Thrust of the Thoracic

by
L. Vince Lepak, PT, DPT, MPH, CWS, CES
 Dangers?
• Risk is unknown, but considered low if properly screened.
• Puentedura & O'Grady, 2015 did a systematic review and found ten cases; females
(8) more than males (2), mean age being 43.5 years (SD=18.73, Range = 17 -71).
The most frequent Adverse Event reported was injury (mechanical or vascular) to
the spinal cord (7/10), with pneumothorax and hematothorax (2/10) and CSF leak
secondary to dural sleeve injury (1/10).
• Neither cervical manipulation nor thoracic manipulation produced significant
changes in the CPK, LDH, CRP, troponin-I, myoglobin, NSE, or aldolase blood
levels. (Achalandabaso et al., 2014)
• Pediatrics
– Pediatric case after Chiropractic manipulation (Wilson, Greiner, & Duma, 2012)
– Adverse Events in Children (not specific to Thoracic) (Todd, Carroll, Robinson, & Mitchell,
2015)
• Three deaths occurred under the care of various providers (1 PT, 1 unknown, & 1 craniosacral therapist)
• 12 serious injuries (7 chiropractors, 1 medical practitioner, 1 DO, 2 PTs, & 1 unkown).
• High-velocity, extension, and rotational spinal manipulation was reported in most cases, with 1 case
involving forcibly applied craniosacral dural tension and another involved use of an adjusting instrument.
 Causes of Complications
Complications associated with the use of HVLA thrust techniques generally
relate to either incorrect patient selection or poor technique.

Incorrect patient
selection
• Lack of or incorrect
diagnosis
• Lack of awareness of
possible complications
• Inadequate palpatory
assessment
• Lack of patient consent
(Gibbons & Tehan, 2016, p.43)
Poor technique
• Excessive force
• Excessive amplitude
• Excessive leverage
• Inappropriate combination of
leverage
• Incorrect plane of thrust
• Poor patient positioning
• Poor operator positioning
• Lack of patient feedback
 Absolute Contraindications
• Bone Pathology that results in weakening
– Tumor
– Infection (e.g., TB)
– Metabolic (e.g., osteomalacia)
– Congenital (e.g., dysplasia)
– Iatrogenic (e.g., long-term steroid use)
– Inflammatory (e.g., severe RA)
– Traumatic (e.g., Fx)
• Neurological
– Cord compression
– Nerve root compression with increasing deficits
• Vascular
– VBI
– Carotid
– Hemophilia
• Lack of a diagnosis
• Lack of patient consent
• Cannot achieve proper position secondary pain or resistance
• Not an inclusive list 4
(Gibbons & Tehan, 2016 )
 Relative Contraindications
• Adverse reaction to previous manual therapy
• Disc herniation or prolapse
• Inflammatory arthritis
• Pregnancy
• Spondylosis or spondylolisthesis
• OP (not the clothing line)
• Anticoagulants
• Advanced DJD or DDD
• Vertigo
• Ligamentous laxity
• Arterial calcification
• Not an inclusive list

5
(Gibbons & Tehan, 2016 )
 General Transient Effects for the Spine
• Local pain or discomfort
• Stiffness
• Headache (likely related to cervical manipulation)
• Tiredness/fatigue
• Radiating pain or discomfort
• Approximately half of patients experience
some transient effects that last 24-72 hours
(Gibbons & Tehan, 2016, p.43)
N=9 total asymptomatic (2 females
N=15 total symptomatic, 21 total
7 males), 40 total injections, 29 or
72.5% of the injections produced
pain sensations different than the
Facet injections, Fukui, 1994

injections (Dreyfuss , 1994)

(Dreyfuss, Tibiletti, & Dreyer, 1994; Fukui, Ohseto, & Shiotani, 1997)
 Costotransverse
N=8 asymptomatic males, 21
total R-sided injections, 14 of the
injections produced pain
sensations different than the
injections

(Young, Gill, Wainner, & Flynn, fig. 4., 2008)

