <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>, thoracic kyphosis, or an <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> 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 <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based</a>, systematic, <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a>, patient-centered, patient-centered, and outcome-driven approach.&#xA0;
<h3>Techniques Covered in this Course:</h3>
<ul>
 <li><a href="https://brookbushinstitute.com/video/cervicothoracic-junction-manipulation" target="_blank" rel="noopener">Cervicothoracic Junction Manipulation</a></li>
 <li><a href="https://brookbushinstitute.com/video/thoracic-spine-manipulation" target="_blank" rel="noopener">Thoracic Screw Manipulation</a></li>
 <li><a href="https://brookbushinstitute.com/video/thoracic-pistol-manipulation" target="_blank" rel="noopener">Thoracic Pistol Manipulation</a></li>
</ul>
<h3>Sample Intervention (Cervicothoracic Junction Pain)</h3>
<ul>
 <li>Manual Release
 <ul>
 <li><a href="https://brookbushinstitute.com/video/levator-scapulae-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Levator Scapulae</a></li>
 <li><a href="https://brookbushinstitute.com/video/upper-trapezius-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Upper Trapezius</a></li>
 <li><a href="https://brookbushinstitute.com/video/rhomboid-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Rhomboids</a></li>
 <li><a href="https://brookbushinstitute.com/video/pectoralis-minor-static-manual-release" target="_blank" rel="noopener">Pectoralis Minor</a></li>
 </ul>
 </li>
 <li>Mobilization or Manipulation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/cervicothoracic-junction-manipulation" target="_blank" rel="noopener">Cervicothoracic Junction Manipulation</a></li>
 <li><a href="https://brookbushinstitute.com/video/thoracic-spine-manipulation" target="_blank" rel="noopener">Thoracic Screw Manipulation</a></li>
 </ul>
 </li>
 <li>Manual Lengthening
 <ul>
 <li><a href="https://brookbushinstitute.com/video/pectoralis-minor-manual-stretch" target="_blank" rel="noopener">Manual Pectoralis Minor Stretch</a></li>
 </ul>
 </li>
 <li>Activation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/deep-cervical-flexor-isolated-activation" target="_blank" rel="noopener">Deep Cervical Flexor Activation</a></li>
 <li><a href="https://brookbushinstitute.com/video/serratus-anterior-isolated-activation-2" target="_blank" rel="noopener">Serratus </a><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> Activation</li>
 </ul>
 </li>
 <li>Integration
 <ul>
 <li><a href="https://brookbushinstitute.com/video/prone-cobra-on-foam-roll-activation-for-muscles-of-the-scapula-thorax-deep-cervical-flexors" target="_blank" rel="noopener">Cobra on Foam Roll</a></li>
 </ul>
 </li>
</ul>
<h3>Related Courses</h3>
Additional Joint Mobilization Courses
<ul>
 <li><a href="https://brookbushinstitute.com/courses/manipulations-cervical-spine" title="Cervical manipulation" target="_blank" rel="noopener">Joint Manipulation: Cervical Spine</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-manipulation-thoracic-spine" title="Thoracic Manipulation" target="_blank" rel="noopener">Joint Manipulation: Thoracic Spine</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-manipulation-lumbar-spine-sacroiliac-joint-and-pubic-symphysis" title="Lumbar Manipulation" target="_blank" rel="noopener">Joint Manipulation: Lumbar Spine, Sacroiliac Joint, and Pubic Symphysis</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-manipulation-wrist-and-elbow" title="Elbow Manipulation" target="_blank" rel="noopener">Joint Manipulation: Elbow (Radial Head) and Wrist</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-manipulation-foot-ankle-and-tibiofibular-joint" title="Foot Manipulation" target="_blank" rel="noopener">Joint Manipulation: Ankle, Midfoot, and Tibiofibular Joint</a></li>
</ul>
For an introduction to joint mobilizations and manipulations:
<ul>
 <li><a href="https://brookbushinstitute.com/courses/introduction-joint-mobilizations-joint-manipulations" title="Introduction to Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Introduction</a></li>
 <li><a href="https://brookbushinstitute.com/courses/mobilization-and-manipulation-reliability-of-palpation-and-assessment" title="Reliability of Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Reliability</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" title="Effects of Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: Effects</a>&#xA0;</li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Risk of Adverse Effects</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilizations-and-manipulations-evidence-based-teaching-and-learning" title="Evidence-based Teaching and Learning" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: </a><a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">Evidence-based</a> Teaching and Learning</li>
</ul>

Course Description: Thoracic Spine Manipulation

<h2>For Cervicothoracic Dysfunction and <a href="https://brookbushinstitute.com/article/upper-body-dysfunction-ubd" target="_blank" rel="noopener">Upper-Body Dysfunction</a>:</h2>
For an introduction to joint mobilizations and manipulations:
<ul>
 <li><a href="https://brookbushinstitute.com/courses/introduction-joint-mobilizations-joint-manipulations" title="Introduction to Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Introduction</a></li>
 <li><a href="https://brookbushinstitute.com/courses/mobilization-and-manipulation-reliability-of-palpation-and-assessment" title="Reliability of Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Reliability</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" title="Effects of Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: Effects</a>&#xA0;</li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Risk of Adverse Effects</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilizations-and-manipulations-evidence-based-teaching-and-learning" title="Evidence-based Teaching and Learning" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: </a><a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">Evidence-based</a> Teaching and Learning</li>
</ul>
<h3>Techniques Covered in this Course:</h3>
<ul>
 <li><a href="https://brookbushinstitute.com/video/cervicothoracic-junction-manipulation" target="_blank" rel="noopener">Cervicothoracic Junction Manipulation</a></li>
 <li><a href="https://brookbushinstitute.com/video/thoracic-spine-manipulation" target="_blank" rel="noopener">Thoracic Screw Manipulation</a></li>
 <li><a href="https://brookbushinstitute.com/video/thoracic-pistol-manipulation" target="_blank" rel="noopener">Thoracic Pistol Manipulation</a></li>
</ul>
<h3>Signs of correlated dysfunction:</h3>
<ul>
 <li><a href="https://brookbushinstitute.com/article/introduction-overhead-squat-assessment" target="_blank" rel="noopener">Overhead Squat Assessment:</a>
 <ul>
 <li>Forward Head</li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-11-shoulders-elevate" target="_blank" rel="noopener">Shoulders Elevate</a></li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-10-arms-fall" target="_blank" rel="noopener">Arms Fall</a></li>
 </ul>
 </li>
 <li><a href="https://brookbushinstitute.com/article/introduction-to-goniometry" target="_blank" rel="noopener">Goniometry</a>
 <ul>
 <li><a href="https://brookbushinstitute.com/video/cervical-lateral-flexion-goniometry" target="_blank" rel="noopener">Cervical </a><a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">Lateral</a> Flexion &lt; 35 - 45&#xB0;
 <ul>
 <li>Note: Gross movement exams may be beneficial for identifying asymmetry, significant restriction, and pain with movement; however, cervical rotation, flexion, and extension are not <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> <a id="goniometry" data-tip="1524" target="_blank" href="/glossary-term/goniometry" class="glossary">goniometric</a> <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a>.</li>
 </ul>
 </li>
 <li><a href="https://brookbushinstitute.com/video/shoulder-flexion-goniometry" target="_blank" rel="noopener">Shoulder Flexion</a> &lt; 180&#xB0;</li>
 <li><a href="https://brookbushinstitute.com/video/shoulder-external-rotation-goniometry" target="_blank" rel="noopener">Shoulder External Rotation</a> &lt;90 - 95&#xB0;
 <ul>
 <li>Although shoulder flexion and external rotation are not a measure of cervical/thoracic spine motion, <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> thoracic <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> is needed to achieve <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> <a href="https://brookbushinstitute.com/article/sternoclavicular-acromioclavicular-scapulothoracic-joints" target="_blank" rel="noopener">scapular</a> motion, which is necessary to achieve <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> - assuming the patient/client does not exhibit signs of shoulder <a id="hypermobility" data-tip="1678" target="_blank" href="/glossary-term/hypermobility" class="glossary">hyper-mobility</a>. Although measuring <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> ROM is not a direct measure of thoracic <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a>, <a id="goniometry" data-tip="1523" target="_blank" href="/glossary-term/goniometry" class="glossary">Goniometry</a> of the cervical spine, thoracic spine and scapula is not <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a>.</li>
 </ul>
 </li>
 </ul>
 </li>
 <li><a href="https://brookbushinstitute.com/article/introduction-manual-muscle-testing-active-population" target="_blank" rel="noopener">Manual </a><a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> Testing MMT:
 <ul>
 <li><a href="https://brookbushinstitute.com/video/deep-cervical-flexor-endurance-test" target="_blank" rel="noopener">Deep Cervical Flexor Endurance Test</a>: Weak or With Compensation (cervical protraction)</li>
 <li><a href="https://brookbushinstitute.com/video/serratus-anterior-manual-muscle-testing-mmt-for-an-active-population" target="_blank" rel="noopener">Serratus </a><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> MMT: Weak or With Compensation (scapular protraction or elevation)</li>
 <li><a href="https://brookbushinstitute.com/video/lower-trapezius-manual-muscle-testing-mmt-for-an-active-population" target="_blank" rel="noopener">Lower Trapezius MMT</a>: Weak or With Compensation (scapular protraction or elevation)</li>
 </ul>
 </li>
</ul>
<h3>Sample Intervention (Cervicothoracic Junction Pain)</h3>
<ul>
 <li>Manual Release
 <ul>
 <li><a href="https://brookbushinstitute.com/video/levator-scapulae-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Levator Scapulae</a></li>
 <li><a href="https://brookbushinstitute.com/video/upper-trapezius-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Upper Trapezius</a></li>
 <li><a href="https://brookbushinstitute.com/video/rhomboid-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Rhomboids</a></li>
 <li><a href="https://brookbushinstitute.com/video/pectoralis-minor-static-manual-release" target="_blank" rel="noopener">Pectoralis Minor</a></li>
 </ul>
 </li>
 <li>Mobilization or Manipulation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/cervicothoracic-junction-manipulation" target="_blank" rel="noopener">Cervicothoracic Junction Manipulation</a></li>
 <li><a href="https://brookbushinstitute.com/video/thoracic-spine-manipulation" target="_blank" rel="noopener">Thoracic Screw Manipulation</a></li>
 </ul>
 </li>
 <li>Manual Lengthening
 <ul>
 <li><a href="https://brookbushinstitute.com/video/pectoralis-minor-manual-stretch" target="_blank" rel="noopener">Manual Pectoralis Minor Stretch</a></li>
 </ul>
 </li>
 <li>Activation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/deep-cervical-flexor-isolated-activation" target="_blank" rel="noopener">Deep Cervical Flexor Activation</a></li>
 <li><a href="https://brookbushinstitute.com/video/serratus-anterior-isolated-activation-2" target="_blank" rel="noopener">Serratus </a><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> Activation</li>
 </ul>
 </li>
 <li>Integration
 <ul>
 <li><a href="https://brookbushinstitute.com/video/prone-cobra-on-foam-roll-activation-for-muscles-of-the-scapula-thorax-deep-cervical-flexors" target="_blank" rel="noopener">Cobra on Foam Roll</a></li>
 </ul>
 </li>
</ul>

