Thoracic Spine Mobilization for Shoulder Pain Scott Tauferner PT, ATC
Conflicts of Interest None
1 2 3 Participants will be able to select thoracic mobilization strategies in patients with shoulder pain. Participants will be able to identify thoracic hypomobility conducive to thoracic mobilization. Participants will recognize contraindications to manual therapy of the thoracic spine. Learning Objectives
Clinical Prediction Rule for patients who will benefit from cervicothoracic manipulation Examination of the Validity of a Clinical Prediction Rule to Identify Patients With Shoulder Pain Likely to Benefit From Cervicothoracic Manipulation Preplanned secondary analysis next study Did not validate the previously identified prognostic variables IMPLICATIONS: It is currently not possible to identify individuals with shoulder pain who are more likely to benefit from CT manipulation. Mintken et al. JOSPT April 2017 Vol 47 No. 4 252-260
Cervicothoracic Manual Therapy Plus Exercise Therapy Versus Exercise Therapy Alone in the Management of Individuals With Shoulder Pain: A Multicenter Randomized Controlled Trial Methods 140 individuals with shoulder pain 2 sessions of high-dose cervicothoracic manual therapy and range-of-motion exercises plus 6 sessions of exercise therapy OR 2 sessions of cervicothoracic rangeof-motion exercises plus 6 sessions of exercise therapy Results Both groups experienced similar improvements in pain and disability ratings at all time points Conclusion These results do not support the addition of cervicothoracic manual therapy to a standardized exercise program to improve pain and disability in individuals with shoulder pain However patients in manual therapy group did improve patient-perceived success at 4 weeks and 6 months and acceptability of symptoms at 4 weeks Mintken et al. JOSPT April 2016 Vol 46 No 8 617-628
Cervicothoracic Manual Therapy Plus Exercise Therapy Versus Exercise Therapy Alone in the Management of Individuals With Shoulder Pain: A Multicenter Randomized Controlled Trial Potential explanations for lack of benefit Only 2 sessions of manual therapy applied Majority of individuals had chronic pain >2 years duration Manual therapy was applied in a prescriptive fashion with limited clinical decision making on the part of the therapist Mintken et al. JOSPT April 2016 Vol 46 No 8 617-628
Regional Interdependence Seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient s primary complaint Focuses primarily on impairments present in proximal or distal segments and is distinct from the phenomenon of referred pain If a patient s presentation is unclear or if the response to intervention is less favorable than expected, practical application of the regionalinterdependence model may add clarity to the patient s clinical picture and guide subsequent interventions Wainner R, et al. J Orthop Sports Phys Ther 2007;37(11):658-660
Second and Third Rib Syndrome Palpation of the second and third ribs found to be painful significantly more often in patients with shoulder pain v controls Sobel JS, et al. J Manip Physio Ther 1997;20:257-62 Neuroanatomical rationale 2 nd rib entrapping or irritating dorsal ramus of 2 nd thoracic nerve, this nerve provides cutaneous distribution to posterolateral shoulder. Dunning J, et al. J Manip and Physio Thera Vol 38, 6
Changes In Shoulder Pain and Disability After Thrust Manipulation In Subjects Presenting with Second and Third Rib Syndrome Descriptive Case Series Methods 10 consecutive individuals with shoulder pain Negative Neer With/without brachial pain Duration of symptoms ranged from 1 and 270 days Exam findings linking shoulder pain with dysfunction of the cervicothoracic spine and the adjacent ribs 2 sessions thrust manipulation upper thoracic spine and second/third ribs on symptomatic side Results Significant decrease in Shoulder Pain and Disability Index at 48 hours, 1 and 3 months Significant decrease in Numeric Pain Rating Scale Dunning J, et al. J Manip and Physio Thera Vol 38, 6 2015
The Immediate Effects of Thoracic Spine and Rib Manipulation on Subjects with Primary Complaints of Shoulder Pain Test Retest Design Methods 21 consecutive subjects 18-65yo Decreased shoulder motion Pain with Kennedy Hawkins or Neer Thrust manipulation to all subjects upper thoracic spine and or ribs Results 51% reduction in shoulder pain Increased ROM (30-38 ) Patient perceived GROC 4.2 Strunce et al. J of Manual and Manip Therapy volume 17, 4
