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Thoracic Spine Manipulation
Thoracic spine manipulation is a form of manual therapy through which the joints and tissues in the thoracic spine (upper to mid-back) are specifically targeted with gentle pressure and passive movements. It is intended to improve range of motion, reduce pain, and restore optimal thoracic biomechanics. It is often used to treat chronic thoracic pain, tightness, and restrictions and help reduce ostephatic, discogenic, and radiculapathic pain
Transcript
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This is Brent of the Brookbush Institute and
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in this video we're going to go over
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manipulations, or high-velocity thrust techniques. I assume that if you're
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watching this video you're watching it for educational purposes and that you
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are a licensed professional with high velocity thrust or manipulation
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techniques in your scope of practice. If you are not sure check with your state
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board, most physical therapists, chiropractors and osteopaths you're in
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the clear, I believe that ATC's you can't do manipulations in the United States,
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although other countries again check your scope. Of course massage therapists
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and personal trainers these are generally not within your scope. Of
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course you could continue to watch these videos just for educational purposes,
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learn a little Anatomy learn a little biomechanics. If you're going to do these
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techniques please make sure that you have a good rationale for putting your
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hands on a patient, this should be based on assessment, and if you're going to
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assess I'm hoping that you'll assess use these interventions and reassess to
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ensure that you're getting the result that you're looking for, and have good
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reason to continue using this technique. In this video we're going to go over thoracic
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manipulations, these are the thoracic manipulations that are P to A high
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velocity thrust, also sometimes referred to as the screw manipulation. I'm going to
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have my friend a Yvette come out, she's going to help me demonstrate. Now remember
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if we're doing manipulations we're doing manipulations because we need to
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increase mobility in a segment that we think is stiff, and that's going to be based
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on not just subjective information but objective information as well. For
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example, maybe we've seen some signs of upper-body dysfunction during like a
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postural exam,maybe arms fall forward or shoulders elevate during one of our
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movement patterns, and then maybe since we don't have great goniometric
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assessments for our thoracic spine we could use something like a rotation test
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for thoracic mobility, that we could at least use as an assessment and
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reassessment as we're going through our interventions.
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Now the screw technique is probably the one that everybody is most familiar with
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and tends to be the most detailed as far as its explanation, and that's the one
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where we find transverse processes right and we go the transverse process
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above and below on opposite sides, and then this is called the screw
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manipulation because we press down on both sides which is supposed to do this
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with our thoracic spine which causes the manipulation. That's great and I think
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it's a good technique to start with to get some detail in, but I've also seen
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people just come and press, I've seen people come and press this way. I think
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all of these techniques generally work, and the reason being is it's very hard
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to be specific to a particular joint in the thoracic spine especially when you
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consider not only the number of facets but the number of costovertebral facets. So you have
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two costovertebral joints on every transverse process, plus your facet
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joints. I think when people do these manipulations a lot of times we're
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getting multiple cavitations because we're manipulating a lot of joints
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in it's segmented area. So with that being said let's
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start with the detailed screw P-A thrust. So the first thing I need to
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do is maybe start with some palpation, in this position I'd probably do my P-A's
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using my pisiform hamate grip this way. So we'll say I've already done
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cervical, I've already done my upper thoracic spine as part of my cervical
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exam and now I'm kind of in through here. I'm just going to feel for some stiffness
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here, maybe I asked Yvette, hey Yvette is any of this painful, or just a lot of
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pressure? Just a lot of pressure right, and you do have to put quite a bit of
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pressure just to get to the end of arhrokinematic motion in the
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thoracic spine, there is definitely some movement this way that can happen,
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and I think what we're finding here is I feel Yvette's a little stiff right here.