 Rib or Thoracic Vertebrae

(Dutton, p. 2008,1450) 9
 Thoracic Spinal Muscles

• Multifidus active with

contralateral rotation
• Longissimus active with
ipsilateral rotation
• Both active with ipsilateral
sidebending/extension
 Serratus Posterior –
Transversospinalis Scalenes
abduct scap to palpate
Group

(Simmons, Travell & Simmons,

1999, p.917) (Simmons,
(Simmons, Travell Travell &
& Simmons, Simmons,
1999, p.901) 1999, p.506)
Levator Scapulae Iliocostalis thoracis
Middle Trapezium

Rhomboids

(Simmons, Travell &

Simmons, 1999, p.915)
(Simmons, (Simmons,
Travell & Travell & (Simmons, Travell
Simmons, Simmons, & Simmons,
1999, p.281) 11
1999, p.492) 1999, p.614)
 Cervicothoracic Spine C7-
T3: Extension Gliding 8.21

Delivering the thrust: The direction of thrust with your arms is

towards you. Simultaneously, apply a thrust directly forwards
against the spinous process of T3 with your sternum.
12
(Gibbons & Tehan, 2016, p. 195-197 )
 Thoracic Spine T4-9 9.1
Extension Gliding

Positioning for thrust: Lean forwards with the thrusting part of your chest
against the spinous process of T6. Introduce a backwards (compressive) and upwards force to the
patient's folded arms. Maintaining all holds and pressures, bring the patient backwards until your
body weight is evenly distributed between both feet
Adjustments to achieve appropriate pre-thrust tension
Immediately pre-thrust: Relax and adjust your balance
Delivering the thrust: The direction of thrust with your arms is towards you
and slightly upwards. Simultaneously, apply a thrust directly forwards against
the spinous process of T6 with your sternum 13
(Gibbons & Tehan, 2016, p.203-205 )
Hand Position

14
 Thoracic Spine T4-9 Rotation 9.4

Contact points: Transverse processes of T5 (right applicator) and T6 (left applicator)

• Applicators: Hypothenar eminence of left and right hands
• Patient positioning: Prone with arms hanging over the edge of the couch
• Operator stance: To the left side of the patient, facing the couch
• Palpation of contact points: Place the hypothenar eminence of your right hand
against the left transverse process of T5 and establish a firm contact. Place the
hypothenar eminence of your left hand against the right transverse process of T6.15
(Gibbons & Tehan, 2016, p.220 )
It is easy to apply too much
force – use only the force
generated by a basic head
nod
Thoracic Spine T4-9
9.4
Positioning for thrust: This is a short lever
technique and the velocity of the thrust is
critical. Move your centre of gravity over the
patient by leaning your body weight forwards
onto your arms and hypothenar eminences.
Apply an additional force directed caudad with
the left hand and cephalad with the right hand
Adjustments to achieve appropriate pre-thrust
tension
Immediately pre-thrust: Relax and adjust your
balance
Delivering the thrust: The direction of thrust is in
a downward and cephalad direction against
the transverse process of T5 while
simultaneously applying a thrust downwards
and in a caudad direction against the
transverse process of T6

16
(Gibbons & Tehan, 2016, p.220 )
 Thoracic Spine T4-9 9.3

Applicators:
-Palm of the operator's right hand, held in a clenched position
-Operator's lower sternum or upper abdomen
Patient positioning: Supine with arms crossed over the chest
Operator stance: To the right side of the patient, facing the couch

(Gibbons & Tehan, 2016, p.214 ) 17

 Thoracic Spine T4-9
9.3

(Gibbons & Tehan, 2016, p.215 )

