Thoracic Pistol Manipulation

Patient and Practitioner set-up

1. The patient should be supine, with upper-back on a flat part of the table (no seams or creases).
2. The table should be low so the practitioner can get their trunk over the trunk of the patient.
3. The patient is asked to cross their arms or interlace fingers behind the base of their neck.
   • Note, if the patient chooses to interlace fingers, they should be fingertips to opposite hand web space, and not web space to web space. If the fingers are interlaced too far it will be impossible to touch one elbow to the other without squeezing the patient's face with their own arms.

Passive Motion Assessment

1. Motion can be assessed using a unilateral posterior-to-anterior thoracic mobilization .
   • Note: this usually happens with the patient in prone prior to this technique
2. During set-up of this technique, the therapist may also feel increased tissue density of the paraspinals adjacent to stiffer segments.

Lockout Position:

1. Use the patient's elbow to tip the thorax, allowing the clinician to slide a fist under the stiff segment of the thoracic spine.
2. The clinician can use tissue density as a general indicator of stiff segment location.
3. The fist should be positioned so the patient's spinous processes lay in the groove between the distal interphalangeal joints (IP), and the thenar eminence.
4. The lowest segment the clinician is attempting to block should be at the level of the 2nd finger, with the segment to be mobilized hanging just past the second finger.
5. The clinician then lowers the patient's body weight on to their fist.
6. Lock position is created by maintaining some thoracic flexion, with some anterior to posterior force, and caudal to cranial force. (As if you were trying to "retract" the thoracic spine like you "retract" a cervical spine).
7. With a little practice, it is not uncommon to get a manipulation and cavitation from the patient's body weight alone.

High-Velocity Thrust

Important Note: 90% of manipulation technique is set-up. If you have not achieved lock-out in the previous steps, having great "thrust technique" will be rendered useless.

1. The motion is a posterior to anterior force, with force coming primarily from the practitioner's body weight.
2. Visualize the small, rapid motion (maybe 2 - 3".). You are trying to force the "one joint" to extend just over your 2nd distal IP.
3. Ensure the patient is not guarding.
   • Tip: have the patient take a deep breath or wiggle their toes. Your goal is to distract them so that they allow you to passively control their trunk with as little muscle activity as possible.
4. Quickly, thrust the patient into the new position.
5. Without letting go of the patient's elbows, gently tip the patient show that you can slide your hand to the next stiff segment, or out from under the patient's trunk.