The Effectiveness of Manual Therapies on the Thoracic Spine​

Introduction:

There is limited epidemiological literature surrounding the thoracic spine. This was made evident when a systematic review found that thoracic spinal pain has prevalence data which ranges greatly from 4.0–72.0% between different studies. It has often been said that the thoracic spine is the ‘Cinderella region’ of the spine but it may be viewed as a ‘silent contributor’ to clinical presentations of shoulder and neck pain. Therefore, understanding the effectiveness of manual therapy on the thoracic spine may improve patient’s symptoms when suffering from thoracic and/or referred pain. There are various common disorders in the thoracic spine. Hertling identified the following as the most common; thoracic disc herniations, minor intervertebral derangement theory of Maigne, thoracic pain of lower cervical origin, thoracic pain of thoracic origin, thoracic hypo-mobility syndromes, upper thoracic spinal syndromes, mid-thoracic and costovertebral disorders, lower thoracic spine and thoracolumbar junction dysfunction, thoracic derangement theory of McKenzie, thoracic hyper-mobility problems, rib conditions, kyphosis, senile kyphosis, osteoporosis and postural disorders.

This page sets out how manual therapy techniques such as joint mobilisation, manipulation and soft tissue mobilisation can be used in order to improve patient symptoms, along with their contraindications. 

Manual Therapy Definition:

The International Federation of Orthopaedic Manipulative Physical Therapists (http://www.ifompt.org) defines manual therapy techniques as:

"Any hands on treatment provided by the Physiotherapist; including joint mobilisation, manipulation or soft tissue therapy. With the aim to improve tissue extensibility; increase range of motion of the joint complex; mobilise or manipulate soft tissues and joints; induce relaxation; change muscle function; modulate pain; and reduce soft tissue swelling, inflammation or movement restriction." 

The Thoracic Spine:

Anatomy:

• It is the longest portion of the spine, connecting to the Cervical Spine above and the Lumbar Spine below 
• It comprises of 12 Vertebrae (T1-T12) 
  • The vertebrae bodies have a similar structure to that of the cervical spine. 
  • The spinous process increase in size the further down the thoracic spine. 
  • Each vertebrae sits above and below a IVD.  
• T1-T11 articulate with the ribs to provide stability to the rib cage  

Mobility:

• Least mobile portion of the spine 
• T1-T8 = reduced flexion and extension, increased axial rotation 
• T9-T12 = increased flexion and extension, reduced axial rotation.  

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Contraindications to Manual Therapy:

The contraindications to Manual Therapy are split into Absolute contraindications and precautions. If a patient were to present with any of the absolute contraindications they must not be treated using manual therapies and referred on as appropriate. If any of the precautions present then a patient must be treated with care and their symptoms monitored carefully throughout and after the treatment.

Below is a list of contraindications for spinal manipulations:

Vascular Complications

• Vertebral Basilar Insufficiency
• Atherosclerosis of major vessels
• Aneurism
• Cervical Arterial Dysfunction

Tumours

• Lung
• Thyroid
• Prostate
• Breast
• Bone

Bone infections

• Tuberculosis
• Bacterial Infection

Traumatic injuries

• Fractures
• Joint instability
• Severe strains/sprains
• Unstable Spondylolisthesis

Arthritis

• Rheumatoid Arthritis
• Ankylosing Spondylitis
• Psoriatic Arthritis
• Osteoarthitis (unstable stage)
• Uncoarthrosis

Psychological Consideration

• Malingering
• Hysteria
• Hypochrondriasis
• Pain intolerance
• No cognitive capacity

Metabolic Disorders

• Clotting Disorders
• Osteopenia

Neurological Complication

• Sacral nerve root involvement from disc protrusion
• Disc lesions
• Space Occupying lesion
• Progressive Neurological Disorders
• Cauda Equina

Below is a list for the contraindications for spinal joint mobilisation:

Underlying Pathology

• Infection
• Inflammation
• Sero-positive arthropathy
• Rheumatoid

Blood Vessel Patency

• Aortic aneurysm
• Vertebral arterial dysfunction

Bone/Joint

• Osteoporosis
• Unstable Joint
• Fracture

Skin Integrity

• Frail skin
• Peripheral vascular disease

Below is a list for the contraindications for massage therapy:

Cardiovascular

• Thrombus
• Varicose Veins
• Atherosclerosis
• Anti-coagulation disease
• Heart Failure
• Phlebitis

Integumentary

• Open wound
• Skin disease
• Recent Scar

Musculoskeletal

• Inflammed tissue
• Recent Fracture
• Inflammatory Arthritis
• Bleeding
• Oedema

Infection

• Infected tissue
• Contagious infection
• Fever

Miscellaneous

• Cancer
• Pregnant
• Psychiatric
• Intoxication

Precautions for manual therapy:

• Pregnancy 
• Children  
• Elderly 

• Frailty 

• OA (how advanced and signs and symptoms) 

• Neurological signs and symptoms 
• Cognitive Deficit 
• SIN Factor 
• Previous Spinal Surgery  
• Auto-immune Disorders 

• Fibromyalgia 
• Chronic Fatigue 

• Scoliosis 

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Manual Therapies

Mobilisations:

Sympo-excitatory response​

Mobilisation of the Thoracic Spine

Joint mobilisations have been defined by maitland as an externally imposed, small amplitude passive motion that is intended to produce gliding or traction at a joint. ​

They are often used in the Physiotherapy management in order to produce mechanical and neurophysiological effects. It has been theorised by many authors that this is achieved when the sympathetic nervous system is excited following mobilisations, and thus the pain threshold increases. There have been several RCT's surrounding this area of interest so a systematic review was written by Kingston et al (2014) on the topic and found that each study did demonstrate an sympo-excitatory response. Therefore following an acute injury, or where a patient is suffering from painful inflammation of the target area, it would be useful to treat them centrally, using mobilisations, away from the target area. This can be performed at any level of the spine, including the thoracic spine.​

Pulmonary Function​

Pulmonary Function

Recent evidence has been published ​acknowledging the benefits of thoracic mobilisations on pulmonary function in patients. When combined with self stretching exercises on the pec minor and major muscle group along with the trapezius muscles, thoracic joint mobilisations have been shown to be statistically superior in improving FEV1, and PEF than self stretching alone. However, self stretching and thoracic mobilisations was statistically greater in improving FVC than thoracic joint mobilisations alone.

Mobilisations are not limited to use in the solely MSK setting, they can also be used with patients who suffer neurological deficit. Stroke patients often suffer with limited thoracic movement and impaired coughing ability leading to further respiratory complications. Combined weekly thoracic and cervical joint mobilisations ( with movement) along with 30 minutes of exercise, 15 minutes of ergometer training and 15 minutes of functional electrical stimulation a week, has been shown to improve FEV1, FVC and coughing function greater than exercise, ergometer training and electrical stimulation alone. To add to this, mobilisation of the thoracic spine promotes mobility and improves the respiratory function in patients with Ankylosing Spondylitis (p<0.05).

Shoulder Pain

Shoulder pain is a very prevalent condition with 1 in 3 people expected to suffer from it in their lifetimes. As most clinical tests lack specificity, there is no gold standard clinical test for shoulder pathologies so clinical trials lead to the use of the term 'non specific shoulder pain'. Due to the anatomical position of the shoulder girdle and thoracic spine. Treatment on the thoracic spine can treat pain in the shoulder. Thoracic joint mobilisations have been found to statistically accelerate recovery and reduction of pain and disability in patients with non specific pain between 12 and 52 weeks.

To further this, Thoracic Mulligans Concept SNAGs may influence short term pain levels and shoulder mobility in patients with secondary impingement syndrome. This is where SNAGs are defined as a sustained natural apophoseal glide.

Neck Pain

Decreased mobility of the thoracic spine has become significantly related to neck pain because of biomechanical links between the thoracic and cervical spine.

Inclusion of thoracic mobilisation with cranio-cervical flexor exercise in patients with chronic neck pain versus exercises alone showed greater improvements in VAS pain, muscular endurance and the neck disability index.

