The Effectiveness of Manual Therapies on the Thoracic Spine
The Thoracic Spine:[edit | edit source]
Anatomy:[edit | edit source]
- 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. [1]
- T1-T11 articulate with the ribs to provide stability to the rib cage
Mobility:[edit | edit source]
- Least mobile portion of the spine
- T1-T8 = reduced flexion and extension, increased axial rotation
- T9-T12 = increased flexion and extension, reduced axial rotation. [1]
Main Conditions:[edit | edit source]
Bone Structures:[edit | edit source]
- Osteoarthritis
- Osteoporosis
- Scoliosis
- Fracture
- Vertebral Body
- Facet joint
- Spinous Process
Trauma:[edit | edit source]
- Impact
Muscular Structures:[edit | edit source]
- Muscle Sprain/Strain
- Myofascial Pain
- Degeneration
- Inflammation/Irritation
Neurological Pain:[edit | edit source]
- Compression of nerve root
- Referred Pain
Contraindications to Manual Therapy:[edit | edit source]
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.
Absolute Contraindications:[edit | edit source]
- Fractures
- Bone disorders
- Osteoporosis
- Progressive Neurological Disorders
- Cauda Equina
- CAD/VBI signs
- Rheumatoid Arthritis and other Inflammatory Disorders
- No cognitive capacity
Precautions:[edit | edit source]
- Pregnancy
- Children
- Elderly
- Frailty
- Arthritis
- 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
Manual Therapies[edit | edit source]
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."
Mobilisations:[edit | edit source]
Sympo-excitatory response[edit | edit source]
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[2].
They are often used in the Physiotherapy management in order to produce mechanical and neurophysiological effects[2]. 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[3] 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[edit | edit source]
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.[4]
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[5] and impaired coughing ability leading to further respiratory complications[6]. 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[7].
Video:
Manipulations:[edit | edit source]
"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." [8]
Grades: Maitland Joint Mobilisation Scale [9][edit | edit source]
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
Thoracic Spine Manipulations in the Management of Cervicogenic Headaches: [edit | edit source]
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 [10]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, but not conclusive.[10]
- RCT, using manipulations alongside soft tissue therapy showed a 50% decrease in tension headache length. (Bove and Nilsson, 1998)
- Many authors promote postural re-education and muscle strengthening exercises along with Manipulations and therefore the specific effects of manipulations alone are not clear. (Castein et al., 2009)
Video:
Soft Tissue (STT):[edit | edit source]
Video:
Summary:[edit | edit source]
References:[edit | edit source]
- ↑ 1.0 1.1 Palastanga, N. and Field, D. (2014). Anatomy and Human Movement. Kent: Elsevier Science.
- ↑ 2.0 2.1 Edmond S. Joint Mobilization/Manipulation - E-Book. 3rd ed. Elsevier Health Sciences.; 2016.
- ↑ Kingston L, Claydon L, Tumilty S. The effects of spinal mobilizations on the sympathetic nervous system: A systematic review. Manual Therapy. 2014;19(4):281-287.
- ↑ Hwangbo P, Hwangbo G, Park J, Lee S. The Effect of Thoracic Joint Mobilization and Self-stretching Exercise on Pulmonary Functions of Patients with Chronic Neck Pain. Journal of Physical Therapy Science. 2014;26(11):1783-1786.
- ↑ Ogiwara S, Ogura K. Antero-Posterior Excursion of the Hemithorax in Hemiplegia. Journal of Physical Therapy Science. 2001;13(1):11-15.
- ↑ Gauld L, Boynton A. Relationship between peak cough flow and spirometry in Duchenne muscular dystrophy. Pediatric Pulmonology. 2005;39(5):457-460.
- ↑ 6. Jang S, Bang H. Effect of thoracic and cervical joint mobilization on pulmonary function in stroke patients. Journal of Physical Therapy Science. 2016;28(1):257-260.
- ↑ Mintken PE, et al. A Model for Standardizing Manipulation Terminology in Physical Therapy Practice. J Orthop Sports Phys Ther 2008;38(3):A1-A6.
- ↑ Rao, R., Balthillaya, G., Prabhu, A. and Kamath, A. (2018). Immediate effects of Maitland mobilization versus Mulligan Mobilization with Movement in Osteoarthritis knee- A Randomized Crossover trial. Journal of Bodywork and Movement Therapies, 22(3), pp.572-579.
- ↑ 10.0 10.1 Posadzki, P. and Ernst, E. (2012). Spinal manipulations for tension-type headaches: A systematic review of randomized controlled trials. Complementary Therapies in Medicine, 20(4), pp.232-239.
