30 Seconds Of Therapy: Manual Therapy for the Thoracic Spine

Jun 16

7 min read

Man holding his lower back in pain with spine highlighted, showing thoracic and lumbar spine discomfort on a dark background — *The* ***Thoracic Spine*** *is the mid-back region of the vertebral column, made up of 12 vertebrae (T1–T12). It is anatomically located between the cervical spine (neck) and the lumbar spine (lower back).*

START

Start using thoracic manipulation as a first-line treatment for mechanical neck pain.
1. Increases cervical range of motion.
2. Reduces pain and self-reported disability.
  1. T1–T4 thrusts can reduce neck pain even in the absence of cervical interventions.
Start screening for hypomobility in the cervicothoracic junction (T1–T4)
1. Patients with limited thoracic mobility often present with forward head posture and scapular dysfunction.
2. Normal thoracic ROM benchmarks:
  1. Rotation: ~45°, Side flexion: ~35°, Thoracolumbar flexion: ~10 cm (tape measure)
Start using movement-based exams to guide manual therapy
1. Reproduction of familiar symptoms through thoracic rotation/flexion indicates likely contributors.
  1. Match thrust or non-thrust technique to SINSS presentation.
  2. Thoracic Examination & Technique Selection Guide PDF Download

STOP

Isolating interventions to the cervical spine
1. Thoracic manipulation offers global benefit to upper quadrant symptoms.
  1. It improves cervical mobility and decreases pain intensity.
  2. Focusing only on cervical joints can miss upstream or downstream contributors.
Assuming thoracic stability = no dysfunction
1. The thoracic spine supports posture and load transfer.
  1. Thoracic kyphosis, poor posture, and stiffness can drive upper quadrant issues.
  2. Think of the thoracic spine as a kinetic bridge: dysfunction here affects the neck, shoulder, and rib cage.
Applying the same manual therapy technique to all patients
1. Adapt the grade, direction, and technique based on assessment.
  1. Early-stage pain? Use gentle PA mobilization.
  2. Chronic stiffness? A targeted HVLA thrust may restore segmental motion more effectively.

WHY

Why thoracic manipulation for neck pain?
1. Because upper thoracic hypomobility (T1–T4) alters cervical mechanics, leading to overload and pain. Manipulating the thoracic spine improves cervical ROM, reduces pain, and offers a safer alternative for sensitive or high-risk cervical cases often with immediate effect.
Why prioritize T1–T4?
1. These segments stabilize cervical motion and influence posture and scapular control. Restoring mobility here addresses the root of cervicogenic headaches, upper trap tension, and postural dysfunction—driving long-term relief beyond the neck.