Thoracic mobilisations on non-specific neck pain found Maitland mobilisation along with the conventional treatment proved to be more effective in improving Neck Disability Index (NDI) and Numeric Pain Rating Scale scores in patients with nonspecific neck pain than Mulligan mobilisation along with the conventional treatment.

The effectiveness between manipulation (thrust manipulation) and mobilsations directed at the thoracic spine in patients with neck pain found that patients in the manipulation group experienced greater reductions in disability and pain compared to the mobilisations group . Subjects receiving manipulation experienced greater reductions in disability, with a between-group difference of 10%, and pain, with a between-group difference of 2% .

Spondylolisthesis​ & Lower Back Pain

Segmental instability due to lumbar spondylolisthesis can be a cause of chronic low back pain. Hypomobility of the spine can result in compensatory segmental hypermobility of the segment above or below restricted vertebrae. A study investigated the effects of mobilisation therapy of the hypomobile upper thoracic spine along with conventional exercises.​

The study concludes that lower back pain due to spondylolisthesis may be benefited by mobilisation of the thoracic spine along with stretching of short hip flexors, piriformis, lumbar flexion range of motion exercises, core strengthening exercises, etc.

Ankylosing Spondylitis

A recent study investigated the effects of manual mobilisation on the mobility of the thoracic spine in patients with Ankylosing Spondylitis. They found that range of movement of the thoracic spine (Ott’s sign) increased significantly within the group of manually mobilised patients compared to baseline at each of the follow-up visits, whereas no significant change on thoracic spine mobility could be detected in the control group at each of the follow-ups.​

By comparing both groups, a significantly improved mobility of the manually mobilised patients at discharge and one month later was observed. There was no difference between the two groups at baseline and after 3 months. An impact on pain reduction (VAS) was not achieved in the control group, in the manually mobilised group pain reduction became obvious compared to baseline. Parameters of the respiratory function improved significantly during therapy with manual mobilisation.

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Manipulations:

"A manual therapy technique comprising a continuum of skilled passive movements to the joint complex that are applied at varying speeds and amplitudes, that may include a small-amplitude/ high velocity therapeutic movement with the intent to restore optimal motion, function, and/ or to reduce pain."

Grades: Maitland Joint Mobilisation Scale 

Grade I - Small amplitude rhythmic oscillating mobilization in early range of movement 

Grade II - Large amplitude rhythmic oscillating mobilization in midrange of movement 

Grade III - Large amplitude rhythmic oscillating mobilization to point of limitation in range of movement  

Grade IV - Small amplitude rhythmic oscillating mobilization at endrange of movement  

Grade V (Thrust Manipulation) - Small amplitude, quick thrust at endrange of movement

Cervicogenic Headaches : 

Evidence surrounding manipulations in the management of cervicogenic headaches is constantly evolving, with current evidence suggesting that thoracic manipulations should be used as a longterm treatment plan. A systematic review by Posadzki and Ernst, (2012), including 5 RCT's showed that no significant differences between the manipulation and control groups were observed in any of the 3 outcome measures. However, by week 7, each group experienced significant reductions in mean daily headache hours and mean number of analgesics per day. These changes were maintained through the observation period. From this it can be seen that thoracic manipulations for the treatment of Cercicogenic headaches is encouraging, with long term effects, but not conclusive.

Research also suggest that manipulations alongside soft tissue therapy, re- education and muscle strengthening exercises showed a 50% decrease in tension headache length. Therefore the specific effects of manipulations alone are not clear, but a positive effect can be seen through using them as a treatment option.

Neck Pain:

Neck pain is prevalent in the general population, often leading to physical impairments and disability; with the the 2016 Global Burden of Disease, Injuries, and Risk Factors ranking neck pain 11th overall in global cause of disability-adjusted life years. Conservative treatment of neck pain, often includes various interventions, such as education, modalities, therapeutic exercises, mobilisation and manipulation. A 2019 systematic review and meta - analysis compared thoracic and cervical mobilisations to thoracic manipulations using the outcome measures of pain (VAS Scale) and disability (Neck Disability Index). The results of this systematic review conveyed that thoracic manipulations are more effective than cervical and thoracic mobilisations in reducing perceived pain and disability on a short term basis. These results are consistent with the findings of previous reviews conducted by Huisman et al and Young et al, who also concluded that thoracic manipulations have a short-term clinical benefit when compared to modalities, thoracic manipulations and exercise.