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This is kind of common actually with women, you'll find that right about where
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the bra strap would end up they'd either end up really stiff or hypermobile, it
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seems like they either end up stiff because
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of all of the, maybe pressure and maybe that's a compensatory pattern. Or they
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end up hinging over that point and then of course we wouldn't want to do a
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manipulation there, but she is definitely stiff a little bit right here. All right so I can
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keep doing my P-A's, you just saw me cheat there with a little bit of like
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general spring testing. You will see like P-A's would be specific, sometimes you'll
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see people just do this thing right this is just kind of a spring test
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to see if they can feel any of resistance. Another thing that you might
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be able to feel is like tissue density, so maybe some overactivity around the
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segments, and we definitely have some stuff going on here. So what I'm
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going to do is I'm going to find my transverse process, now if I go out
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just a about an inch from either spinous process I can feel the transverse
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process, and then I can actually feel a bump right here about two inches from
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the spinous process, that's where the ribs start, alright there's that little
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bump there at the the beginning of the ribs. But let's say I find these two
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transverse process and I'm going to switch my fingers this way a couple
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times so that I rotate in both directions, figure out which one's
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stiffest. Alright so she tends to be more stiff this way so what I'm
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going to do is get my pisiform hamate on either of those transverse process. I'm
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going to take up all the tissue slack so that my hands don't move around
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and there's a couple ways to do that, you guys can twist your hands, you
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can move up into position so you take up tissue slack this way, but you
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definitely want to do something to take up a little tissue slack because
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otherwise you'll go on press and your your hands will move off those
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transverse process. Then I'm going to ask a Yvette to take a nice deep breath,
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and when she breathes out at the bottom I'm just going to do a little quick, and
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that's it. I think you have seen Yvette in some earlier videos, Yvette's not
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used to getting manipulations which I actually like for these videos
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because I feel like she's very similar to a new patient which I think you
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need to be aware of, that not everybody loves to get manipulated. Some of you
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might like to get manipulated, other people hate to get manipulated, but it's what they
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need. Manipulations are are very effective for increasing mobility,
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they're very effective for decreasing pain for a lot of different pathologies.
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So again going through that, all I did was find two of these
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transverse process where she was tight and I just kind of set my body up right
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over the top, and then just gave a quick P-A down. Now since my hands are set up on
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on the caddy corner transverse
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processes here, when I press down it did this to the two vertebrae. Now could I
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have just laid my hands down like this? The chances are yes. I think people get a
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little too caught up in the details, if I have somebody who's coming in for
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general thoracic stiffness, and I'm not dealing with somebody who's like has a
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very specific pain. For example if Yvette had come in with very specific pain
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right underneath where her bra strap was, I thought there was a chance that there
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was a hypermobile segment surrounded by stiff segments, that's a good reason for
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me to be very specific on where I'm going to apply these techniques. But if
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Yvette's coming in because she's been suffering from thoracic spine tightness,
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maybe you know we started hearing about things like she's got desk work followed
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by these group classes that she teaches, and we think she's probably sitting in
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really bad posture and then reinforcing it with workouts because she doesn't
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really get a chance to do any sort of movement prep before she goes into this
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group class, like I just want to loosen this up. I probably can just put my hands
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down, I take up my tissue slack, big deep breath for me,
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breathe all the way out for me, there you go,
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relax and there you go. Alright you saw I just set my hands down and
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I got multiple cavitations. Do I know whether it was thoracic facets or
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costovertebral facets? No, and honestly it might not matter in a case of general
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stiffness. In the case of general stiffness all we want to do is see
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improvement on a reassessment, and if that was for example upper-body for
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example, maybe she didn't get her arms all the way back during an overhead
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squat assessment, or she was performing poorly on a thoracic spine assessment
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now I would just reassess and see if that got better. If it did good, then
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that was the right technique to use. I've seen people do this thing as well and
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sometimes that works really well, that's not a technique I'm particularly
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comfortable with, but you could just do hand over hand and push down, and now
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you're doing a central P-A high-velocity thrust. I think with all
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these techniques you need to practice, the ability to feel where the stiffness
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is probably is the most important thing because the techniques themselves aren't
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hard. The only part that you as a practitioner you need to get real
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comfortable with, is setting your body up in a way that you're using your
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biomechanics and not your arm strength, because if we were to flip places and
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Yvette was to try to do this on me, granted I probably outweigh Yvette by about
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a hundred pounds, I'm almost twice her size. She's
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going to have to have really good mechanics to be able to move my thoracic spine in
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a way that's going to get a good manipulation, and the way to do that of
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course is to get the table low enough to get your arms straight so that you can
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then use the weight of your torso in a quick fashion. You're almost
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thinking about I'm just going to drop my weight in and try to straighten my arms