Introduction

<h2>Summary</h2>
<ul>
 <li>Cervical: Studies suggest that thoracic manipulation alone may have a positive effect on cervical pain, ROM, <a href="https://brookbushinstitute.com/video/deep-cervical-flexor-endurance-test" target="_blank" rel="noopener">deep cervical flexor endurance</a>, and disability, especially when cervical dysfunction includes limited ROM, low to moderate levels of pain, and thoracic <a id="hypomobility" data-tip="1673" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobility</a>.
 <ul>
 <li>Further studies demonstrate that integrating thoracic manipulation with cervical manipulation, massage, exercise, and other conventional modalities is likely to result in <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> outcomes.</li>
 </ul>
 </li>
 <li>Cervicothoracic junction (CTJ) manipulation: may have a therapeutic effect on <a id="movement-impairment" data-tip="1579" target="_blank" href="/glossary-term/movement-impairment" class="glossary">dysfunctions</a> of the <a href="https://brookbushinstitute.com/article/cervical-spine/" target="_blank" rel="noopener">cervical spine</a>, thoracic spine, and <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a>, may have beneficial analgesic effects for elbow <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylalgia, but likely has no direct effect on temporomandibular joint (TMJ) dysfunction.</li>
 <li>Thoracic Spine and Lumbar Spine: 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.</li>
 <li>Shoulder: - Thoracic spine <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> 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.
 <ul>
 <li>Research suggests that the combination of thoracic manipulation(s) and exercise for the treatment of shoulder pain results in <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> 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.</li>
 </ul>
 </li>
 <li>Elbow: Studies imply that patients exhibiting symptoms of <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylalgia also commonly have cervical/thoracic dysfunction; further, thoracic manipulation may only improve elbow dysfunction when cervical/thoracic dysfunction is also present.</li>
 <li>Compared to Other Interventions: 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.</li>
 <li>Combined with Other Interventions: Whether <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> with heat, electrotherapy, infrared radiation (IRR) therapy, exercise, injections, NSAIDS, educational materials, or physician care, research ubiquitously supports the addition of manipulation, demonstrating <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> outcomes both short-term and long-term.</li>
 <li>Manipulation versus Mobilization: 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.</li>
 <li>Better Thoracic Manipulation Technique: Studies suggest that <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">supine</a> and <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> thoracic manipulation (like taught in this course) may be more effective than sitting variations, direction <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a> may not matter, and sing pull on the skin to &quot;hook&quot; spinous process likely does not matter.</li>
 <li>Risk of Adverse Events - 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.</li>
</ul>
<h4>Systemic Effects:</h4>
<ul>
 <li>Analgesia - Studies suggest that the analgesic effects of thoracic manipulation may be <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> to inhibition of neuromodulators related to symptoms of dysfunction. That is, the analgesic reflexes, perhaps supraspinal, may only be capable of inhibiting <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> afferent information associated with the pain experience that results from injury and dysfunction.</li>
 <li>Sympathoexcitatory effects: 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).
 <ul>
 <li>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.</li>
 </ul>
 </li>
 <li>Manipulation and Blood Chemistry: 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.</li>
 <li>Muscle Activity: Studies suggest that the largest decreases in <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> activity can be expected following high-velocity thoracic manipulation in individuals experiencing relatively constant symptoms. Further, thoracic manipulation may affect both <a id="proximal" data-tip="1564" target="_blank" href="/glossary-term/proximal" class="glossary">proximal</a> and relatively <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> musculature, resulting in changes that normalize the altered <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> activity associated with dysfunction.</li>
 <li>Pulmonary Function: 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.</li>
</ul>

Research Summary

Research Corner: Cervical Spine

Several studies have demonstrated that thoracic spine manipulations are an effective modality for the treatment of cervical dysfunction. A <a id="randomized-control-trial" data-tip="1403" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">randomized controlled </a><a id="randomized-control-trial" data-tip="1407" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">trial</a> (RCT) by Cleland et al. demonstrated that thoracic manipulation resulted in an immediate decrease in mechanical cervical pain (1). Ferreira et al. demonstrated that five sessions of thoracic spine manipulation were effective for reducing cervical pain and disability (2). And, an RCT by Young et al. demonstrated that one session of thoracic manipulation for patients with cervical radiculopathy resulted in immediate improvements in pain, disability, cervical range of motion (ROM), and <a href="https://brookbushinstitute.com/article/longus-colli-longus-capitis-rectus-capitis-anterior-rectus-capitis-lateralis-deep-neck-flexors" target="_blank" rel="noopener">deep neck flexor</a> endurance when compared to sham manipulation (3). These studies suggest that thoracic manipulation alone may have a significant effect on cervical dysfunction.
Thoracic manipulation in conjunction with other modalities has demonstrated <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> efficacy in several studies, many of these studies being high-quality <a id="randomized-control-trial" data-tip="1406" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">randomized controlled</a> trials (RCTs). An RCT by Cleland et al. demonstrated that thoracic manipulation and exercise resulted in larger improvements in pain and disability when compared to exercise alone (4). Yang et al. demonstrated that patients with chronic neck pain exhibited larger improvements in pain and proprioception when cervical stabilization exercise was combined with upper thoracic manipulation (5). In an RCT by Gonz&#xE1;lez-Iglesias et al., neck pain patients receiving thoracic manipulation and electrotherapy/thermal program experienced greater improvements in pain and disability at the fifth (final) treatment session and at 2-week and 4-week follow-ups when compared to the control group receiving electrotherapy/thermal program alone (6). The combination of thoracic manipulation and electrothermal therapy resulted in better outcomes in each of 3 consecutive, weekly sessions for individuals with cervical pain (119). In a similar RCT by Gonz&#xE1;lez-Iglesias et al., the inclusion of just 3 thoracic manipulations to electrotherapy/thermal program and massage resulted in larger decreases in neck pain and disability and increased active cervical ROM in patients with acute neck pain (7). An RCT by Lau et al. demonstrated that mechanical neck pain patients receiving infrared radiation therapy (IRR) and standardized educational materials improved more when thoracic manipulation was added to their program, including improvements in neck <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>, neck range of motion (ROM), neck pain and disability, and during follow-up 6 months post-treatment (8). An RCT by Puntumetakul et al. demonstrated that massage and thoracic manipulation were more effective than manipulation alone for reducing mechanical neck pain and neural <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> (9). In an RCT by Masaracchio et al. mechanical neck pain patients either received 2 treatment sessions of cervical spine non-thrust manipulations and a home exercise program or were assigned to the experimental group which received the same treatment with the addition of a thoracic spine thrust manipulation. Participants in the thoracic manipulation group reported larger improvements on a numeric pain rating scale and a Neck Disability Index, including 31 of 33 participants in the thoracic manipulation group improving by 4+ points, compared to only 11 of 31 patients in the non-manipulation group (10). In an RCT by Lee et al. chronic neck pain patients were assigned to one of three groups: group A received thoracic manipulation combined with <a href="https://brookbushinstitute.com/article/deep-cervical-flexor-activation" target="_blank" rel="noopener">deep cervical flexor training</a>, group B received <a href="https://brookbushinstitute.com/article/deep-cervical-flexor-activation" target="_blank" rel="noopener">deep cervical flexor training</a> alone, and a control group performed non-specific active self-exercise. Patients in group A demonstrated significant increases in <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> strength, endurance, and cervical/thoracic spine ROM, and significant decreases in disability index scores, when compared to the other groups (Note, group B also out-performed group C) (11). Two RCTs, one by Muralidharan et al, and the other by MPTh et al. demonstrated that mechanical neck patients benefited more from the addition of thoracic manipulation to cervical mobilization and conventional therapy when compared to the results from cervical mobilization and conventional therapy, and from conventional therapy alone (12, 13). An RCT by Fern&#xE1;ndez-de-las-Pe&#xF1;as demonstrated that whiplash syndrome patients exhibited thoracic dysfunction more often than mechanical neck pain patients, and that whiplash patients receiving thoracic manipulation on the 5th and 10th sessions of a conventional physiotherapy program including electrotherapy, ultrasound therapy, and manual therapy, had larger improvements in pain than individuals who did not receive thoracic manipulation (14). These high-quality studies suggest that although thoracic manipulation alone may be effective for addressing cervical dysfunction, the <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> of thoracic manipulation with cervical manipulation, massage, exercise, and other conventional modalities may be <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a>.
Some attempts have been made to predict which cervical dysfunction patients would benefit from thoracic manipulation. Cleland et al. attempted to identify prognostic indicators that may aid in the development of a clinical prediction rule, demonstrating a 54 - 86% success rate when the patient exhibited the following 6 variables: symptom duration &lt;30 days, no symptoms <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> to the shoulder, subject reports looking up (cervical extension) does not aggravate symptoms, FABQPA score of &lt;12 (minimal fear-avoidance), diminished upper thoracic spine kyphosis (T3&#x2013;T5), and cervical extension of &lt;30 degrees (15). Saavedra-Hern&#xE1;ndez et al. also attempted to develop a clinical prediction rule, demonstrating a 75.4% success rate of thoracic manipulation when patient&apos;s presentation matched 4 out of 5 of the following signs; intensity was greater than 4.5/10 points; cervical extension ROM was less than 46&#xB0;; the presence of <a id="hypomobility" data-tip="1673" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobility</a> at T1; a negative <a href="https://brookbushinstitute.com/video/upper-limb-tension-tests-ultt" target="_blank" rel="noopener">upper limb </a><a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> and female sex were identified (16). In summary, these studies suggest that thoracic manipulation should be considered in combination with other effective modalities (especially exercise), when cervical dysfunction results in moderate pain, limited ROM, and thoracic stiffness.

Cervical Pain and Dysfunction

Several studies have demonstrated a correlation between neck and shoulder dysfunction, cervicothoracic stiffness, and the efficacy of cervicothoracic junction (CTJ) manipulation. Norlander et al. determined that cervicothoracic stiffness and limitations in flexion were indicative of neck and shoulder pain (17). In another study by Norlander et al., the researchers determined that asynchronous <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> between C7 - T2 accounted for only 14% of neck-shoulder pain, and 15% of weakness in the hands (18). The impact on future risk may be better represented by a previously conducted <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a> with 2-year follow-up, demonstrating that the inverse function of C7/T1 had a positive <a id="predictive-values" data-tip="1738" target="_blank" href="/glossary-term/predictive-values" class="glossary">predictive value</a> of 84% for neck-shoulder pain (19). Several studies have demonstrated the efficacy of manipulation directed at this portion of the spine. An RCT by Krauss et al. demonstrated that CTJ manipulation significantly increased rotation range of motion and decreased end-range pain in patients experiencing <a id="bilateral" data-tip="1552" target="_blank" href="/glossary-term/bilateral" class="glossary">bilateral</a> cervical pain during rotation (20). Fern&#xE1;ndez-de-las-Pe&#xF1;as demonstrated that CTJ manipulation improved pain pressure threshold in both right and left C5-C6 zygapophyseal joints in asymptomatic participants (21). In a case series by Jayaseelan et al., CTJ manipulation was a beneficial adjunct to an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> therapeutic program for patients with simultaneous complaints of jaw and cervical pain (22). However, in a blinded RCT by Packer et al., CTJ manipulation did not significantly effect temporomandibular joint (TMJ) ROM or pain in a group of patients with TMJ disorder (23). Another study by Packer et al. added EMG data, demonstrating that CTJ manipulation had no effect on TMJ ROM or masseter <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity (24). These studies may suggest that CTJ manipulation is effective for cervical pain, including cervical pain in conjunction with TMJ dysfunction; however, CTJ manipulation likely has no direct effect on TMJ dysfunction. An RCT by Vinuesa-Montoya demonstrated that cervicothoracic manipulation and supervised exercise was more effective than home exercise alone for improving shoulder ROM deficits and pain in patients with shoulder impingement (25). A study by Mintkin et al. alluded to a clinical prediction rule, suggesting that cervical and thoracic spine manipulation would be beneficial for shoulder pain patients exhibiting one or more of the following signs (clinical prediction rule): pain-free <a href="https://brookbushinstitute.com/video/shoulder-flexion-goniometry" target="_blank" rel="noopener">shoulder flexion</a> &lt;127&#xB0;, <a href="https://brookbushinstitute.com/video/shoulder-internal-rotation-goniometry" target="_blank" rel="noopener">shoulder internal rotation</a> &lt;53&#xB0;, negative <a href="https://brookbushinstitute.com/video/neer-impingement-test" target="_blank" rel="noopener">Neer test</a>, not taking medications for shoulder pain, and symptoms for less than 90 days (more signs increased the odds of successful outcomes) (26). Unfortunately, a follow-up study by Mintken et al. could not validate the prognostic variables, suggesting further research is needed (27). Last, Cleland et al. demonstrated that the incorporation of CTJ manipulation may be an effective adjunct to treatment for elbow <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylalgia (28). Based on these studies, CTJ manipulation may have a therapeutic effect on <a id="movement-impairment" data-tip="1579" target="_blank" href="/glossary-term/movement-impairment" class="glossary">dysfunctions</a> of the <a href="https://brookbushinstitute.com/article/cervical-spine/" target="_blank" rel="noopener">cervical spine</a>, thoracic spine, and <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a>, may have beneficial analgesic effects for elbow <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylalgia, but likely has no direct effect on temporomandibular joint (TMJ) dysfunction.