Adesive Capsulitis:

Adhesive capsulitis (AC) is a common and disabling shoulder condition which has no clear consensus as to the best treatment approach. Recently there has been emerging evidence that mobilisations directed at the thoracic spine may be beneficial for patients with shoulder pain. 

In many patients with AC pain it is noted that they have thoracic spine mobility and ROM deficits. Therefore a case report was created where treatment consisted of both low-velocity mid-range (grade III and IV), and high-velocity end-range (grade V), posterior to anterior forces directed at the mid and upper thoracic spine. The high-velocity techniques were repeated 1–2 times at each of those levels, without attempting to identify specific segmental levels due to research by Beffa et al, (2004) suggesting an inability to localize treatment.

Shoulder flexion ROM was measured both immediately before and after the thoracic manipulations to be used as an outcome measure. Prior to treatment active shoulder flexion ROM was 110°, and immediately following treatment it had improved to 135°. This represents an immediate post treatment improvement of 25° which greatly exceeds the 10° difference required to be confident a real change has occurred.

The same treatment regimen for the thoracic spine was repeated over the next three visits (visits 12–14) in addition to the previously established plan of active/passive ROM and joint mobilizations of the glenohumeral joint. At each visit the patient continued to report decreased pain and improved function.After only four visits of thoracic manipulations, substantial improvements were noted,. The patient continued to make progress once it was determined the thoracic spine deficits had been address and thoracic manipulations were discontinued.

This case suggests that thoracic manipulations may be a useful treatment for patients with AC. Though this is only a case report, it is the first to look at using thoracic manipulations for AC specifically, and it adds to the emerging evidence that manual therapy directed at the thoracic spine should be considered for patients with shoulder pain.

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Soft Tissue (STT):

Soft tissue therapy is a mechanical, hands on type of therapy that stretches, kneads, or presses the soft tissue (muscles, fascia, ligaments, tendons). The technique is normally applied with mechanical forces, administered through the hands, elbows, or mechanical devices (e.g. graston technique / instrument assisted soft tissue therapy).  STT can be categorised into several classifications, all of which are thought to serve a different purpose, these include: 

o   Massage Therapy

o   Trigger point therapy 

o   Myofascial release  

o   Instrument assisted soft tissue therapy 

Massage Therapy:

Massage is widely used as a therapeutic technique to help improve outcomes in a range of conditions including: skin conditions (surgical sores/scars, burns scars, cleft lip scars), pain syndromes (including fibromyalgia and arthritis), hypertension, autoimmune conditions (including asthma and multiple sclerosis), immune disorders (including HIV/AIDS), cancer patients and degenerative conditions common in ageing populations (including Parkinson's and Dementia).

The technique generally follows a

·      Effleurage: Long gliding strokes with the hands (palms, thumbs and/or fingers).  

·      Petrissage: Global kneading motion with the hands (palms, thumbs and/or fingers).   

·      Friction: Circular pressures with the palms of hands, thumbs and/or fingers.   

·      Vibration: Oscillatory movements that shake or vibrate the body. 

·      Percussion: Brisk hacking or tapping. 

·      Passive and active movements: Bending and stretching. 

Massage therapy theories: 

·      Melzack and Wall (1965) gate control theory:  

o  This theory suggests that the amount of mechanical pressure provided during a massage is sufficient enough to create a large enough stimulus that interferes with transmission of pain stimuli to the brain, therefore reducing the perceived levels of pain an individual will experience (Barbour, McGuire, & Kirchhoff, 1986; Field, 1998; Malkin, 1994).  

o  The effects are only short lived however, and meta-analytical data suggests there is no significant immediate effect on pain following a massage (Moyer, Rounds, & Hannum, 2004). However, it is to note that studies included in the M-A had varying treatment times (15 minutes – 1 hour), so it may be plausible that the treatment time was not sufficient enough to elicit an effect on the spinal pain gate. In addition, modalities used to quantify pain varied, perhaps reducing the internal validity of the study.  

o  Effect size for immediate pain was 0.28, non-significant, but still shows some improvement.  

o  The notion of MT having an analgesic effect consistent with gate control theory, appears in the literature more than any other theory pertaining to MT. 

