Taylor Mills

March 1, 2019
PTH 662: Manual Therapy II
Throughout the past semester in Manual Therapy II, the instructors have mentioned how

beneficial upper thoracic spine manipulations are in treating cervical spine pain and

hypomobility at the cervicothoracic junction. They reported having positive outcomes in the

clinic after performing this intervention. I have been curious on if the literature has also found

upper thoracic manipulations to be effective in treating cervical and upper thoracic pain. I have

selected two research articles to compare and contrast that both examine the short-term effects of

performing an upper thoracic spinal manipulation to treat neck pain, primarily in middle-aged

individuals. I hope to gain insight on if these manipulations improve subjective findings, such as

pain, quality of life, or disability, and/or improve objective findings, such as range of motion

(ROM) or strength. Neck pain is a common complaint seen in the outpatient physical therapy

setting, so understanding the effectiveness of this technique may be helpful for me as a future

clinician who hopes to work in this setting.

The “Short-Term Effects of Thrust Versus Nonthrust Mobilization/Manipulation Directed

at the Thoracic Spine in Patients with Neck Pain: A Random Clinical Trial,” written by Cleland

et al., randomly and equally assigned their 60 subjects to the experimental group (who received a

thrust manipulation) and the control group (who received a nonthrust mobilization).1 The

average age of the groups was 42.5 years-old. The subjects completed pre-intervention and post-

intervention outcome measures including the Numeric Pain Rating Scale, Neck Disability Index,

and Fear-Avoidance Beliefs Questionnaire.1

The nonthrust, control group received Grade III or IV posterior-anterior mobilizations for

30 seconds at each spinous process from T1 to T6 while in the prone position.1 The experimental

group received a manipulation targeted at the segments between T1 and T4 while lying in the

supine position and interlocking their fingers behind their neck. The physical therapist stabilized
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the inferior vertebra and applied a thrust utilizing the patient’s arms as a long lever by pushing

downward to create spinal flexion at the targeted motion segment. Then the physical therapist

moved caudally and performed another thrust between the T5 and T8 segments utilizing the

same technique but with the subject’s hands clasped to the opposite shoulder. The manipulation

was performed once more if a pop did not occur at the targeted region for a maximum of two

attempts. The control and experimental groups both received instruction on how to perform a

general cervical mobility exercise that they utilized for a home exercise program (HEP).1

Both groups were reassessed 2-4 days after the initial intervention of a manipulation or

mobilization.1 The subjects completed the post-intervention outcome measures and were also

asked about any side effects experienced from the manual therapy technique that they received.

This study found no significant difference in the number of experienced side effects from the

manipulation group compared to the mobilization group. The researchers did find a greater

reduction in disability and pain in the manipulation group compared to the mobilization group.

Their results suggest that a generalized thrust technique to the upper and middle thoracic spine is

beneficial in treating patients with neck pain.1

“The Immediate Effects of Upper Thoracic Translatoric Spinal Manipulation on Cervical

Pain and Range of Motion: A Randomized Clinical Trial” examined if an upper thoracic

manipulation reduced pain and/or improved range of motion in the cervical spine in subjects with

an average age of 34.5 years-old.2 This study had less subjects: 22 received a manipulation in the

experimental group and 10 subjects received no treatment in the control group. Cervical range of

motion was assessed with a CROM inclinometer and cervical pain was assessed at the end range

of cervical rotation using a Faces Pain Scale. Both measures were assessed before and after the

intervention session.2
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The researchers performed an anterior-posterior joint play assessment of the upper

thoracic spine (T1-T4) to determine areas of hypomobility.2 This study involved a specific

manipulation(s) to the restricted motion segment(s) that were found during the joint play

assessment,2 which differs from the first article because they performed a non-specific

manipulation in the mid region of the upper and mid thoracic levels.1 This is something to

consider when performing a manipulation in my future and based on the studies, specifically

targeting the hypomobile segments seems more appropriate.