Cervicothoracic Junction (CTJ) Manipulation:

Several studies have demonstrated the relationship between thoracic spine <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> and shoulder function, and the efficacy of thoracic spine manipulations for the treatment of shoulder pain. Edmondston et al. demonstrated a strong correlation between <a id="bilateral" data-tip="1552" target="_blank" href="/glossary-term/bilateral" class="glossary">bilateral</a> arm elevation and thoracic extension (10 to 13&#xB0; &#xB1;7) (29). Kanlayanaphotporn et al. demonstrated that changes in sitting <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> resulting in small changes in kyphosis angle could significantly limit shoulder ROM in all directions (30). In a <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a> by Theisen et al., a strong correlation was demonstrated between mid and lower thoracic spine stiffness, decreased thoracic <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a>, and limited shoulder ROM (31). In another <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a> by Imagama et al., a strong correlation was demonstrated between increased thoracic kyphosis, thoracic inclination angle, <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">trapezius</a> weakness, and limited shoulder ROM (32). These studies demonstrate a strong relationship between thoracic spine and shoulder function, and further, that thoracic <a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">postural</a> dysfunction may contribute to future shoulder pain and injury.
Most studies investigating the impact of thoracic manipulation on kinematics show small changes in motion, despite moderate effect sizes for subjective outcomes measures. A study by Muth et al. investigated the effect of thoracic manipulation on patients with rotator cuff tendinopathy, demonstrating a small but significant decrease in upward rotation during elevation, an increase in <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">middle trapezius</a> activation during shoulder flexion, less pain during shoulder flexion, <a href="https://brookbushinstitute.com/video/full-can-empty-can-test" target="_blank" rel="noopener">Jobe&apos;s Empty Can Test</a>, <a href="https://brookbushinstitute.com/video/neer-impingement-test" target="_blank" rel="noopener">Neer Test</a>, <a href="https://brookbushinstitute.com/video/hawkins-kennedy-and-yokum-tests" target="_blank" rel="noopener">Hawkins-Kennedy test</a>, and better function based on DASH disability score (33). An RCT by Haik et al. demonstrated that thoracic manipulation improved pain and function and increased scapular upward rotation during arm lowering 2 days post-intervention; however, most of the data regarding kinematics and <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity was inconclusive (34). In another RCT by Haik et al., thoracic manipulation resulted in significant changes in shoulder impingement syndrome symptoms; however, kinematic analysis resulted in inconclusive data when compared to sham and asymptomatic groups (35). An RCT by Kardouni et al. demonstrated that thoracic manipulation for <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> pain and dysfunction, resulted in small changes in pain, function and scapular internal rotation, but no immediate changes to thoracic spine kinematics (36). An RCT by Rosa et al. comparing thoracic manipulation techniques did not demonstrate a difference in scapular kinematics or scapulohumeral rhythm, but these techniques were performed on young asymptomatic individuals (37). These studies suggest a relationship exists between thoracic spine <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> and shoulder function, that thoracic spine manipulation significantly improves symptoms of shoulder dysfunction; however, the effect of thoracic manipulation alone on thoracic spine and scapular kinematics may be relatively small compared to subjective measures.
Thoracic manipulation has demonstrated efficacy for the treatment of a variety of upper body <a id="movement-impairment" data-tip="1579" target="_blank" href="/glossary-term/movement-impairment" class="glossary">dysfunctions</a>. Boyles et al. demonstrated that a single session of thoracic spine manipulation resulted in a significant decrease in pain during a variety of shoulder impingement tests, as well as decreased shoulder disability index scores (38). Two studies have demonstrated the efficacy of thoracic spine and 1st/2nd rib manipulation. Dunning et al. demonstrated significant reductions in disability and pain following upper thoracic and upper rib thrust manipulations in shoulder patients who tested negative on the <a href="https://brookbushinstitute.com/video/neer-impingement-test" target="_blank" rel="noopener">Neer Impingement Test</a> (39). Strunce et al. demonstrated that a single session of thrust manipulation to the thoracic spine and first rib resulted in an immediate 51% reduction in shoulder pain and 30&#xB0;-38&#xB0; increase in shoulder ROM (40). An RCT by da Silva et al. demonstrated thoracic manipulation improved shoulder abduction ROM in patients with shoulder pain, better than placebo (41) A study by Wassinger et al. demonstrated that cervical, cervicothoracic and thoracic manipulation significantly decreased acute shoulder pain and pain pressure threshold over the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> following experimentally (exercise) induced shoulder pain (42). An RCT by Munday et al. demonstrated that 8 manipulations in 3 weeks were <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to sham treatment (detuned ultrasound) for general pain and pain pressure threshold at 1-month follow-up (43). And, a <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a> Bel&#xF3;n-Perez et al. demonstrated that thoracic manipulation post-surgery for <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/rotator-cuff" target="_blank" rel="noopener">rotator cuff</a> rupture resulted in more active shoulder flexion and abduction ROM, as well as a significant increase in subacromial space when the shoulder was in neutral and/or an externally rotated position (44). Note, this study may give rehab professionals additional goals while waiting for tissues to heal post-surgery. As mentioned above, Mintkin et al. attempted to determine a set of prognostic indicators for determining if thoracic manipulation would improve shoulder dysfunction; however, the prognostic indicators could not be validated in a follow-up study, suggesting further research is needed (27, 28). One RCT by Kardoni et al., demonstrated that thoracic manipulation had no significant effect on pain pressure threshold when compared to sham manipulation for the treatment of shoulder impingement syndrome (45). This study contradicts the findings of all other studies, and no notable difference could be found to determine a rationale. These studies in aggregate suggest that despite small kinematic changes and an inability to predict the best prognostic indicators, thoracic manipulation alone may be beneficial for improving shoulder pain, ROM and function.
The combination of thoracic manipulation with exercise has demonstrated <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> efficacy to either technique alone. As mentioned above, an RCT by Vinuesa-Montoya demonstrated that cervicothoracic manipulation and supervised exercise was more effective than home exercise alone for improving shoulder ROM deficits and pain in patients with shoulder impingement (25). An RCT by Coronado et al. demonstrated that the combination of manipulation and exercise was <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to exercise alone; however, no significant differences were noted between shoulder and thoracic manipulation (46). Author&apos;s note, it is unfortunate that a combination of shoulder manipulation, thoracic manipulation, and exercise was not attempted in this study. An RCT by Rainbow et al. investigated the treatment of adhesive capsulitis, comparing the combination of thoracic, cervical, and shoulder manipulation with home exercise to the combination of grade 4 shoulder mobilization and exercise, demonstrated significantly better outcomes for the combined manipulation group (47). An RCT by Mintken et al. demonstrated that adding 2 sessions of high-dose cervicothoracic manual therapy to an exercise program did not improve pain or disability in patients with shoulder pain, but did improve patient-perceived success/acceptability of symptoms at 4 weeks and 6 months (48). This study likely implies that 2 sessions in 4 weeks is insufficient to have a significant effect on objective outcomes. In summary, research suggests that the combination of exercise and thoracic manipulation(s), and potentially the addition of cervical manipulation results in larger improvements in pain, ROM, and shoulder function when compared to manipulation or exercise alone.
Additional studies have investigated the combination of thoracic manipulation and physician care. An RCT by Winters et al. demonstrated that manipulation was the <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> treatment option for treating <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> girdle disorders, while corticosteroid injection was a better option for synovial <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> disorders (e.g. adhesive capsulitis) (49). In another RCT by Winters et al., steroid injections and manipulation were more beneficial in the short-term than physiotherapy; however, long-term results were similar (50). An RCT by Bergman et al. demonstrated that the combination of manipulation with normal care (advice, analgesics, NSAIDs, exercise, and massage) did not result in significant difference at 6 weeks, but did result in significant differences in shoulder/neck <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> and shoulder/neck pain at 12 and 24 weeks (51). Another RCT by Bergman et al. demonstrated that the addition of manipulation (up to 6 sessions in 12 weeks) to general medical care resulted in better outcomes including, improvements of severity of the main complaint, shoulder pain and disability, and general health, 43% of the intervention group compared to 21% of the control group reporting full recovery, and a consistent between-group difference was maintained at 52-week follow-up (52). Based on these studies it appears that 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 success long-term.
<table>
 <tbody>
 <tr>
 <td>
 <h4>Interesting Note:</h4>
 A doctoral dissertation by Sood demonstrated spinal manipulation resulted in a significant increase in cricket bowling speed in asymptomatic athletes (53). This may imply that manipulation has a place in performance training as part of an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> warm-up program.
 </td>
 </tr>
 </tbody>
</table>

Shoulder Pain and Dysfunction

Research Corner: Thoracic Spine

Four studies could be located that investigated the effect of cervicothoracic (CTJ) manipulation on TMJ Dysfunction. As mentioned above, a case series by Jayaseelan et al. demonstrated CTJ manipulation was a beneficial adjunct to an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> therapeutic program for patients with simultaneous complaints of jaw and cervical pain (22). Further, a prospective case series by Gonz&#xE1;lez-Iglesias et al. demonstrated the efficacy of an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> program including dry needling, mobilization with movement, and spine manipulation for TMJ dysfunction patients (54). However, studies do not <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a> the use of CTJ manipulation alone for treatment of the TMJ specifically. The blinded RCT by Packer et al. mentioned above, demonstrated CTJ manipulation had no effect on TMJ ROM or pain (23), and another study by Packer et al. demonstrated CTJ manipulation had no effect on TMJ ROM or masseter <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity (24). These studies likely suggest that CTJ manipulation is effective for cervical pain, including the common occurrence of cervical pain with TMJ dysfunction; however, CTJ manipulation likely has no effect on TMJ dysfunction.

Temperomandibular Joint (TMJ) and Thoracic Manipulation

Several studies have investigated the effect thoracic manipulation has on elbow <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylalgia. An interesting study by Berglund et al. demonstrated that patients with <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylalgia were more likely to exhibit limited radial <a id="nerve-cell" data-tip="1361" target="_blank" href="/glossary-term/nerve-cell" class="glossary">nerve</a> neurodynamics, pain provocation during cervical spine and thoracic spine tests, and limited cervical flexion and extension (which has also been correlated with upper thoracic <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> issues) (61). However, an RCT by Bautista-Aguirre et al. demonstrated no difference between cervical, thoracic and sham manipulation when elbow mechanosensitivity and grip strength were measured in a group of patients exhibiting mechanical neck pain (with no mention of elbow symptoms) (62). Fern&#xE1;ndez-Carnero demonstrated that both cervical and thoracic manipulation had similar effects on grip strength; however, cervical manipulation resulted in larger changes in pain (63). As mentioned above, Cleland et al. demonstrated that the incorporation of CTJ manipulation into conventional therapy for <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylalgia improved outcomes (26). These studies likely imply that a relationship between <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylalgia and cervical/thoracic dysfunction exists; however, thoracic manipulation is only effective for elbow dysfunction when cervical dysfunction is accompanied by subjective symptoms of <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylalgia.

Thoracic Spine Manipulation and the Elbow

There are surprisingly few studies investigating the efficacy of thoracic spine manipulation on thoracic spine pain, likely due to the relatively rare occurrence of thoracic spine pain when compared to <a href="https://brookbushinstitute.com/article/cervical-spine/" target="_blank" rel="noopener">cervical spine</a> and/or <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> pain. A pilot RCT with Schiller et al. demonstrated that patients with mid-back pain, improved more following 6 sessions of thoracic manipulation over a 2 - 3 week period, including larger improvements in <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> flexion and pain, than a sham group receiving nonfunctional ultrasound (55). A doctoral dissertation by Peterson et al. demonstrated that thoracic manipulation alone was as effective as the combination of thoracic manipulation and costovertebral manipulation for the treatment of mid-back pain (56). A study by Campbell et al. validates the use of thoracic manipulation for improving <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a>, noting a small but significant change in <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> to <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> thoracic stiffness following the technique (57). An interesting pilot RCT by Ditcharles et al. demonstrated that thoracic manipulation resulted in an immediate increase in ROM, especially thoracic flexion, during gait (58). In an RCT by Crothers et al., individuals with non-specific thoracic spine pain were randomly allocated to thoracic manipulation, Graston or placebo (de-tuned ultrasound) groups. No significant difference was noted between the groups; however, all groups improved over time (59). An RCT by Pag&#xE9; et al. used thoracic manipulation performed by a machine, demonstrating little difference between the control group and machine manipulation groups at two different force parameters (60). These last two studies allude to a lack of benefit; however, they also lack <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> for thoracic stiffness, and the study by Pag&#xE9; et al. used a machine that may not be representative of the effects of manual manipulation. Considering the relatively small number of low-powered studies and lack of congruence between study findings, more high-powered research is recommended; however, these preliminary studies likely imply that thoracic manipulation may be a beneficial addition to therapeutic intervention for thoracic pain correlated with thoracic stiffness.

