Thoracic Spine Mobilization: Posterior-to-Anterior and Transverse

Set-Up

1. The patient should be prone, face-down in a "cut-out" or headrest, with a towel placed under the forehead to reduce the force on sensitive cheekbones.
2. Arms should be in a supported and comfortable position to reduce the amount of muscle activity in scapulothoracic and cervicoscapular muscles.
3. The table should be low enough so that leaning forward slightly allows the practitioner to get their chest over the cervical spine, with arms fully extended and thumbs in position over the affected segment.
4. Ideally, the set-up would allow the practitioner to oscillate pressure by gently rocking the torso (not by using grip or triceps strength).
   • Note: It is worth spending some time reviewing the anatomy of the thoracic spine and practicing on a plastic model before practicing these techniques on a colleague.
   • Note: Unlike the cervical spine, all segments of the thoracic spine can be addressed in a similar manner.

Central Posterior to Anterior (PA) Mobilization

1. Place the lateral aspect of the hypothenar eminence on the spinous process of the intended segment.
2. Place the other hand over the palpating hand by saddling the palpating hand between fingers 2 and 3 of the top hand.
3. Check body mechanics to ensure the chest is over the target segment and the arms are straight.
4. Apply force in posterior to anterior direction with a slight inclination toward the client's chest.

Unilateral PA

1. Find the spinous process of the affected segment, or the segment exhibiting stiffness.
2. Generally, the facet associated with the spinous process of the same vertebrae is two segments lower. Locate the facet of the intended segment by mobilizing the spinous process laterally, while palpating the facets on the affected side.
3. Slide your thumbs (thumb over thumb) into the laminar trough over the facet.
4. Apply force in posterior to anterior direction with a slight inclination toward the client's chest.

Bilateral PA

1. Find the spinous process of the affected segment, or the segment exhibiting stiffness.
2. Locate the facet of the intended segment by mobilizing the spinous process laterally, while palpating the facets on the affected side. Generally, the facet of the vertebrae associated with the spinous process exhibiting stiffness is 2 segments (spinous processes) higher.
3. Slide your second and 3rd fingers over the intended facets on either side of the spinous processes.
4. Use the lateral aspect of the hypothenar eminence to apply pressure through the palpating fingers.
5. Apply force in posterior to anterior direction with a slight inclination toward the client's chest.

Transverse

1. Find the spinous process of the affected segment, or the segment exhibiting stiffness.
2. Use a thumb over thumb palpation to gently pull some skin back over the spinous process you intend the mobilize. This will allow some slack in the tissue so that your mobilization is not impeded by stretched skin and irritation.
3. Depress your thumbs into the tissue to gain purchase on the lateral aspect of the intended spinous process (this is not easy and takes some practice).
4. Apply force in a lateral direction.
   • Note: Pay careful attention to the direction of rotation you intend to improve. For example, if you are trying to improve right rotation, you would at least start by trying mobilizations standing on the patient's right side, pushing the spinous process from right to left.

Mobilization:

1. Once you have located the segment you wish to mobilize, start with small test oscillations to locate the facet, feel for articular motion, and identify any exquisite tenderness.
2. When you are satisfied with your test motions, identify the amount of pressure required before you first feel resistance, just before articular motion, and then identify the amount of pressure applied before any additional pressure results in no further articular motion.
   • Note: The end of articular motion is the end of glide, not the end of cervical extension or rotation. Locate the point where the joint will not glide any further, but there is little if any osteokinematic motion.
3. Identify the mid-point between the first resistance barrier and articular end-range; approximately 50% resistance.
   • Grade III - Larger oscillations between the first resistance barrier and approximately 50% resistance. Note, these oscillations are large compared to grade IV oscillations, but are still very small motions.
   • Grade IV - Small oscillations at 50% resistance or more.
4. Oscillate at 1 - 2 pulses per second.
5. Continue oscillating until you feel a change in tissue resistance/joint stiffness.