The subjects in this study2 were not given a home exercise program and the manipulation

intervention was not provided on the same day as the initial examination, as the previous article

included.1 All of the subjects returned one to two days after the examination and the control

group sat on the treatment table for the same amount of time as the experimental group but did

not receive any interventions.2 The subjects in the experimental group received a bilateral

translatoric facet joint traction manipulation in the supine position at the previously noted

hypomobile motion segment(s).2 This is the same position and technique that was used in the

previous study.1

The results from this study found that upper thoracic manipulation(s) did significantly

improve cervical spine rotation in over half of the subjects in the experimental group by

increasing their active range of motion by 10 to 30 degrees.2 The manipulation technique was

found to reduce neck pain during end range cervical rotation for subjects who complained of

symptoms with bilateral cervical rotation. However, subjects in the experimental group who

presented with pain that was aggravated with only unilateral rotation did not have a significant

decrease in their neck pain after receiving an upper thoracic manipulation.2

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The researchers believe that the manipulation intervention to the thoracic spine did

improve cervical rotation range of motion, but that the cervical pain could continue to be

provoked at the new end range of motion.2 This study utilized the Faces Pain Scale, which the

authors believe is a weakness to their study because there has not been an analysis on what is

considered to be a meaningful change for this pain assessment tool.2 Cleland et al. used the

Numeric Pain Rating Scale for their study and reported that a two-point change on this scale was

found to be significant and both authors agree that this is the preferred assessment tool to

monitor changes in pain compared to the Faces Pain Scale.1,2 I will consider utilizing this scale

for my future practice. Another weakness of the Krauss et al. study is that their subjects did not

describe the type of cervical pain that they were experiencing at the initial evaluation.2 Some

individuals may have had pain, while others may have felt stiffness. This may be the reason why

most of the subjects in the manipulation group improved their ROM but did not significantly

decrease their pain with end range rotation.2

The Krauss et al. study had their experimental group receive a hands-on treatment from a

clinician and their control group did not receive any hands-on intervention. This may have

played a role in the experimental group having a more significant reduction in their pain due to

the placebo effect.2 The first article1 did; however, perform hands-on interventions for both the

experimental and control groups, which gives this manipulation technique more vigor.

A strength of the Cleland et al. study1 was that both groups received physical therapy

interventions that included a home exercise program along with the manual therapy intervention.

This supports the need for physical therapy over seeking out chiropractic services for a

manipulation because a patient can receive this skilled intervention from both healthcare

providers but can learn ways to help prevent future neck pain by going to physical therapy.
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Hopefully with the help of a physical therapist, these interventions can help keep their spine in

proper alignment and continue to reduce their pain. This is important to consider when educating

patients on ways to manage their spinal dysfunctions.

Overall, both articles utilized a randomized clinical trial design and compared results

from a control and experimental group.1,2 This research design decreases bias of the clinician

who is conducting the experiment and has a strong level of evidence within clinical practice,3

which increased the quality of these research articles. However, an important factor to note is

that the first article excluded subjects who presented with manipulation/mobilization

contraindications, history of recent whiplash injuries, diagnosis of cervical spine stenosis, history

of spine surgery to treatment areas, or complaints/presentation of central nervous system or nerve

root involvement.1 The second article only included subjects with non-traumatic, mid-cervical

pain that increased with active cervical rotation.2 This is important to consider when trying to

generalize these studies to the general population that I will be treating in the future. An upper

thoracic spine manipulation may not be appropriate, indicated, or safe for all patients presenting

with neck pain, so it is important to screen patients and consider clinical prediction rules when

considering this thrust intervention.

The purpose of this paper was to determine if performing an upper thoracic manipulation

can be effective in treating individuals with neck pain. Both articles utilized the same

manipulation technique and had positive outcomes involving subjects’ pain, disability, or active

range of motion in the cervical spine for middle-aged individuals.1,2 These random clinical trials

support the utilization of an upper thoracic manipulation to effectively treat individuals with

cervical pain.1,2 For future references, it may be helpful to examine more studies to determine the
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long-term effectiveness of these manipulations for treating cervical pain because both of these

articles assessed only the short-term effects of this high velocity, low amplitude intervention.
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References

1 Cleland JA, Glynn P, Whitman JM, Eberhart SL, MacDonald C, Childs JD. Short-term effects

of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in

patients with neck pain: a randomized clinical trial. Physical Therapy. 2007;87(4): 431-

440.

2 Krauss J, Creighton D, Ely JD, Podlewska-Ely J. The immediate effects of upper thoracic

translatoric spinal manipulation on cervical pain and range of motion: a randomized

clinical trial. J Man Manip Ther. 2008;16(2): 93-99.

3 Guerrera F, Renaud S, Tabbò F, Filosso PL. How to design a randomized clinical trial: tips and

tricks for conduct a successful study in thoracic disease domain. J Thorac Dis.

2017;9(8):2692-2696.
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