Thoracic Spine Pain

Several studies have compared the efficacy of thoracic manipulations to other modalities; two of these studies were mentioned above. The RCT by Winters et al. demonstrated steroid injections and manipulation were more beneficial in the short-term than physiotherapy; however, long-term results were similar (51). And, the RCT by Crothers et al., compared thoracic manipulation, Graston, and placebo (de-tuned ultrasound), demonstrating no significant differences between the groups (59). Further studies suggest manipulation may have a larger effect size than many other modalities. An RCT by Savolainen et al. demonstrated that neck/shoulder pain patients improved more following four thoracic manipulations than instructions to perform a therapeutic exercise at 6 and 12 month follow-ups (66). An RCT by Giles et al. compared to acupuncture, medication, and manipulation for the treatment of spinal pain, demonstrating the manipulation group (followed by acupuncture and then medication) had the highest proportion of early recovery (asymptomatic status) and overall best results on pain, disability index scores, and ROM (67). An RCT by El-Sodany et al. demonstrated that cervical manipulation and cervical SNAG mobilization resulted in larger improvements in ROM, pain, and Neck Disability Index scores when compared to exercise alone (68). In a follow up of the Giles et al. RCT, Muller et al. (same group) found spinal manipulation resulted in long-term benefits (12 months) in 5 of the 7 outcome measures, compared to long-term benefits in just one outcome measure each for acupuncture and medication groups (69). In an interesting RCT by Korthals-de <a id="base-of-support" data-tip="1198" target="_blank" href="/glossary-term/base-of-support" class="glossary">Bos</a> et al., manual therapy (including manipulation) resulted in faster improvements (up to 26 weeks) and lower cost than either physiotherapy or physician care for neck pain. The total costs of manual therapy (approx $500) were around one-third of the costs of physiotherapy (approx. $1435), or general practitioner care (approx. $1525) (70). An RCT by Stochkendahl demonstrated that chiropractic treatment resulted in better outcomes for chest pain not related to acute coronary syndrome than self-management, which may have implications for both the efficacy of manipulations for orthopedic chest pain and for emergency room visits resulting from orthopedic pain being referred to rehab professionals (71). These studies suggest that thoracic manipulation is more beneficial than acupuncture, physician care, and self-directed exercise in the short and long-term, and more effective than conventional physiotherapy in the short-term (especially for cervical dysfunction).

Comparing Thoracic Manipulation to Other Modalities:

Research comparing manipulation techniques (for any joint) to other modalities has resulted in mixed findings; however, research findings on the combination of manipulation techniques with other modalities have demonstrated <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> results nearly ubiquitously. All studies in this section have been discussed above, and are briefly summarized here. Studies by Cleland et al., Yang et al. and Lee et al. have demonstrated the <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> efficacy of combining manipulation and exercise for the treatment of cervical pain (4, 5, 11). RCTs by Gonz&#xE1;lez-Iglesias et al., Puntumetakul et al. and Fern&#xE1;ndez-de-las-Pe&#xF1;as demonstrated better outcomes for neck pain patients when thoracic manipulation was added to electrotherapy/thermal program and/or massage (6, 7, 9, 14, 125). An RCT by Lau et al. demonstrated that mechanical neck pain patients receiving infrared radiation therapy (IRR) and standardized educational materials improved more when thoracic manipulation was added to their program (8). RCTs by Masaracchio et al., Muralidharan et al, and MPTh et al. demonstrated that the combination of cervical and thoracic manipulation with home exercise or conventional therapy was better than cervical manipulation and home exercise for mechanical neck pain (10, 12, 13). These studies have demonstrated that the addition of thoracic manipulation improves outcomes for cervical pain interventions including exercise, heat, electrotherapy, IRR, and/or standardized education materials.
The combination of thoracic manipulation with exercise and physician care has also demonstrated <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> efficacy for shoulder and elbow <a id="movement-impairment" data-tip="1579" target="_blank" href="/glossary-term/movement-impairment" class="glossary">dysfunctions</a> (25, 46 - 48). RCTs by Vinuesa-Montoya et al. and Coronado et al. demonstrated the efficacy of thoracic manipulations and exercise for the treatment of shoulder impingement (25, 46). An RCT by Rainbow et al. demonstrated that the combination of thoracic, cervical, and shoulder manipulation with home exercise was <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to grade 4 shoulder mobilization and exercise (47). An RCT by Mintken et al. demonstrated that adding 2 sessions of high-dose cervicothoracic manual therapy to an exercise program did not improve pain or disability (48), likely implying that 2 sessions in 4 weeks are insufficient to have a significant effect on outcomes. Cleland et al. demonstrated that the incorporation of CTJ manipulation into conventional therapy for <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylalgia significantly improved outcomes (26). An RCT by Winters et al, demonstrated steroid injections and manipulation were more beneficial in the short-term than physiotherapy for neck/shoulder pain (50). And, two RCTs by Bergman et al. demonstrated that the combination of thoracic manipulation with normal care (advice, analgesics, NSAIDs, exercise, and massage) was more successful than physiotherapy in the short-term, and resulted in better outcomes than physician care alone in the long-term for shoulder pain patients (51, 52). Whether <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> with exercise, injections, NSAIDS, educational materials or physician care, research ubiquitously suggests that the addition of manipulation results in better outcomes both short-term and long-term.

Thoracic Manipulation in Combination with Other Modalities:

A few studies have compared thoracic manipulation methods, adding detail to the protocols recommended below. An RCT by Karas et al demonstrated that the direction of the thoracic manipulation may not have an effect on outcomes for neck pain patients (72). Author&apos;s note, I have noted that cervicothoracic junction manipulations are often easier to perform and more effective when manipulating to the less restricted side. Although I have no explanation for this phenomenon, this study would seem to <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a> that either direction is effective. In another study by Karas et al. the <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">supine</a> &quot;targeted&quot; thoracic manipulation resulted in larger improvements in pain and flexion range of motion in individuals with neck pain, than the more &quot;general&quot; seated thoracic manipulations (73). Casanova-M&#xE9;ndez et al. compared the pistol thoracic manipulation and screw thoracic manipulation techniques on patients with mechanical neck pain, demonstrating that both techniques were equally effective for improving pain, ROM, and pain pressure threshold over common <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">trapezius</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> (74). Bereznick et al. demonstrated that the skin&#x2013;fascia interface over the thoracic spine does not impart much friction, suggesting that the ability to hook the spinous process in a <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> or <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a> direction is likely over-rated (75). These studies suggest that <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">supine</a> and <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> thoracic manipulation may be more effective than sitting variations, direction <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a> may not matter, and using pull on the skin to &quot;hook&quot; spinous process likely does not matter either.

Comparing Thoracic Manipulation Techniques

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 <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> 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, <a href="https://brookbushinstitute.com/video/deep-cervical-flexor-endurance-test" target="_blank" rel="noopener">deep cervical flexor endurance</a>, 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). Pag&#xE9; 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 <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> 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

<h4>Analgesia</h4>
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 Mart&#xED;nez-Segura et al. demonstrated that both cervical and thoracic thrust manipulation resulted in similar changes in pain pressure threshold in individuals with <a id="bilateral" data-tip="1552" target="_blank" href="/glossary-term/bilateral" class="glossary">bilateral</a> chronic neck pain (85). Terret et al. demonstrated a significant increase in pain tolerance over the <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">paraspinals</a> 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 <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> 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 (&quot;laser acupuncture&quot;) 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 <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">paraspinals</a> or <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> 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 <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> pain pressure threshold (91). Further, O&apos;Neill et al. demonstrated that thoracic manipulation did not have an effect on experimentally induced (saline injection), deep <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> pain (92). These studies suggest that the analgesic effects may be <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> 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.
<h4>Cardiovascular Changes</h4>
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 <a id="randomized-control-trial" data-tip="1407" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">trial</a> 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 <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> (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 <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> (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 &quot;<a href="https://brookbushinstitute.com/article/manipulations-cervical-spine/" target="_blank" rel="noopener">Joint Manipulations: Cervical Spine</a>&quot; clearly demonstrates that cervical manipulations result in significant sympathoexcitatory effects. It would seem unlikely that these effects are segment <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a>, 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).
<h4>Endocrine</h4>
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 <a id="hypomobility" data-tip="1676" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobile</a> 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.
<h4>Muscular Activity</h4>
Several studies have demonstrated a change in <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> 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 <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> 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 <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> in a group of low back patients (108). Herzog et al. compared thoracic manipulation to <a href="https://brookbushinstitute.com/article/joint-mobilization-cervical-and-thoracic-spine" target="_blank" rel="noopener">thoracic mobilization</a>, 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 <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> 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 <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> 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 <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> 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 <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">lower trapezius</a> strength following thoracic manipulation in asymptomatic individuals (113). These changes in activity suggest that manipulation effects both <a id="proximal" data-tip="1564" target="_blank" href="/glossary-term/proximal" class="glossary">proximal</a> and relatively <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> musculature, and further, that the changes may represent a normalization of activity - a decrease for typically over-active muscles like the <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a>, and an increase for typically under-active muscles like the <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">lower trapezius</a>.
<h4>Pulmonary Function</h4>
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 (<a id="nerve-cell" data-tip="1361" target="_blank" href="/glossary-term/nerve-cell" class="glossary">nerve</a> 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 &quot;uncommon&quot;, 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 <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> 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 <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> to <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> 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 <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> 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 <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> and injury, and defined using the <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/abbreviated-injury-scale" target="_blank" rel="noopener">Abbreviated Injury Scale</a> (AIS), this study suggests chiropractors use 1/5th the force needed to achieve a 10% chance of the lowest-rated <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> 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

Video Demonstration

Cervicothoracic Junction Manipulation

Thoracic Spine Manipulation

Thoracic Screw Manipulation

Bibliography

© 2019 Brent Brookbush
Questions, comments and critiques welcomed and encouraged

Copyright

A-Band - Refers to the part of the muscle cell that looks darker under a microscope.  This area of the cell is darker due to parallel arrangement of thicker filaments (myosin) and overlap with the thinner filaments (actin).
<ul>
 	<li>As a muscle contracts, the A-band is where actin and myosin interact.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

Accuracy - the proportion of individuals correctly identified by the test results.
<ul>
 	<li>For example, a special test with perfect accuracy would imply a test has 100% specificity, 100% sensitivity, 100% positive predictive value and 100% negative predictive values.</li>
</ul>

Action Potential - A rapid change in voltage, resulting in a wave of excitation, that may result in stimulation of a nerve or muscle cell.
<ul>
 	<li>In order for an action potential to be initiated, the resting membrane voltage must exceed the excitation threshold, which then results in a cascade of depolarization and the "wave of excitation." Any stimulus below that threshold will not result in an action potential, and a stimulus greater than the threshold will not increase a single action potential, but may result in additional action potentials.  In this way, the action potential functions more like an on/off switch (all or none), and less like a dimmer switch.</li>
</ul>

A single-joint movement pattern (most often) designed to load a specific under-active muscle(s), while minimizing the contribution of over-active synergists via specific cues/joint motions.
<ul>
 	<li style="text-align: left;">Activation techniques/exercises are performed with the intent of addressing a muscle exhibiting a reduction in activity (tone) as a result of, or contributing to postural dysfunction.</li>
 	<li style="text-align: left;">Activation techniques/exercises cannot be multi-joint movement patterns due to relative flexibility, altered reciprocal inhibition, and synergistic dominance resulting in compensation patterns.</li>
</ul>
Example, <a href="https://brentbrookbush.com/articles/corrective-exercise-articles/activation/gluteus-medius-activation-progression/" target="_blank">gluteus medius activation</a> involves resisted hip abduction while minimizing the contribution of the TFL via hip extension.

Active stretching is a term used to describe a stretch that involves an active contraction of opposing musculature to lengthen a muscle to its end range. Generally these stretches are held for 2-5 seconds and repeated for 8-15 repetitions.

