Thoracic Spine Manipulation

Patient and Practitioner set-up

1. The patient should be prone with head in face-cut out.
2. The table should be low so the practitioner can place their hands on the thoracic spine, with arms straight, and chest over the segment being manipulated.

Passive Motion Assessment

1. Motion can be assessed using a unilateral posterior-to-anterior thoracic mobilization .
2. Rotational stiffness can also be assessed by pressing the transverse processes of adjacent vertebrae.
3. During set-up of this technique the therapist may also feel increased tissue density of the paraspinals adjacent to stiffer segments.

Lockout Position:

1. Identify the target segment.
2. Place the pisiform/hamate portion of each hand over the transverse processes of an adjacent segment.
   • The goal of this technique is to force rotation by pressing transverse processes of adjacent segments into opposing directions of rotation - "screwing one vertebra on another".
3. It is recommended that tissue slack is either gathered caudally to cranially while getting the hands into position or that the hands are twisted to take up tissue slack.
   • As Bereznick et al. demonstrated (discussed above), there is very little friction between the skin, underlying fascia, and the vertebrae, and it is likely not possible to "hook" landmarks (75). However, because of the lack of friction, tissue slack may allow the hands to slide during the thrust.
4. Lock position is created by slowly pressing into the arthrokinematic end range in preparation for the thrust.

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 two segments through extension and rotation.
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 near the end of exhalation of a normal breath
5. Slowly remove and reposition the hands for the next thrust, or allow the patient to sit-up