References: MedBridge Manual Therapy of the Thoracic Spine Amy McDevitt, PT, DPT, PhD, FAAOMPT 1. Bishop, M. D., Mintken, P. E., Bialosky, J. E., & Cleland, J. A. (2013). Patient expectations of benefit from interventions for neck pain and resulting influence on outcomes. The Journal of Orthopaedic and Sports Physical Therapy, 43(7), 457–465. https://doi.org/10.2519/jospt.2013.4492 2. Blanpied, P. R., Gross, A. R., Elliott, J. M., Devaney, L. L., Clewley, D., Walton, D. M., Sparks, C., Robertson, E. K., Altman, R. D., Beattie, P., Boeglin, E., Cleland, J. A., Childs, J. D., DeWitt, J., Flynn, T. W., Ferland, A., Kaplan, S., Killoran, D., & Torburn, L. (2017). Neck pain: Revision 2017: Clinical practice guidelines linked to the International Classification of Functioning, Disability and Health from the orthopaedic section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 47(7), A1–A83. https://doi.org/10.2519/jospt.2017.0302 3. Bogduk, N. (2016). Functional anatomy of the spine. Handbook of Clinical Neurology, 136, 675– 688. https://doi.org/10.1016/B978-0-444-53486-6.00032-6 4. Boyles, R. E., Ritland, B. M., Miracle, B. M., Barclay, D. M., Faul, M. S., Moore, J. H., Koppenhaver, S. L., & Wainner, R. S. (2009). The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Manual Therapy, 14(4), 375–380. https://doi.org/10.1016/j.math.2008.05.005 5. Bullock, M. P., Foster, N. E., & Wright, C. C. (2005). Shoulder impingement: The effect of sitting posture on shoulder pain and range of motion. Manual Therapy, 10(1), 28–37. https://doi.org/10.1016/j.math.2004.07.002 6. Cleland, J. A., Childs, J. D., McRae, M., Palmer, J. A., & Stowell, T. (2005). Immediate effects of thoracic manipulation in patients with neck pain: A randomized clinical trial. Manual Therapy, 10(2), 127–135. https://doi.org/10.1016/j.math.2004.08.005 7. Cook, C. (2011). Orthopedic manual therapy: An evidence-based approach (2nd ed.). Pearson. Cross, K. M., Kuenze, C., Grindstaff, T. L., & Hertel, J. (2011). Thoracic spine thrust manipulation improves pain, range of motion, and self-reported function in patients with mechanical neck pain: A systematic review. The Journal of Orthopaedic and Sports Physical therapy, 41(9), 633–642. https://doi.org/10.2519/jospt.2011.3670 8. Dreyfuss, P., Tibiletti, C., & Dreyer, S. J. (1994). Thoracic zygapophyseal joint pain patterns. A study in normal volunteers. Spine, 19(7), 807–811. https://doi.org/10.1097/00007632-199404000-00014 9. Engell, S., Triano, J. J., & Howarth, S. J. (2019). Force transmission between thoracic and cervical segments of the spine during prone-lying high-velocity low-amplitude spinal manipulation: A proof of principle for the concept of regional interdependence. Clinical Biomechanics (Bristol, Avon), 69, 58–63. https://doi.org/10.1016/j.clinbiomech.2019.07.006 10. Erdem, E. U., Ünver, B., Akbas, E., & Kinikli, G. I. (2021). Immediate effects of thoracic manipulation on cervical joint position sense in individuals with mechanical neck pain: A randomized controlled trial. Journal of Back and Musculoskeletal Rehabilitation, 34(5), 735–743. https://doi.org/10.3233/BMR-191798 11. Fruth, S. J. (2017). Fundamentals of the physical therapy examination: Patient interview and tests & measures (2nd ed.). Jones & Bartlett Learning. Fukui, S., Ohseto, K., & Shiotani, M. (1997). Patterns of pain induced by distending the thoracic zygapophyseal joints. Regional Anesthesia and Pain Medicine, 22(4), 332–336. https://doi.org/10.1016/s1098-7339(97)80007-7 12. González-Iglesias, J., Fernández-de-las-Peñas, C., Cleland, J. A., & Gutiérrez-Vega, M.delR. (2009). Thoracic spine manipulation for the management of patients with neck pain: A randomized clinical trial. The Journal of Orthopaedic and Sports Physical Therapy, 39(1), 20–27. https://doi.org/10.2519/jospt.2009.2914 13. Griswold, D., Learman, K., Kolber, M. J., O’Halloran, B., & Cleland, J. A. (2018). Pragmatically applied cervical and thoracic nonthrust manipulation versus thrust manipulation for patients with mechanical neck pain: A multicenter randomized clinical trial. The Journal of Orthopaedic and Sports Physical Therapy, 48(3), 137–145. https://doi.org/10.2519/jospt.2018.7738 14. Heneghan, N. R., & Rushton, A. (2016). Understanding why the thoracic region is the ‘Cinderella’ region of the spine. Manual Therapy, 21, 274–276. https://doi.org/10.1016/j.math.2015.06.010 15. Hutting, N., Kerry, R., Coppieters, M. W., & Scholten-Peeters, G. G. M. (2018). Considerations to improve the safety of cervical spine manual therapy. Musculoskeletal Science & Practice, 33, 41–45. https://doi.org/10.1016/j.msksp.2017.11.003 16. International Association for the Study of Pain. (2011). Terminology. https://www.iasppain.org/resources/terminology/ 17. Joshi, S., Balthillaya, G., & Neelapala, Y. V. R. (2020). Immediate effects of cervicothoracic junction mobilization versus thoracic manipulation on the range of motion and pain in mechanical neck pain with cervicothoracic junction dysfunction: A pilot randomized controlled trial. Chiropractic & Manual