Adenosine triphosphatase (ATPase): is the enzyme responsible for catalyzing (initiating and accelerating) the decomposition of ATP to ADP.
<ul>
 	<li>This dephosphorylation (breakdown) reaction releases energy for processes like muscular contraction.</li>
</ul>

Adenosine triphosphate (ATP): The molecule that functions as a universal energy-transfer molecule, providing most of the energy associated with muscular contraction and human movement. ATP is composed of an adenine group, a ribose group, and three molecules of inorganic phosphates.
<ul>
 	<li>Energy is provided when hydrolysis results in the cleaving of a phophate group; resulting in adenosine diphosphate, an inorganigic phosphate group, and energy.</li>
</ul>

Algometry - measuring the amount of pressure to result in sensitivity or pain, using an algometer.
<ul>
 	<li>Generally, research uses algometry to establish a minimum pain pressure threshold (PPT), in which a lower PPT implies more sensitivity and pain, and a higher PPT implies less sensitivity and pain. PPT is a common outcome measure in trigger point research.</li>
</ul>
<a href="https://brentbrookbush.com/wp-content/uploads/2019/07/Algometer.jpg"><img class="aligncenter wp-image-140177" src="https://brentbrookbush.com/wp-content/uploads/2019/07/Algometer.jpg" alt="Image of an Algometer" width="500" height="333" /></a>

All-or-none principle - a nerve or muscle cell's response to a stimulus is independent of the strength of the stimulus. If that stimulus exceeds the threshold potential (threshold of an action potential), the nerve or muscle fiber will respond completely; otherwise, there is no response.

Example, when a motor unit in the biceps brachii is stimulated it contracts the same way whether a 10 lb or 50 lb dumbbell is lifted.  It is actually the number of muscle cells and the size of the motor unit that determines force output.

&nbsp;

The transition period between eccentric load and concentric contraction during a repetition of an exercise.  This term is most often used in reference to power/plyometric exercises, in which a shorter amortization phase is believed to be beneficial.  The shorter amortization phase may better use the stored energy from the elastic deformation of connective tissue and enhance synchronization of myotatic (stretch) reflex with maximum voluntary contraction.

Example, the athlete was cued to spend as little time as possible in the bottom of their squat stance (the amortization phase) during a set of box jumps.

Muscles that oppose the prime mover and synergists for a given joint action.

That is, all the muscles that can perform the opposing joint action.

Example: The triceps and anconeus are antagonists during elbow flexion.

An anatomical direction; toward the front

Example, the face is on the anterior aspect of the head

Appendicular Skeleton - referring to the bones the bones of the arms and legs, as well as the bones that support them. This includes the pelvis, clavicle and scapula. There are approximately 126 bones in the appendicular skeleton.
<ul>
 	<li>Etymology - Appendicular, as in appendage, "that which is appended to something as a proper part," 1640s, from <a class="crossreference" href="https://www.etymonline.com/word/append?ref=etymonline_crossreference">append</a> + <a class="crossreference" href="https://www.etymonline.com/word/-age?ref=etymonline_crossreference">-age</a>. - <a href="https://www.etymonline.com/word/appendage" target="_blank" rel="noopener">Etymology Online</a></li>
</ul>
"Appendicular skeleton" is a label referring to a set of bones whose function is distinct from the bones of the "<a href="https://brentbrookbush.com/glossary/axial-skeleton/" target="_blank" rel="noopener">axial skeleton</a>".

A reflexive decrease in muscle activity due to joint dyskinesis.
For example, a reduction in deep cervical flexor activity as a result of cervical spine dyskinesis.

Arthrokinematic Motion - Small amplitude motions between bone surfaces at a joint.  The arthrokinematic motions are roll, glide (slide or translation), spin, compression and distraction (traction). Arthrokinematic motions accompany osteokinematic motions to maintain joint congruence.
<ul>
 	<li>Example, arthrokinematic motion of the talus includes posterior glide on the tibia during ankle dorsiflexion.</li>
</ul>
Synonyms include: arthrokinematics, passive accessory motion, joint play and component motion

&nbsp;

Assessment - is the act of assessing, i.e. determining the importance, size, or value of -

In most cases, the results of an assessment are compared to normative data. If the individual exhibits values that are within normal parameters, it may be assumed that the aspect of health or motion assessed is not contributing to the patient's complaint, symptoms or movement impairment. If the results fall outside of normal parameters, it may indicate that the aspect of health or motion assessed is contributing to, or being affected by the patient/client's complaint, symptoms, or movement impairment. In some cases, the results of an assessment are compared to an "ideal model." In this case, deviations from the ideal are noted as potential issues. For example, deviations noted in the <a title="Introduction to the Overhead Squat Assessment" href="https://brentbrookbush.com/online-courses/articles/assessment/introduction-overhead-squat-assessment/" target="_blank">Overhead Squat Assessment</a> are compared to an "ideal model" of posture and motion.

Assessments used by human movement professionals can be divided into three broad categories:
<ul>
 	<li>"Clear" the Patient/Client for Intervention - These are tests, assessments and evaluations used to determine if a patient/client's issue may improve given the assessing professional's scope, skills, abilities and willingness to treat that individual.
<ul>
 	<li>For example, many of the special tests used in orthopedic medicine assist in determining the level of pathology or likelihood of a particular diagnosis. Certain issues and diagnoses are beyond the scope of the human movement professional, and are better treated by diagnostic professionals in the medical community (physicians, podiatrists, surgeons, etc.). A Calf Squeeze (Thompson) Test is one example, in which a positive sign may indicate a rupture of the Achilles tendon that may be better treated via surgical intervention.</li>
</ul>
</li>
 	<li>Highlight Contraindications - Tests, assessments and evaluations used to stratify risk or preclude a professional from addressing certain tissues, motions or using a particular technique.
<ul>
 	<li>For example, the Vertebral Artery Test (VBI) is often used to determine if high velocity thrust mobilizations (manipulations) are safe for a patient with cervical dysfunction.</li>
</ul>
</li>
 	<li>Refine Exercise/Intervention Selection: Tests, assessments and evaluations used to assist the professional in determining which techniques, modalities and exercises will best address a patient/client's complaints or desired goals.
<ul>
 	<li>Most movement assessments fall into this category. For example, a positive <a href="https://brentbrookbush.com/vimeo_videos/elys-test-rectus-femoris-flexibility-assessment/" target="_blank">Ely's Test</a> may indicate a need to release and/or lengthen the <a href="https://brentbrookbush.com/articles/anatomy-articles/muscular-anatomy/rectus-femoris/" target="_blank">rectus femoris</a>.</li>
</ul>
</li>
</ul>
Note: An assessment, or assessment result, may fall into more than one category. For example, although goniometry is an assessment most often used to Refine Exercise/Intervention Selection, if a range of motion is significantly altered, with an abnormal end-feel, and/or causes the patient or client/pain, the individual may need to be referred to a physician for further testing and Clearance to resume rehab activities.  Further, that same patient may return to the human movement professional with a list of Contraindicated Activities from the physician. - "When in doubt, refer out!"

Axial Skeleton - referring to the bones of the head, neck, trunk and spinal column (does not include pelvis). There are approximately 80 bones in the axial skeleton.
<ul>
 	<li>Etymology - Axial, as in "axis", referring to "imaginary motionless straight line around which a body (such as the Earth) rotates," from Latin axis "axle, pivot, axis of the earth or sky" - <a href="https://www.etymonline.com/word/axis" target="_blank" rel="noopener">Etymology Online</a></li>
</ul>
"Axial skeleton" is a label referring to a set of bones whose function is distinct from the bones of the "<a href="https://brentbrookbush.com/glossary/appendicular-skeleton/" target="_blank" rel="noopener">appendicular skeleton</a>".

Balance - The ability to maintain a body’s center of mass over its base of support. Balance can be static or dynamic.
<ul>
 	<li>For example, maintaining balance is harder on one leg because the center of mass must stay over a much smaller base of support.</li>
</ul>

A ball and socket joint (also called a spheroid joint or spheroidal joint) is a synovial joint in which the rounded or spherical end of one bone fits into a cup-like depression of another bone. The distal bone is capable of motion around an indefinite number of axes, which have one common center. Examples include the hip and shoulder (glenohumeral joint)

Base of support (BoS) - refers to the area beneath an object or person, and the area within the perimeter created by every point of contact that the object or person makes with the supporting surface. This may include the <a href="https://brentbrookbush.com/articles/anatomy-articles/muscular-anatomy/gluteus-maximus/" target="_blank" rel="noopener">glutes</a> of someone sitting on a chair, or the back of someone leaning against a wall.
<ul>
 	<li>For example, during a single leg balance the BoS is the area of the foot in contact with the surface; however, when a person is standing on two feet, the BoS is the area of both feet and the surface between them.</li>
</ul>

Pertaining to both sides

Example, bilateral rows are performed with both arms at the same time.

Case-control Study - a particular form of retrospective study that samples a matched group of people who have, and do not have the outcome being studied. A case-control study is a quasi-experimental design, often used in medicine to aid in determining potential contributing factors (cannot determine causality). In this study type exposure is the dependent variable and outcome is independent.
<ul>
 	<li>Example, in this retrospective case-control, medical records were investigated for trends correlated with cervical pain (1).
<ol>
 	<li>Mäkela, M., Heliövaara, M., Sievers, K., Impivaara, O., Knekt, P., &amp; Aromaa, A. (1991). Prevalence, determinants, and consequences of chronic neck pain in Finland. American journal of epidemiology, 134(11), 1356-1367.</li>
</ol>
</li>
</ul>

An anatomical direction; toward the tail, relative to humans this term is often used to refer to "in the direction of the tale (toward the feet)".

Example, to release the trapezius muscle the therapist used a force directed caudally.

Center of mass (CoM) - an object's mean position of mass; that is, a point that is perfectly surrounded by an equal amount mass in all directions.

Center of gravity (CoG) - point where gravity appears to act. Since the human body is so small compared to the earth, we can assume gravity acts uniformly on the body, and that CoG and CoM are the same.
<ul>
 	<li>Example, the CoM of the human body while lying down or standing straight up is close to our navel. However, it is possible that during a resistance exercise, the combination of the body's weight and the weight of the resistance will place the combined CoM outside the body. For example, during the mid-portion of a <a href="https://brentbrookbush.com/vimeo_videos/back-squat/" target="_blank" rel="noopener">back squat</a> the CoM would be several anterior to the naval.</li>
</ul>

An anatomical direction; toward the head (synonym: cranial)

Example, hip pain was felt with any force directed cephalad.

Cohort Study - a particular form of longitudinal study that samples a cohort (a group of people who share a defining characteristic), performing a cross-section at intervals through-out a period of time. A cohort study is a quasi-experimental design often used in medicine to aid in determining etiology or a cause-and-effect relationship. In this study type exposure is the independent variable and outcome is dependent.
<ul>
 	<li>Example, the study by Cholewicki et al. (1) investigated Yale Varsity Athletes (the cohort) with 2 and 3 year follow up (longitudinal design) and found that trunk muscle response time to off-loading was predictive of future low back injury.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/core/increased-trunk-muscle-latency-may-cause-rather-than-result-from-low-back-pain/" target="_blank" rel="noopener noreferrer">Cholewicki, J., Silfies, S., Shah, R., Greene, H., Reeves, N. Alvi, K., Goldberg, B. (2005). Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine. 30(23), 2614-2620</a></li>
</ol>

Comparable Sign: A combination of pain, stiffness and/or spasm during examination that is comparable to the patients symptoms.
<ul>
 	<li>One common error made during evaluation with special tests is attention given to any discomfort or pain, rather than attempting to identify the pain/discomfort related to the patient's complaint (concordant/comparable sign). Many special tests purposefully test tissue limits and are at least mildly uncomfortable in every individual. Basing your assessment on positive tests that resulted in "concordant/comparable signs" will improve your chances of arriving at the correct diagnosis.</li>
</ul>

An alternative movement pattern that has been adopted to compensate for dysfunction/impairment in the human movement system.
Example: A lack of calf extensibility may limit dorsiflexion, leading to the knees bowing inward (functional valgus) and excessive forward lean of the torso during a squat.

An arthrokinematic motion - the approximation of joint surfaces; that is, a force that directs one bone surface into another resulting in a reduction in intra-articular volume. Although widely thought of as a "destructive force", it is likely best to consider compression as a naturally occurring, stabilizing force. Any arthrokinematic force in excess (spin, glide, roll, traction) may be viewed as potentially deleterious.

For example, during a squat the femoral head is compressed into the acetabulum by muscular forces, bodyweight and any additional external load.