Positioning for thrust: Take hold of the patient's left shoulder and pull it towards you , Place the thenar
eminence of your right hand against the left transverse process of T6. Roll the patient back towards
the supine position. Rest your lower sternum or upper abdomen on the patient's elbows and left
forearm. Apply a slow firm pressure with your lower sternum or upper abdomen downwards
towards the couch. Maintaining this downward leverage, introduce left rotation of the patient's
upper thorax by directing forces towards the patient's left shoulder along the line of the patient's
left upper arm
Adjustments to achieve appropriate pre-thrust tension
Immediately pre-thrust: Relax and adjust your balance
Delivering the thrust: The direction of thrust is downwards towards the couch and in the line of the
patient's left upper arm via your lower sternum or upper abdomen. Simultaneously, apply a thrust
with your right thenar eminence upwards against the left transverse process of T6. The force is
produced by rapid pronation of your right forearm. The hand contacting the transverse process of
18
T6 must actively participate in the generation of thrust forces.
19
 Reference
• Achalandabaso, A., Plaza-Manzano, G., Lomas-Vega, R., Martinez-Amat, A., Camacho, M. V., Gasso, M., . . . Molina, F. (2014). Tissue
Damage Markers after a Spinal Manipulation in Healthy Subjects: A Preliminary Report of a Randomized Controlled Trial. Disease
Markers, 1-7. doi:Artn 81537910.1155/2014/815379
• Dreyfuss, P., Tibiletti, C., & Dreyer, S. J. (1994). Thoracic zygapophyseal joint pain patterns. A study in normal volunteers. Spine,
19(7), 807-811.
• Fruth, S. J. (2006). Differential Diagnosis and Treatment in a Patient With Posterior Upper Thoracic Pain. Physical Therapy, 86(2),
254-268.
• Fukui, S., Ohseto, K., & Shiotani, M. (1997). Patterns of pain induced by distending the thoracic zygapophyseal joints. Regional
Anesthesia, 22(4), 332-336.
• Gibbons, P., & Tehan, P. (2016). Manipulation of the spine, thorax and pelvis (4th ed.). London: Elsevier. Retrieved from
https://evolve.elsevier.com/
• Kisner, C., & Colby, L.A. (2007). Therapeutic exercise (5th ed.). Philadelphia: F.A. Davis.
• Liebenson, C. (Ed.). (2007). Rehabilitation of the spine (2nd ed.). New York: Lippincott Williams & Wilkins.
• Masaracchio, M., Cleland, J. A., Hellman, M., & Hagins, M. (2013). Short-term combined effects of thoracic spine thrust
manipulation and cervical spine nonthrust manipulation in individuals with mechanical neck pain: a randomized clinical trial.
Journal of Orthopedic Sports and Physical Therapy, 43, 118-127. doi: 10.2519/jospt.2013.4221
• Puentedura, E. J., & O'Grady, W. H. (2015). Safety of thrust joint manipulation in the thoracic spine: a systematic review. Journal of
Manual & Manipulative Therapy, 23(3), 154-161. doi:10.1179/2042618615y.0000000012
• Reid, S. A., Rivett, D. A., Katekar, M. G., & Callister, R. (2014). Comparison of Mulligan Sustained Natural Apophyseal Glides and
Maitland Mobilizations for Treatment of Cervicogenic Dizziness: A Randomized Controlled Trial. Physical Therapy, 94(4), 466-476.
doi: 10.2522/ptj.20120483
• Simons, D. G., Travell, J. G., Simons, L. S., & Travell, J. G. (1999). Travell & Simons' myofascial pain and dysfunction: the trigger point
manual: Volume 1. Upper half of the body. (2nd ed.). Baltimore: Williams & Wilkins.
• Todd, A. J., Carroll, M. T., Robinson, A., & Mitchell, E. K. L. (2015). Adverse Events Due to Chiropractic and Other Manual Therapies
for Infants and Children: A Review of the Literature. Journal of Manipulative and Physiological Therapeutics, 38(9), 699-712.
doi:10.1016/j.jmpt.2014.09.008
• Wilson, P. M., Greiner, M. V., & Duma, E. M. (2012). Posterior Rib Fractures in a Young Infant Who Received Chiropractic Care.
Pediatrics, 130(5), E1359-E1362. doi:10.1542/peds.2012-0372
• Young, B. A., Gill, H. E., Wainner, R. S., & Flynn, T. W. (2008). Thoracic costotransverse joint pain patterns: a study in normal
volunteers. BMC Musculoskeletal Disorder, 9, 140. doi:10.1186/1471-2474-9-140 20