·      Promotion of Parasympathetic Activity 

o  Another theory suggests that the positive responses seen with MT is attributable to a shift in autonomic activity; from a state of arousal (sympathetic) to a state of relaxation (parasympathetic). 

o  The pressure applied during massage is thought to stimulate vagal nerve activity; the vagus nerve is the tenth cranial nerve (CN X), and interfaces with parasympathetic control of the cardiovascular systems, and the digestive tract.  

o  The parasympathetic response reduces heart rate, blood pressure, and respiration rate.

o   Opposingly, no significant difference in HR, blood pressure and skin temperature following a 30-minute back massage has been reported (Zeitlin, Keller, Shiflett, et al., 2000). This study did however report a significant decrease in respiration rates. This may support a unique subject response pattern or may indicate that some PSP parameters are activated during massage. However, cautious interpretation of results should be taken due to lack of sample size and no use of a control group.

·      Influence on body chemistry:

o   A few studies have linked MT with the release of serotonin (Field, Grizzle, Scafidi, & Schanberg, 1996 ; Ironsonetal., 1996), which is thought to inhibit the transmission of afferent noxious nerve signals to the brain (Field, 1998, pg. 1274).

o   Other research suggests that the application of massage through pressure stimulates the release of endorphins into the bloodstream (Andersson & Lundeberg, 1995 ; Oumeish, 1998); these mechanisms may provide pain relief or feelings of well-being by influencing the body chemistry.

·      Mechanical Effects:

o   Some published data may indicate that MT can speed healing and reduce pain through mechanical means (pain gaiting). The mechanical pressure and manipulation implemented onto the tissues may break down subcutaneous adhesions and reduce potential of fibrosis occurring (Donnelly & Wilton, 2002, pg. 5).

o   In addition, mechanical pressure applied to superficial and deep tissues can promote circulation (venous return and peripheral circulation) and lymphatic drainage. These processes are believed to lead to a reduction in pain associated with injury and exercise (Fritz, 2000, pg. 475– 478).

·      Promotion and Restoration of Sleep:

o   Individuals who have poor quality of sleep may experience changes in their body chemical balances, of which lead to heightened perceptions of pain.

o   When sleep quality is poor, levels of neurotransmitter substance P increase, and levels of somatostatin decrease, both of which have been shown to influence pain (Sunshine, Field, Quintino, et al., 1996).

o   The use of MT can help to promote ‘deeper’, less disturbed sleep in a sample of fibromyalgia patients – they experienced a reduction in pain rating during the course of the treatment.

o   This may suggest that MT can help reduce pain indirectly, through improve the quality of restorative sleep.

o  Pittsburgh Sleep Quality Index (PSQI) was used to measure sleep in a population of cancer patient care givers when provided with massage treatment (15 minutes daily, 7 days) across lumbar / thoracic spine. Significant improvements in the quality of sleep within this population was observed (rate of poor sleep decreased by 13.7%; p<0.01). Pinar and Afsar 2015.

Effects of Swedish / Sports Massage on Physiological responses: 

·      Single Dose Effects: 

o  State Anxiety:

o  Characterized through tension, apprehension, worry and a heightened autonomic nervous response.

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Summary:

In summary, thoracic mobilisations, manipulations and soft tissue therapies all have a place within rehabilitation and treatment; ranging from musculoskeletal disorders, to respiratory conditions and psychological health. However, the benefits primarily seen are often short-term and non-specific resulting in patients requiring recurrent treatment.

From the research and literature stated above it can be deduced that all three manual therapy techniques reduce perceived pain, muscle tension and disability in the short term, providing the patient with an instant relief. This instant effect often allows the therapist to assess and treat the root cause due to the patient’s reduced pain and increased mobility.

Evidence suggest that all three techniques should be provided alongside other modalities such as exercise in order to produce a long-term reduction in symptoms and reduce the chance of recurrence. Even so manual therapy techniques are essential within physiotherapy and the positive outcomes they provide are crucial to a patient-centred approach and treatment.

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