Concave (Concavity) - Having an outline or surface curved like the interior surface of a bowl or sphere - to cave-in or curve inward.
<ul>
 	<li>Example, the internal surfaces of the pelvis is concave, holding some of the bodies viscera.</li>
</ul>

Concordant Sign - The patient's specific pain, symptom or complaint. 
<ul>
 	<li>One common error made during evaluation with special tests is attention given to any discomfort or pain, rather than attempting to identify the pain/discomfort related to the patient's complaint (concordant/comparable sign). Many special tests purposefully test tissue limits and are at least mildly uncomfortable in every individual. Basing your assessment on positive tests that resulted in "concordant/comparable signs" will improve your chances of arriving at the correct diagnosis.</li>
</ul>

Conductivity: Stimulation results in more than a local effect (1).
<ul>
 	<li>For example, in a muscle cell the stimulation of a motor endplate results in a change in cell membrane polarity that rapidly propagates (is conducted) along the entire length of the muscle cell, stimulating all sacromere.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

A condyloid joint (also called condylar, bicondylar, ellipsoid, or ellipsoidal) is an ovoid articular surface, or condyle, that is received into an elliptical cavity.  These joints permit movement in two planes.  Examples include the knee, metacarpophalangeal joints and metatarsophalangeal joints.

Connective Tissue Cell - One of the four basic types of animal tissue, consisting mostly fibers and ground substance.  These cells are specialized to binds organs together, holds them in place, protect them from external forces, and may fill space in the body's cavities.

Example, the body's muscles are enclosed in durable connective tissue sheets known as the "epimysium", "perimysium", and "endomysium," which and in support and transmitting force.
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

Contractility: The ability to shorten (1).
<ul>
 	<li>Contractility: Muscle cells are unique in the amount they can shorten when stimulated; this is this largerly due to the highly organized and unique arrangement of myofilaments (actin and myosin).</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Pertaining to the opposite side

Example, the external oblique muscle performs contralateral rotation; rotation to the opposite side.

Convex (Convexity) - Having an outline or surface curved like the exterior of a circle or sphere - to bulge or curve outward.
<ul>
 	<li>Example, the top of your head is shaped by the convex exterior surface of your skull.</li>
</ul>

Correlational Research - Non-experimental <a href="https://www.questionpro.com/blog/what-is-research/">research</a> method in which the statistical relationship between two variables is investigated.
<ul>
 	<li>In this research by Kwon et al., a correlation was noted between a decrease in extensibility during a hamstring length test (goniometry) and current knee pain (1).</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/correlation-patellofemoral-pain-syndrome-pfps-hamstring-activity/" target="_blank" rel="noopener">Kwon O, Yun M, and Lee W. (2014). Correlation between intrinsic patellofemoral pain syndrome in young adults and lower extremity biomechanics. J. Phys. Ther. Sci. 26: 961-964</a></li>
</ol>

Counter-nutation - posterior rotation of sacrum relative to ilium, and/or anterior rotation of ilium relative to sacrum.
<ul>
 	<li>The pelvic floor muscles are examples of muscle that may counter-nutate the sacrum.</li>
</ul>
[caption id="attachment_126335" align="aligncenter" width="400"]<a href="https://brentbrookbush.com/wp-content/uploads/2018/10/Nutation.png"><img class=" wp-image-126335" src="https://brentbrookbush.com/wp-content/uploads/2018/10/Nutation.png" alt="Nutation and Counter-nutation of the Sacroiliac Joint" width="400" height="967" /></a> Nutation and Counter-nutation of the Sacroiliac Joint[/caption]

&nbsp;

Crossover (Study) Design - A type of longitudinal, repeated measures quasi-experimental design in which each group receives both treatments, but at different times. It is named "crossover" due to the patients "crossing-over" to the other treatment or sham group after a specified period of time.
<ul>
 	<li>This type of study has the advantage of every individual serving as their own control, which may reduce the influence of confounding variables.</li>
 	<li>Unfortunately, the design itself introduces the chances that anyone receiving the experimental variable in the first period will continue to be effected in the second period.</li>
</ul>
In a study by Senna et al., a cross-over design was used to investigate the difference load made on inter-set rest intervals (1).
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/strength-training-research-corner/heavy-vs-light-load-single-joint-exercise-performance-with-different-rest-periods/" target="_blank" rel="noopener">Senna, G.W., Rodrigues, B.M., Sandy, Scudese, Bianco, A, &amp; Dantas, E.H.M. (2017). Heavy vs light load single-joint exercise performance with different intervals. Journal of Human Kinetics, 58, 197-206. </a></li>
</ol>

Cross-sectional Study - a research design that involves gathering data from a population or representative subset at a specific point in time.
<ul>
 	<li>Example, the study by Karimi-Mobarake et al.(1) investigated the prevalence of genu varum and genu valgum among school children 7-11 years old in Iran.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/low-prevalence-of-genu-varum-and-valgum-among-elementary-school-children/" target="_blank" rel="noopener noreferrer">Karimi-Mobarake, M., Kashefipour, A., Yousfnejad, Z. The prevalence of genu varum and genu valgum in primary school children in Iran 2003-2004. (2005) Journal of Medical Science 5(1). 52-54</a></li>
</ol>

Cytokine - A broad and loose category of small proteins that act through receptors, and are especially important to immune function (inflammation).
<ul>
 	<li>Cytokines include substances such as interferon, interleukin, and growth factors, which are secreted by certain cells of the immune system and have an effect on other cells. Their definite distinction from hormones is a topic of continued research.</li>
</ul>
&nbsp;

Dependent variable - in research, this is the variable that is changed by the independent variable, most often this is the "outcome" of the study.
<ul>
 	<li>Example, in the study by Cleland et al. (1), the independent variable is "thoracic manipulation," and the dependent variable is "lower trapezius muscle strength."</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/short-term-effects-lower-thoracic-manipulation-lower-trapezius-muscle-strength/" target="_blank" rel="noopener noreferrer">Cleland J, Selleck B, Stowell T, Brown L, Alberini S, St. Cyr H, Caron T. Short-term Effects of Thoracic Manipulation on Lower Trapezius Muscle Strength.  Journal of Manual &amp; Manipulative Therapy. 2004; 12(2): 82-90</a></li>
</ol>

An anatomical direction; further from the trunk or center of the body

Example, the foot is at the distal end of the leg.

An arthrokinematic motion - a force applied to a body part that may result in the separation of joint surfaces, a reduction in intra-articular pressure, and/or an increase in intra-articlar space.

For example, to hang from one's hands (i.g. in preparation for a pull-up) results in a traction force on the glenohumeral joint (shoulder).

An anatomical term of location; back or upper surface

Example, shoe laces may compress tissues on the dorsal surface of the foot

The "drawing-in" maneuver is a common cue used during exercise and rehabilitation programs. A light contraction of the <a href="https://brentbrookbush.com/articles/muscular-anatomy/transverse-abdominis/" target="_blank" rel="noopener">transverse abominis</a> (and potentially the entire <a href="https://brentbrookbush.com/articles/corrective-exercise-articles/core-subsystems/intrinsic-stabilization-subsystem/" target="_blank" rel="noopener">intrinsic stabilization subsystem</a>) achieved by gently pulling the lower abdominal region away from one's waist band. This should have minimal effect on breathing, and should not be confused with a maximal contraction of the <a href="https://brentbrookbush.com/articles/muscular-anatomy/transverse-abdominis/" target="_blank" rel="noopener">transverse abdominis</a> resulting in a "vacuum pose".
<ul>
 	<li>Research often refers to this maneuver as the "abdominal drawing-in maneuver"; abbreviated ADIM.</li>
</ul>
Development and introduction of this cue into practice is based on the pivotal research and resulting text:
<ol>
 	<li>Carolyn Richardson, Paul Hodges, Julie Hides. Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004</li>
</ol>

Faulty or abnormal movement; an alteration of normal kinematics.

For example, joint stiffness or a reduction in arthrokinematics motion that results in limited osteokinematic range of motion - inadequate inferior glide of the femoral head resulting in limited abduction of the hip.

The seeping into, or abnormal collection of fluid in a body cavity.

For example, knee effusion describes swelling within the knee joint.

Note: the word "effusion" is used differently in medicine than it is used in reference to the movement (seeping out) of liquids and gases, for example in chemistry.

&nbsp;

A trait of body tissues that allows a tissue to return to its resting length or state after deformation or stretch.
Example:  Muscle is elastic tissue; many muscles will return to their resting length after being stretched to 150% of that length without any appreciable change in tissue quality.

Elasticity: Elasticity refers to the ability of a cell to return to its resting length after being stretched/lengthened.
<ul>
 	<li>Note: this term is often confused with extensibility. Elasticity is not the ability to stretch; it is the ability to return to normal length after being stretched. Muscle tissue, connective tissue and even nerve tissue have varying levels of elasticity.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Epithelial cell - One of the four basic cell types, found lining the body's cavities, blood vessels, organs and constitutes most gland tissue.  These cells are specialized to aid with absorption, secretion, or act as a barrier from foreign objects.
<ol>
 	<li>Saladin, K. S., &amp; Miller, L. (1998). Anatomy &amp; physiology. New York (NY): WCB/McGraw-Hill.</li>
</ol>

Equilibrium - a state in which opposing forces or influences are balanced.
<ul>
 	<li>For example, to maintain a neutral trunk while pushing or pulling a weight in one hand, your core musculature must balance the force by creating an equal amount of force in the opposite direction.</li>
</ul>

The study of causation, or origination. The word is commonly used in the medical professions, where it may refer to the study of why things occur, or the reason behind why things act a certain way.

For example, the etiology of low back pain is a complex subject, with multiple contributing factors and various structures implicated.

<div class="gs_citr" tabindex="0">Evidence-based medicine (practice) is the integration of best research evidence with clinical expertise and patient(client) values (2)."</div>
<ul>
 	<li class="gs_citr" tabindex="0">...the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients (clients).  It involves the integration of at least (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve (1).</li>
</ul>
&nbsp;
<ol>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Sackett, D. L., Rosenberg, W. M., Gray, J. M., Haynes, R. B., &amp; Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn't. Bmj, 312(7023), 71-72.</li>
 	<li class="gs_citr" tabindex="0">Sackett D et al. Evidence-Based Medicine: How to Practice and Teach EBM, 2nd edition. Churchill Livingstone, Edinburgh, 2000, p.1</li>
</ol>

Excitability: The ability of a cell to change in membrane conductance as a response to stimulation.

<ul>
 	<li>For example, muscle cells are specialized to react to a change in membrane potential with contraction, where as nerve cells are specialized to propagate a change in membrane potential along there axons and communicate that message to other tissues via neurotransmitters.
</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Excitation threshold: The level that a depolarization must reach for an action potential to occur.
<ul>
 	<li>The excitation threshold is a contributing factor to the "all-or-none" response of muscle and nerves cells to a stimulus.</li>
</ul>

Exercise Progression - Modification of an exercise with the intent of promoting adaptation by increasing demand. This can be accomplished by increasing reps, load, tempo, range of motion, complexity, and/or challenge to an individual's stability.
<ul>
 	<li>Because load, reps, tempo and complexity are often explicitly noted, the term "exercise progression" is most often used throughout Brookbush Institute (BI) content to refer to an exercise, or series of exercises that make it harder to maintain stability with good form.
<ul>
 	<li>Sample Exercise Progression: <a href="https://brentbrookbush.com/vimeo_videos/kneeling-chop-pattern/" target="_blank" rel="noopener">Kneeling Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/static-standing-chop-pattern/" target="_blank" rel="noopener">Standing Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/single-leg-chop-pattern/" target="_blank" rel="noopener">Single-leg Chop</a></li>
</ul>
</li>
</ul>

Exercise regression - The opposite of progression; that is, modification of an exercise with the intent of reducing demand. This can be accomplished by decreasing reps, load, tempo, range of motion, complexity, and/or challenge to an individual's stability. Generally, regressions are used to modify an exercise to the client's current level of ability, with the intent of improving form, motor learning and retention.
<ul>
 	<li>Because load, reps, tempo and complexity are often explicitly noted, the term "exercise regression" is most often used throughout Brookbush Institute (BI) content to refer to an exercise or series of exercises that make it easier to maintain stability with good form.
<ul>
 	<li>Sample Exercise Regression: <a href="https://brentbrookbush.com/vimeo_videos/single-leg-chop-pattern/" target="_blank" rel="noopener">Single-leg Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/static-standing-chop-pattern/" target="_blank" rel="noopener">Standing Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/kneeling-chop-pattern/" target="_blank" rel="noopener">Kneeling Chop</a></li>
</ul>
</li>
</ul>