Therapies, 28(1), 38. https://doi.org/10.1186/s12998-020-00327-4 18. Maitland, G. D. (2001). Maitland’s vertebral manipulation (6th ed). Butterworth-Heinemann. Masaracchio, M., Kirker, K., States, R., Hanney, W. J., Liu, X., & Kolber, M. (2019). Thoracic spine manipulation for the management of mechanical neck pain: A systematic review and meta-analysis. PloS One, 14(2), e0211877. https://doi.org/10.1371/journal.pone.0211877 19. McDevitt, A. W., Cleland, J. A., Rhon, D. I., Altic, R. A. K., Courtney, D. J., Glynn, P. E., & Mintken, P. E. (2022). Thoracic spine thrust manipulation for individuals with cervicogenic headache: A crossover randomized clinical trial. The Journal of Manual & Manipulative Therapy, 30(2), 78–95. https://doi.org/10.1080/10669817.2021.1947663 20. McDevitt, A., Young, J., Mintken, P., & Cleland, J. (2015). Regional interdependence and manual therapy directed at the thoracic spine. The Journal of Manual & Manipulative Therapy, 23(3), 139–146. https://doi.org/10.1179/2042618615Y.0000000005 21. Mintken, P. E., Cleland, J. A., Carpenter, K. J., Bieniek, M. L., Keirns, M., & Whitman, J. M. (2010). Some factors predict successful short-term outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: A single-arm trial. Physical Therapy, 90(1), 26– 42. https://doi.org/10.2522/ptj.20090095 22. Mintken, P. E., McDevitt, A. W., Cleland, J. A., Boyles, R. E., Beardslee, A. R., Burns, S. A., Haberl, M. D., Hinrichs, L. A., & Michener, L. A. (2016). Cervicothoracic manual therapy plus exercise therapy versus exercise therapy alone in the management of individuals with 3 shoulder pain: A multicenter randomized controlled trial. The Journal of Orthopaedic and Sports Physical Therapy, 46(8), 617–628. https://doi.org/10.2519/jospt.2016.6319 23. Norlander, S., Gustavsson, B. A., Lindell, J., & Nordgren, B. (1997). Reduced mobility in the cervico-thoracic motion segment--A risk factor for musculoskeletal neck-shoulder pain: A two-year prospective follow-up study. Scandinavian Journal of Rehabilitation Medicine, 29(3), 167–174. 24. Peek, A. L., Miller, C., & Heneghan, N. R. (2015). Thoracic manual therapy in the management of non-specific shoulder pain: A systematic review. The Journal of Manual & Manipulative Therapy, 23(4), 176–187. https://doi.org/10.1179/2042618615Y.0000000003 25. Petersen, E. J., Thurmond, S. M., & Jensen, G. M. (2021). Severity, Irritability, Nature, Stage, and Stability (SINSS): A clinical perspective. The Journal of Manual & Manipulative Therapy, 29(5), 297–309. https://doi.org/10.1080/10669817.2021.1919284 26. Petersen, S. B., Cook, C., Donaldson, M., Hassen, A., Ellis, A., & Learman, K. (2015). The effect of manual therapy with augmentative exercises for neck pain: A randomised clinical trial. The Journal of Manual & Manipulative Therapy, 23(5), 264–275. https://doi.org/10.1179/2042618615Y.0000000011 27. Puentedura, E. J., & O'Grady, W. H. (2015). Safety of thrust joint manipulation in the thoracic spine: A systematic review. The Journal of Manual & Manipulative Therapy, 23(3), 154– 161. https://doi.org/10.1179/2042618615Y.0000000012 28. Schneider, G. M., Jull, G., Thomas, K., Smith, A., Emery, C., Faris, P., Cook, C., Frizzell, B., & Salo, P. (2014). Derivation of a clinical decision guide in the diagnosis of cervical facet joint pain. Archives of Physical Medicine and Rehabilitation, 95(9), 1695–1701. https://doi.org/10.1016/j.apmr.2014.02.026 29. Strunce, J. B., Walker, M. J., Boyles, R. E., & Young, B. A. (2009). The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. The Journal of Manual & Manipulative Therapy, 17(4), 230–236. https://doi.org/10.1179/106698109791352102 30. Tsang, S. M., Szeto, G. P., & Lee, R. Y. (2013). Normal kinematics of the neck: The interplay between the cervical and thoracic spines. Manual Therapy, 18(5), 431–437. https://doi.org/10.1016/j.math.2013.03.002 31. Wainner, R. S., Whitman, J. M., Cleland, J. A., & Flynn, T. W. (2007). Regional interdependence: A musculoskeletal examination model whose time has come. The Journal of Orthopaedic and Sports Physical Therapy, 37(11), 658–660. https://doi.org/10.2519/jospt.2007.0110 33. Tsegay, G. S., Gebregergs, G. B., Weleslassie, G. G., & Hailemariam, T. T. (2023). Effectiveness of thoracic spine manipulation on the management of neck pain: A systematic review and meta-analysis of randomized control trials. Journal of Pain Research, 16, 597–609. https://doi.org/10.2147/JPR.S368910 34. Wassinger, C. A., Rich, D., Cameron, N., Clark, S., Davenport, S., Lingelbach, M., Smith, A., Baxter, G. D., & Davidson, J. (2016). Cervical & thoracic manipulations: Acute effects upon pain pressure threshold and self-reported pain in experimentally induced shoulder pain. Manual Therapy, 21, 227–232. https://doi.org/10.1016/j.math.2015.08.009 35. Young, J. L., Walker, D., Snyder, S., & Daly, K. (2014). Thoracic manipulation versus mobilization in patients with mechanical neck pain: A systematic review. The Journal of Manual & Manipulative Therapy, 22(3), 141–153. https://doi.org/10.1179/2042618613Y.0000000043.