The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome Pre-test/Post-test study Methods 56 patients with shoulder impingement syndrome Treated with thoracic spine thrust manipulation Results 48 hour follow up statistically significant changes in NPRS for Neer, Hawkins impingement, resisted empty can, resisted ER/IR/ABD Boyles et al. Manual Therapy (2009) 14 375-380
Treatment of Shoulder Impingement Syndrome Using Non-thrust Mobilizations to the Thoracic Spine and Ribs: A Case Report 47 yo male with 4 month history of left shoulder pain Intent was to treat with mobilization rather than manipulation T1-8 hypomobility and Left ribs 4-7 hypomobile Treatment Manual therapy of non-thrust thoracic mobilization GrIII-IV Therapeutic exercise self mobilization and strengthening Following 6 physical therapy appointments with manual interventions and progressive exercises, the patient had reduced pain with all overhead tasks, exercises, and improved posture and scapular positioning Curtis et al. Orthopedic Practice Volume 30 / number 1 / 2018
Manipulative Therapy For Shoulder Pain and Disorders: Expansion of a Systematic Review Manual and Manipulative Therapy (MMT), whether grade V thrust or grades III and IV mobilizations, should be considered for inclusion in the treatment of shoulder pain and disorders Evaluation of the GH, AC, SC, spine, and upper ribs should be assessed for ROM, accessory glide, end-range play, feel, or accessory motions Grade III, IV, or V mobilization should be applied in the direction of the restriction after adequate diagnosis has been made and contraindications have been ruled out Brantingham et al. J of Manip and Physio Thera Vol 34, 5 2011
Thoracic manual therapy in the management of non-specific shoulder pain: a systematic review Methods Key databases were searched (1990 2014) Results Over 912 articles were retrieved: three RCTs, one single-arm trial and three pre post test studies were eligible Three RCTs demonstrated that Thoracic manual therapy (TMT) reduced pain and disability at 6, 26 and 52 weeks compared with usual care Two pre post test studies found between 76% and 100% of patients experienced significant pain reduction immediately post-tmt. An additional pre post test study and a single-arm trial showed reductions in pain and disability scores 48 hours post-tmt Discussion Thoracic manual therapy accelerated recovery and reduced pain and disability immediately and for up to 52 weeks compared with usual care for NSSP Further, high-quality RCTs investigating the effect of TMT in isolation for the treatment of patients with NSSP are now required Peek et al. J of Manual and Manip Therapy 2015 vol 23 no. 4
Contraindications to Manipulation/Mobilization Absolute Vascular CAD, aortic aneurysm >5cm, severe hemophilia Bone Tumor, TB infection, metabolic ie osteomalacia, congenital dysplasias, fracture, long term corticosteroid use, Inflammatory Arthritis Fracture, upper cervical instability Neurologic Cauda equina, cervical myelopathy Radiculopathy or neurogenic pain is NOT an absolute contraindication Excessive or extreme pain Lack of a clinical diagnosis Lack of patient consent (verbal or written) Dr James Dunning Spinal Manipulation Institute 2014
Contraindications to Manipulation/Mobilization Relative Disc herniation or prolapse Risk of worsening lumbar disc herniation: 1 in 3.7 million (Oliphant et al 2002) Pregnancy DO NOT thrust at the 12-16 th weeks as can lose the baby at these intervals HVLAT has never been shown to cause a miscarriage Osteoporosis, Rheumatoid Arthritis Spondylolysis, spondylolisthesis Avoid extension and do primary lever of flexion or non-thrust procedures Advanced DJD, spondylosis Recent trauma Dr James Dunning Spinal Manipulation Institute 2014
Prone Techniques
PA Thoracic Vertebral Mobilization
PA rib mobilization
Rib glide
1 st rib mobilization
Lower rib mobilization
Supine Techniques
Opening mobilization
Upper rib mobilization
1 st rib
Seated Techniques
Genie mobs Upper thoracic PA
Rib mobilization
Thoracic PA with extension
Side Lying Technique
Rib