Experimental Research - Studies in which the researchers introduce the variable to be studied, with the intent of observing the outcome. This is different than observational research which observes the effect of a variable already present. Many texts also assert that experimental research should include randomization and ideally a control group, as is seen in Randomized Control Trials. Studies in which the variable is introduced by the researchers, but participants are not randomized may be considered Quasi-experimental research.
<ul>
 	<li>In this study by Esformes, the experimental variable was squat depth and the outcome measures observed were various performance measures related to power (1).</li>
</ul>
<ol>
 	<li><a href="https://brookbushinstitute.com/article/back-squat-depth-lower-body-post-activation-potentiation/" target="_blank" rel="noopener">Esformes, J., &amp; Bampouras, T. (2013). Effect of back squat depth on lower-body postactivation potentiation. Journal of Strength and Conditioning Research, 27(11), 2997-3000.</a></li>
</ol>
&nbsp;

Extensibility: The ability of a cell to be stretched or lengthened without damage (1).
<ul>
 	<li>For example, most cells would rupture with even a modest stretch, but muscles can stretch up to 3 times their contracted length.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

False Negative - the proportion of negatives in a group that were assessed incorrectly (assessed as negative when the patient was actually positive)
<ul>
 	<li>Test Results: Although most tests/assessments result in either a positive or negative, the accuracy of a test is dependent on the number  of positives and negatives that are correct. Therefore, when the accuracy of a test is determined, their are 4 possible results, because a positive or negative result could be right (true) or wrong (false).</li>
</ul>

False Positive - the proportion of positives in a group that were assessed incorrectly (assessed as positive when the patient was actually negative)
<ul>
 	<li>Test Results: Although most tests/assessments result in either a positive or negative, the accuracy of a test is dependent on the number  of positives and negatives that are correct. Therefore, when the accuracy of a test is determined, their are 4 possible results, because a positive or negative result could be right (true) or wrong (false).</li>
</ul>

The function of fascia is to transmit force, provide support, and protect tissues. Fascia can effect motion by:
Transmitting force from one or more muscles (example: the thoracolumbar fascia)
Restricting motion in cases of adaptive shortening and/or adhesion to proximal structures (example: iliotibial band in cases of lower-leg dysfunction)
Elastic recoil after stretching can contribute to force production (example: plyometric exercise)

Note: There is evidence that fascia may house more receptors related to human movement than other tissues. In this way fascia may act as a motherboard for the nervous system

The fascial system does not contract or develop trigger points, and its capacity to adapt to stretching and or strengthening exercise is limited, especially when compared to the adaptive capacity of muscle tissue.

Fibromyalgia - A loosely defined diagnosis that is associated with a combination of widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. Consideration may also be given to the presence of psychosocial stressors and inflammatory disease in the patients history. Newer research suggests that fibromyalgia may be at least in part due to central sensitization of myofascial pain, often associated with trigger points (1 - 4).
<ol>
 	<li>Wolfe, F. (2018). Fibromyalgia Syndrome and Fibromyalgia Syndrome Criteria: Problems in Definition and Validity. Fibromyalgia Syndrome and Widespread Pain: From Construction to Relevant Recognition.</li>
 	<li>Wolfe, F., Smythe, H. A., Yunus, M. B., Bennett, R. M., Bombardier, C., Goldenberg, D. L., ... &amp; Fam, A. G. (1990). The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis &amp; Rheumatism: Official Journal of the American College of Rheumatology, 33(2), 160-172.</li>
 	<li>Alonso-Blanco, C., Fernandez-de-las-Penas, C., Morales-Cabezas, M., Zarco-Moreno, P., Ge, H. Y., &amp; Florez-García, M. (2011). Multiple active myofascial trigger points reproduce the overall spontaneous pain pattern in women with fibromyalgia and are related to widespread mechanical hypersensitivity. The Clinical journal of pain, 27(5), 405-413.</li>
 	<li>Staud, R., Nagel, S., Robinson, M. E., &amp; Price, D. D. (2009). Enhanced central pain processing of fibromyalgia patients is maintained by muscle afferent input: a randomized, double-blind, placebo-controlled study. PAIN®, 145(1-2), 96-104.</li>
</ol>
&nbsp;

Muscles that act to reduce or prevent movement at proximal joints to improve force transmission.
Example: The muscles of the core are important fixators; reducing motion of the spine/trunk to enhance force transmission between the extremities and environment.

An increase in joint stability via compressive forces resulting from muscular contraction and increased tension in fascial structures (1,2).
<ul>
 	<li>This term is most often used in reference to core intrinsic stabilizers, the thoracolumbar fascia and the sacroiliac joint; however, force closure and form closure have been mentioned in the literature referring to other joints.</li>
 	<li>Related term: Form closure</li>
</ul>
<ol>
 	<li>Andry Vleeming, Vert Mooney, Rob Stoeckart. Movement, Stability &amp; Lumbopelvic Pain: <a class="glossaryLink " title="Glossary: Integration" href="https://brentbrookbush.com/glossary/integration/" target="_blank" rel="noopener noreferrer" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Integration&lt;/div&gt;&lt;div class=glossaryItemBody&gt;Making a whole of parts.&lt;br /&gt;&lt;br /&gt;Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.&lt;/div&gt;">Integration</a> of Research and Therapy. (c) 2007 Elsevier Limited</li>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Vleeming, A., Pool-Goudzwaard, A. L., Stoeckart, R., van Wingerden, J. P., &amp; Snijders, C. J. (1995). The Posterior Layer of the Thoracolumbar Fascia| Its Function in Load Transfer From Spine to Legs. Spine, 20(7), 753-758.</li>
</ol>

The relative contribution of joint shape and structure to the stability of a joint (1,2).
<ul>
 	<li>This term is most often used in reference to the "rough" articulating surfaces of the sacroiliac joint and the wedge shape of the sacrum; however, force closure and form closure have been mentioned in the literature referring to other joints.</li>
 	<li>Related term: Force closure</li>
</ul>
<ol>
 	<li>Andry Vleeming, Vert Mooney, Rob Stoeckart. Movement, Stability &amp; Lumbopelvic Pain: <a class="glossaryLink " title="Glossary: Integration" href="https://brentbrookbush.com/glossary/integration/" target="_blank" rel="noopener noreferrer" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Integration&lt;/div&gt;&lt;div class=glossaryItemBody&gt;Making a whole of parts.&lt;br /&gt;&lt;br /&gt;Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.&lt;/div&gt;">Integration</a> of Research and Therapy. (c) 2007 Elsevier Limited</li>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Vleeming, A., Pool-Goudzwaard, A. L., Stoeckart, R., van Wingerden, J. P., &amp; Snijders, C. J. (1995). The Posterior Layer of the Thoracolumbar Fascia| Its Function in Load Transfer From Spine to Legs. Spine, 20(7), 753-758.</li>
</ol>

An arthrokinematic motion - linear motion across a joint surface parallel to the plane of the adjacent joint surface, just as your posterior moves relative to a "slide" in a park.

For example, the glide of facet joint in the spine during spinal flexion and extension, or the posterior glide of the humeral head that must accompany anterior roll to maintain congruence with glenoid fossa during shoulder horizontal adduction.

A plane joint (also called an arthrodial joint, gliding joint or plane articulation) is a synovial joint which allows only gliding movement in the plane of the articular surfaces. The opposed surfaces of the bones are flat or almost flat, with movement generally limited by tight capsules and ligaments. Plane joints are numerous, are most often small, and allow very little motion.  Examples include the carpal joints of the wrist, the tarsal joints of the ankle, and the facet joints of the spine.

"...refers to the measurement of angles, in particular the measurement of angles created at human joints by the bones of the body (1).

&nbsp;
<ol>
 	<li>Cynthia C. Norkin, D. Joyce White. Measurement of Joint Motion: A Guide to Goniometry 3rd Edition. Copyright (C) 2003 by F.A. Davis Company</li>
</ol>

Ground reaction force (GRF) - The force exerted by the ground on the body in contact with it.

For example, when a runner's foot strikes the ground with a force equal to the mass of the individual times their acceleration due to gravity, momentum and muscular exertion, the ground exerts an equal and opposite force on the runner's foot.
<ul>
 	<li>GRF is often measured in research studies using force plates as a means of quantitatively measuring the force generated by an individual.</li>
</ul>

H-Band - Refers to the central zone of a sarcomere that looks lighter under a microscope.  This area of the sarcomere is a lighter portion of the A-band where there is no overlap between the thinner filaments (actin), and the thicker filaments (myosin).
<ul>
 	<li>Example, when a muscle contracts, actin and myosin cross-bridging occurs in the region of the A-band until the H-band is reached where no overlap occurs.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

A hinge joint (also called a ginglymus) is a synovial joint in which the articular surfaces fit one another in a way that only permits motion in one plane. Examples include the elbow, the knee (unless considered a condyloid joint) and the interphalangeal joints.

Holism (holistic) (biological holism) - (from Greek holos "all, whole, entire") is the idea that systems and their properties should be viewed as wholes, not just as a collection of parts.
<ul>
 	<li>Summarized by Aristotle in his "Metaphysics": "The whole is more than the sum of its parts". However, the term "holism" was introduced into language by the South African statesman Jan Smuts as recently as 1926. (Smuts J. C. 1987 [1926]. Holism and evolution. Cape Town: N &amp; S Press.)</li>
</ul>
Example: The Brookbush Institute promotes a holistic approach to human movement science, in which the muscular, fascial, articular and neural systems are not viewed as separable and all proximal segments are considered.

Hormone: Chemical messengers produced by the endocrine system, transported via tissue fluids such as blood, to stimulate cells to "act."
<ul>
 	<li>Example: Growth hormone is secreted by the pituitary gland in the brain; stimulating growth, cell reproduction and cell regeneration in certain types of cells</li>
</ul>
The English physician E. H. Starling discovered in collaboration with the physiologist W. M. Bayliss secretin, the first hormone, in 1902. (1).
<ol>
 	<li>Henriksen, J. H., &amp; de Muckadell, O. S. (2000). Secretin, its discovery, and the introduction of the hormone concept. Scandinavian journal of clinical and laboratory investigation, 60(6), 463-472.</li>
</ol>

A range of motion achieved by the patient/client that is more than normal.
<ul>
 	<li>Note: Both hyper-mobility and hypo-mobility may adversely affect motion and may lead to deleterious effects on joints and soft tissue over time. There is no evidence to suggest that more or less flexibility than normal is beneficial.</li>
</ul>
Example: If an individual can place their forehead on their knees they are likely hypermobile at one, if not several joints

Example 2: 110° of shoulder external rotation would be considered hyper-mobile.

Hyperplasia is an increase in organic tissue size due to an adaptive increase in the number of cells per organ.
<ul>
 	<li>Although muscle hyperplasia has been noted in some animals, human muscle tissue does not seem to have this adaptive ability.</li>
</ul>

A condition of excessive tone of the skeletal muscles; increased resistance of muscle to passive stretching.  May be related to increased neural drive, synergistic dominance, trigger points, reflexive over-activity, and/or muscle length.
Example:  Individuals who exhibit ankle eversion and abduction during an overhead squat assessment likely have hypertonic fibularis (peroneal) muscles.

Muscular hypertrophy is an increase in muscle mass/size due to increase in the volume and cross-sectional area (CSA) of individual muscle cells. The increase in cross-sectional area can be attributed to an an increase in contractile proteins and structural elements (myofibrillar hypertophy), as well as an increase in glycogen storage and elements related to metabolism (sarcoplasmic hypertophy). Hypertrophy is an adaptation of both cardiac and skeletal muscle fibers in response to progressive increases in workload.
<ul>
 	<li>Note: Hypertrophy is not hyperplasia. Hyperplasia is an increase in muscle size due to an adaptive increase in the number of muscle fibers/cells per muscle. This type of adaptation does not occur in human muscle tissue.</li>
</ul>

A range of motion achieved by a patient/client that is less than normal.
<ul>
 	<li>Note: Both hyper-mobility and hypo-mobility may adversely affect motion and may lead to deleterious effects on joints and soft tissue over time. There is no evidence to suggest that more or less flexibility than normal is beneficial.</li>
</ul>
Example: If the end range of shoulder external rotation is reached and measured as 75° during goniometric assessment, the client/patient is exhibiting hypomobility of the glenohumeral joint (shoulder).

Hypothesis - a proposed explanation for a phenomenon; "scientific hypotheses" are generally constructed in a way that is testable or falsifiable.
<ul>
 	<li>Example: The hypothesis, "excessive knee valgus may be correlated with future knee pain and injury," has been the subject of several studies published over the last decade.</li>
</ul>

Diminished tone of skeletal muscles; diminished resistance of muscles to passive stretching.   May be related to inhibition, reciprocal inhibition, arthrokinematics inhibition and/or  increased resting length of muscle.
Example:  If your knees cave (hip adduction) during a squat or leg-press it is likely that your gluteus medius is hypotonic.