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out at the same time, and kind of like a a little bit of a, I don't want to say
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like punching motion, but like you're just kind of doing one of,
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alright I'm all set up and then I'm just going to drop in. So I'm going to
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straighten my arms, let my bodyweight all fall at the same time very quickly. You
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are going to have to move a little more than you expect. If you have
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ever done like the CPR training think about how far a sternum is willing to
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move, you know you have to push the thoracic spine a good couple of
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centimeters before you're going to get any of these cavitations to happen. Last,
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you could potentially, I wouldn't suggest this for everybody, but you might be able
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to get some of the upper thoracic spine by doing a technique up here. Notice that
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if I'm going to do this I'm going to tilt her head down a little bit into flexion, that
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seems to help. I might go cross hand,or this way. I'm
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pushing in this direction. Alright nice deep breaths, and then I
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would push down hard here. The one problem with that particular technique,
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where you want to be careful is you do have to use quite a bit of force, and
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it does tend to push people's clavicle very hard into a tablem and for some
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people that's enough to be uncomfortable enough that they don't want to do it
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again. For individuals like that I would go back to my mobilization techniques
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remembering that most of the research points to manipulations being a little
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more effective than mobilizations, but mobilizations being generally very
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effective unto themselves. Stay tuned for the close-up recap. All right
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for your close-up recap I wanted to give you a little different view here. Of
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course we would go through and do our palpation, take up all that
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arthrokinematic range, ask Yvette here, hey does that cause you any pain? No, so we might
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get a little extra information on top of palpating stiffness on whether that
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particular segment seemed to be the one that was causing some of her symptoms,
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especially if that pain is related to our concordance sign. Now other things we
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might be able to tell is do we have increases in tissue density,
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overactivity and any of the muscles
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around a particular segment, and I mentioned sometimes
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it's coming through and just doing a general spring test, you'll feel where
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the spine is generally tighter. We found with Yvette this seemed to be your
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tighter area. Now if we wanted to get real specific with our screw technique
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and we had found a couple of spinous process that we're really stiff,
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remember that your spinous process actually are quite long in the
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thoracic spine. So the transverse process that is related to it, a little
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trickier, if you fall off that spinous process to the side and start
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rotating. I'm probably going to have to go about two spinous process up, but you can
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lay a thumb down and feel where that transverse process related to that
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spinous process is. So right here would be that particular segment I could
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put one hand here, I could then go one below it or one above it with
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the other hand, and then have Yvette take a nice deep breath, breathe all the way out,
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follow her down and then of course my chest is right over my hand so I can
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just drop in and give a quick thrust, and just like that we got a nice little
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cavitation via our screw technique which is called screw technique because it
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basically does this with the two vertebrae that we're pressing. Now I did
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mention that just general hand placement like as long as you're on either side of
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the spine, chances are a PA thrusts will get you some good manipulations. The
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problem with that technique is it's not specific, the advantage of that technique
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is it's not specific. You're probably getting a lot of stiff joints involved,
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maybe some costovertebral joints as well as facet joints. Of course I've even
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seen this work where the spinous process is put in between the thenar eminence. Essentially that's just
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a central P-A thrust. I don't tend to use that one very often. I think it;s
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a little bit more uncomfortable for the patient and not as effective as the
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other techniques I just showed you for the thoracic spine. Give these a try,
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really start doing some palpation before you try the thoracic
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manipulation if you haven't been successful. I think just determining
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where on the spine is stiff will be the biggest to jump in your ability to make
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this technique successful, as as opposed to continuing to just work on smashing
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the thoracic spine which I think with a little practice anybody can get pretty
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good at by itself. A couple of points to recap, knowing your Anatomy and knowing
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your biomechanics will certainly help you choose the right technique for the
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right patient. If you're unsure whether manipulations are appropriate due to
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their higher intensity, it's okay to do mobilizations. Most research points to
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manipulations being slightly more effective, but mobilizations being very
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effective and of course we have those videos for you if you want to start with
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those less intense techniques. Make sure that if you are doing any technique that
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is based on assessment, and of course that you're reassessing ensuring that
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the technique is effective for the patient that you're working on, and when
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it comes to all manual techniques, manipulations maybe more than any other,
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look for opportunities to get live education. Although I know videos are
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convenient and I'm happy to have these up for you to watch, it would be so
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much more helpful to use those videos as a recap of one-on-one attention with
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somebody who's experienced with manipulation techniques. At the very
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least grab a colleague and grab a friend and start practising these before you
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bring them into clinic and start using them on patients and clients. I hope you
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enjoyed this video, if you have any questions please leave them in the
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