I-Band - Refers to the part of the muscle cell that looks lighter under a microscope.  This area of the cell is lighter due to parallel arrangement of thinner filaments (actin), and no overlap with the thicker filaments (myosin).
<ul>
 	<li>As a muscle contracts, the I-bands will decrease in width and move closer to one another.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

Independent variable - in research, this is the variable or phenomenon being manipulated in the study.
<ul>
 	<li>Example, in the study by Ghanbari et al. (1), the independent variable is "knee joint mobilization", the dependent variable is "quadriceps muscle strength."</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/effect-knee-joint-mobilization-quadriceps-muscle-strength/" target="_blank" rel="noopener noreferrer">Ghanbari A. and Kamalgharibi S. (2013). Effect of knee joint mobilization on quadriceps muscle strength. International Journal of Health and Rehabilitation Sciences. 2(4): 186-191</a></li>
</ol>

An anatomical direction; toward the bottom (below)

Example, the mouth is inferior to the eyes

A reduction in neural drive, muscular activity, and or force output due to altered neuromuscular reflex.  Alterations in neuromuscular reflex may occur due to increases in muscle length (hypothesis: increased excitation threshold), altered reciprocal inhibition in response to increased antagonist tone, and or alterations in joint motion (arthrokinematics inhibition).

Making a whole of parts.

Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.

Intermuscular Coordination - Optimal timing and motor unit recruitment of agonists, antagonists, synergists, neutralizers, stabilizers and fixators.

Example: Role of Muscles during Hip Extension
<ul>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Prime Mover" href="https://brentbrookbush.com/glossary/prime-mover/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Prime Mover&lt;/div&gt;The muscle most responsible for a joint action under load -&lt;br /&gt;&lt;br /&gt;That is, the muscle that can produce the most force for a given joint action. Often this term is used synonymously with the term agonist. The prime mover as defined above, may or may not be the most active muscle for a joint action during activities of daily living.&lt;br /&gt;&lt;br /&gt;Example: the gluteus maximus is the most powerful hip extensor and therefore the prime mover; however, the hamstrings are likely the most active hip extensors during low level activities like walking or standing.">Prime Mover</a>:  <a href="https://player.vimeo.com/external/82855344.hd.mp4?s=54c3e7d98fb9d4e0af8d282c85ba9b3e">Gluteus maximus</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Synergists" href="https://brentbrookbush.com/glossary/synergists/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Synergists&lt;/div&gt;Muscles that assist the prime mover in performing a joint action.&lt;br /&gt;&lt;br /&gt;That is, all muscles that can perform a joint action that are not the prime mover, are termed synergists.&lt;br /&gt;Example: The rectus abdominis is the prime mover of spinal flexion. All other muscles that can perform spinal flexion are synergists including – external obliques, internal obliques and psoas.">Synergists</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/biceps-femoris/">Biceps femoris (long head)</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/semitendinosus-and-semimembranosus/">semitendinosus, semimembranosus</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/adductors/">posterior head of adductor magnus</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Antagonist" href="https://brentbrookbush.com/glossary/antagonists/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Antagonist&lt;/div&gt;Muscles that oppose the prime mover and synergists for a given joint action.&lt;br /&gt;&lt;br /&gt;That is, all the muscles that can perform the opposing joint action.&lt;br /&gt;&lt;br /&gt;Example: The triceps and anconeus are antagonists during elbow flexion.">Antagonists</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/psoas/">Psoas</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/iliacus/">iliacus</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/tensor-fascia-latae-tfl/">tensor fascia latae</a> (TFL),<a href="https://brentbrookbush.com/articles/muscular-anatomy/rectus-femoris/"> rectus femoris</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/adductors/">anterior adductors (especially pectineus)</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/sartorius/">sartorius</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Neutralizer" href="https://brentbrookbush.com/glossary/neutralizers/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Neutralizer&lt;/div&gt;Muscles that oppose unwanted joint motions created by the prime mover and/or synergists, and/or muscles that prevent unwanted ancillary motion.&lt;br /&gt;Example: The teres minor and infraspinatus neutralize the internal rotation force created by the pectoralis major during horizontal adduction of the shoulder.">Neutralizers</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-minimus/">Gluteus minimus</a> and <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-medius/">anterior fibers of gluteus medius</a> neutralize external rotation force of <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-maximus/">gluteus maximus</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Stabilizer" href="https://brentbrookbush.com/glossary/stabilizers/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Stabilizer&lt;/div&gt;Muscles whose primary role is to improve arthrokinematics by maintaining optimal alignment of joint surfaces.&lt;br /&gt;&lt;br /&gt;Most often these muscles are the most intrinsic muscles of a joint, have a larger percentage of Type I muscle fibers and are rich in proprioceptors.&lt;br /&gt;Example: The muscles of the rotator cuff act as stabilizers for most shoulder motions.">Stabilizers</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/deep-rotators-of-the-hip/">Deep rotators of hip</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Fixator" href="https://brentbrookbush.com/glossary/fixators/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Fixator&lt;/div&gt;Muscles that act to reduce or prevent movement at proximal joints to improve force transmission.&lt;br /&gt;Example: The muscles of the core are important fixators; reducing motion of the spine/trunk to enhance force transmission between the extremities and environment.">Fixators</a>: <a href="https://brentbrookbush.com/articles/core-subsystems/intrinsic-stabilization-subsystem/">Intrinsic stabilization subsystem</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/rectus-abdominis/">rectus abdominis</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/internal-obliques/">internal</a> and <a href="https://brentbrookbush.com/articles/muscular-anatomy/external-obliques/">external obliques</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/quadratus-lumborum/">quadratus lumborum</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/erector-spinae/">erector spinae</a></li>
</ul>
&nbsp;

Example from: <a href="https://brentbrookbush.com/articles/anatomy-articles/introduction-to-functional-anatomy/kinesiology-of-the-hip/" target="_blank" rel="noopener">Introduction to Functional Anatomy: Kinesiology of the Hip</a>

Intramuscular coordination refers to the coordinated recruitment of motor units within a single muscle. This concept is used to explain increases in maximal strength and power; however, the coordinated and sequential recruitment of motor units is also essential to strength endurance and smooth coordinated motion.  Related terminology may include; motor unit recruitment, preferential recruitment, rate coding, sequence, etc..

Example: It is hypothesized that the "shaking" noted during a novice exercisers attempt at an activity like the <a href="https://brentbrookbush.com/vimeo_videos/ball-crunch-and-progressions/" target="_blank">stability ball crunch</a> may be due to relatively poor intramuscular coordination. Rather than smooth, sequential firing of rectus abdominis motor units, groups of motor units turn on and off in an uncoordinated manner.

Pertaining to the same side

Example, the quadratus lumborum performs ipsilateral flexion; lateral flexion toward the same side as the muscle.

An isoform, or variant, is a member of a set of similar proteins, that originate from the same gene, or gene family.
<ul>
 	<li>Example, the variations in myosin heavy chain proteins (MHC I, MHC IIA, MHC IIB/X) that contribute to the characteristic differences between muscle fiber types.</li>
</ul>

“The Prime Assumption”
Everything crossing a joint will influence joint motion during every joint action.

A concept that has expanded over the past several decades to describe the integration of 4 body systems (muscle, joints, fascia and nerves), as well as, the coordinated function of various body segments (e.g. hip, knee and ankle) to produce motion. Kinetic referring to motion, and chain being an analogy for the interdependent link between systems.

Example, the posterior kinetic chain, refers to the integrated function of nerves, muscles, fascia and joints on the posterior side of the body.

The concept of the kinetic chain was originally adapted from the work of a mechanical engineer named Franz Reuleaux (Kinematics of Machinery (1875)) by Dr. Arthur Steindler in 1955 (Steindler A: Kinesiology of the Human Body. Springfield, IL, Charles C. Thomas Co.. 1955).

Latent Trigger Point - A myofascial trigger point that is not painful at rest, only painful when palpated, and may or may not exhibit a characteristic referral pain pattern when palpated.  Latent trigger points do result in an acute point of sensitivity, in a taut band of muscle, and may restrict range of motion (1).

Note: Based on the clinical experience, the Brookbush Institute suggests that latent trigger points (sometimes refereed to as Tender Points) are more common than active trigger points. Further, they are likely addressed more often than trigger points; being the intended target of many soft-tissue mobility techniques.
<ol>
 	<li>David G. Simons, Janet Travell, Lois S. Simons, Travell &amp; Simmons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body: Second Edition,© 1999 Williams and Wilkens</li>
</ol>

An anatomical direction; further from the midline

Example, the anterior deltoid is lateral to the pectoralis major

Length/Tension Relationship - The amount of force generated by a muscle is dependent on sarcomere length.
<ul>
 	<li>The ability of sarcomere to maximally produce force occurs when sarcomere length results in optimal overlap between actin and myosin. Stretching a sarcomere decreases overlap between actin and myosin filaments and reduces force production (1-3). When length is less than optimal, actin from opposite ends overlap and interfere with cross-bridging, and myosin filament are compressed as they contact the the Z-disk also reducing force (4)</li>
</ul>
<ol>
 	<li>Gordon, A. M., Huxley, A. F., &amp; Julian, F. J. (1966). The variation in isometric tension with sarcomere length in vertebrate muscle fibres. The Journal of physiology, 184(1), 170-192.</li>
 	<li>Edman, K. A. P. (1966). The relation between sarcomere length and active tension in isolated semitendinosus fibres of the frog. The Journal of Physiology, 183(2), 407-417.</li>
 	<li>Lieber, R. L., Loren, G. J., &amp; Friden, J. (1994). In vivo measurement of human wrist extensor muscle sarcomere length changes. Journal of neurophysiology, 71(3), 874-881.</li>
 	<li>Lieber, R. L. (2002). Skeletal muscle structure, function, and plasticity. Lippincott Williams &amp; Wilkins.</li>
</ol>
&nbsp;

Levels of Evidence - Relative to evidence-based practice, levels of evidence are an attempt to describe the strength of the results measured in a clinical trial or research study.  Note: levels of evidence do not supersede the critical evaluation of an experienced professional, and should be viewed as guidelines - a meta-analysis may be poorly constructed (Level IA), and a comparative study (Level III) may employ new technologies and a strong methodology.


The Levels of Evidence used by the Brookbush Institute, as described by Shekelle et al.(1):
<ul>
 	<li class="p1">IA - Evidence from meta-analysis of randomized controlled trials</li>
 	<li class="p1">IB - Evidence from at least one randomized controlled trial</li>
 	<li class="p1">IIA - Evidence from at least one controlled study without randomization</li>
 	<li class="p1">IIB - Evidence from at least one other type of quasi-experimental study</li>
 	<li class="p1">III - Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies</li>
 	<li class="p1">IV - Evidence from expert committee reports or opinions or clinical experience of respected authorities, or both</li>
</ul>
<ol>
 	<li>Shekelle, P. G., Woolf, S. H., Eccles, M., &amp; Grimshaw, J. (1999). Developing clinical guidelines. Western Journal of Medicine, 170(6), 348.</li>
</ol>

Likelihood Ratios - Likilihood ratios are used for assessing the value of performing a diagnostic test. They use sensitivity and specificity to determine whether a test result usefully changes the practitioner's chance (probability) of reaching the correct assessment. Calculation of likelihood ratios is based on Baye's theorem.
<ul>
 	<li>Positive Likelihood Ratio (LR+) - The ratio of a positive test result in people with the pathology to a positive test result in people without the pathology.</li>
 	<li>Negative Likelihood Ratio (LR-) - The ratio of a negative test result in people with the pathology to a negative test result in people without the pathology.</li>
</ul>

Longitudinal Study - a research design that involves observing the same variables, several times over a period of time.
<ul>
 	<li>Example, the study by Hewett et al. (1) is a type of longitudinal study called a "cohort study." This study investigated whether excessive knee valgus during landing was a predictor of knee injury risk in adolescent females over the course of a season.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/research-review-increased-valgus-during-landing-predicts-acl-injury-in-adolescent-female-athletes/" target="_blank" rel="noopener noreferrer">Hewett, T. E., Myer, G. D., Ford, K. R., Heidt, R. S., Colosimo, A. J., McLean, S. G., &amp; Succop, P. (2005). Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes A prospective study. The American journal of sports medicine, 33(4), 492-501</a></li>
</ol>

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