Management of thoracic spine disorders

• Deformity due to Scheuermann's disease or idiopathic scoliosis, especially in children and young adults

• Infections such as vertebral osteomyelitis presenting with pain, pyrexia and local tenderness

• Tumours (primary – benign or malignant and secondary metastatic). Patients with known tumours should be treated as suspicious for metastases, especially if the pain is predominantly constant, unremitting and felt at night

• High velocity injury or osteoporotic fractures

• Degenerative conditions associated with neurogenic claudication and stenotic impairments.

1. With the patient seated and facing straight ahead towards the physiotherapist, he is asked if he has any symptoms (Fig. 5.15A).

2. Assuming that his symptoms can only be provoked at the end of the range of rotation, he is asked to turn his head fully to the right with his trunk still facing straight ahead. If he feels no change in symptoms, the physiotherapist applies over-pressure to the cervical rotation by pressing her right forearm behind his right shoulder and her right hand behind the back of his head on the right side, while also placing her left hand against his left zygomatic arch. In this position she is able to apply over-pressure to the cervical area without movement of his shoulders. This is not testing cervical rotation to the exclusion of any thoracic rotation, as the upper thoracic spine does also rotate somewhat. Nevertheless, it is a useful attempt at differentiating (Fig. 5.15B).

3. Once the pain response with over-pressure to cervical rotation is assessed, the patient is asked to rotate his thorax to the right without there being any rotation of the head to the right. The physiotherapist applies over-pressure to the thoracic rotation by applying further rotary pressure through his shoulders (Fig. 5.15C).

4. With the pain response noted when over-pressure is applied to the thoracic rotation, the patient is then asked to turn his head fully to the right and any further change in symptoms is noted. If there is a change of symptoms when the cervical spine is rotated to the right, then movement of the cervical spine must be involved in the patient's symptoms (Fig. 5.15D).

5. While in the position described above, the physiotherapist changes her application of over-pressure from the upper thoracic area to cervical rotation to the right while at the same time allowing the patient to release the upper thoracic rotation slightly, and the change in symptoms is assessed. With this change of over-pressure, the emphasis of the rotation is released from the upper thoracic area and increased at the cervical area (see Fig. 5.15E).

Flexion: Having adopted the above position, the patient is then instructed to curl his elbows into his groin to produce thoracic flexion. The therapist notes the range of movement, symptom response and quality of movement. If necessary, over-pressure can be added via the supraclavicular and suprascapular areas. The therapist stands in front of the patient and places her hands over the top of his shoulders with her fingers posteriorly and her thumbs anteriorly. Over-pressure is applied in the direction of the continuing arc of flexion. Over-pressure directed cranially, horizontally or caudally can put emphasis on the upper, middle and lower parts of the thoracic spine respectively (Fig. 5.16B).

Extension: The same starting position as for flexion is adopted, with one exception: the patient places one or both feet on a chair in order to flex the lumbar spine. The patient is instructed to direct his elbows upwards. The therapist notes the range, symptom response and quality of movement. If necessary, over-pressure can be added by the therapist, who stands by the side of the patient and places an arm under both his axillae and across his sternum. She places the other hand on his thoracic spine to localize the over-pressure, at the same time side-flexing her trunk in the direction of the thoracic extension (Fig. 5.16C).

1. With the patient sitting he is asked to turn fully to the left, and when the physiotherapist has added over-pressure to this movement his symptoms are assessed (Fig. 5.17).

2. While over-pressure is maintained for rotation to the left, the physiotherapist laterally flexes the patient's trunk to the left while at the same time assessing changes in symptoms. It is important, during the movement of lateral flexion to the left, that the same strength of pressure to the rotation is maintained. This is not as easy as it may seem; with her right axilla stabilizing his right shoulder she must follow his lateral flexion (Fig. 5.18).

3. The physiotherapist then laterally flexes his trunk to the right, again using her right axilla to stabilize and control the lateral flexion, while noting changes in symptoms. Once more, it is necessary to retain the same strength to the rotary over-pressure (Fig. 5.19).

4. To the sustained over-pressure of the thoracic rotation to the left, the physiotherapist then adds flexing at the appropriate level of the thoracic spine and assesses the changes in symptoms (Fig. 5.20).

5. To the sustained over-pressure to the thoracic rotation to the left, the physiotherapist then adds thoracic extension at the appropriate level while noting changes in symptoms. To produce the extension, the physiotherapist uses her right forearm as a fulcrum while using her two hands to extend the patient's thoracic spine (Fig. 5.21).

Starting position: With the patient sitting, the physiotherapist stands in front of him and slightly to the patient's right. She rests her left hand over his right shoulder with the middle finger positioned between two spinous processes, while the index finger palpates the upper margin of the spinous process of the upper vertebra and the ring finger palpates the lower margin of the lower spinous process. To produce a firm yet comfortable grasp with the left hand, the pad of the thumb is placed in the supraclavicular fossa. The right hand and forearm are placed over the top of the patient's head so that they lie in the sagittal plane. The fingers and thumb grasp the occiput near the nuchal lines, and the wrist is flexed to permit firm pressure on the front of the head by the forearm (Fig. 5.22).

Method: Movement of the patient's head is controlled by the physiotherapist's right hand and forearm. All scalp looseness must be taken up by the grasp between the fingers and forearm to permit complete control of the patient's head and make him feel that support of his head can be left to the physiotherapist.

As the amount of movement that can be felt at this level is much less than elsewhere in the vertebral column, two complementary actions are necessary to produce the maximum intervertebral movement. First, the oscillation of the head and neck needs to be through a range at least of 30° performed near the limit of forward flexion. Secondly, because the lever producing movement is long, pressure by the three palpating fingers over the spine will help to localize movement as the head is moved back through a range of 30°.

The intervertebral movement is felt by the ring, middle and index fingers as the spinous processes move away from and towards each other during the back and forth movements of the head and neck.

Starting position: The patient lies comfortably on his right side, near the forward edge of the couch, with his head resting on pillows. The physiotherapist stands in front of the patient, cradling his head in her left arm with her fingers covering the posterior surface of his neck, her little finger reaching down to the vertebral level being examined. She stabilizes his head between her left forearm and the front of her left shoulder. Next she leans across the patient, placing her right forearm along his back to stabilize his thorax, and palpates the under-surface of the interspinous space with the pad of her index or middle finger facing upwards (Fig. 5.23).

Method: With her left arm, the physiotherapist flexes and extends the patient's lower neck as much as possible. The spine above C6 and the head are not flexed or extended, because movement in this area makes movement in the test area less controlled and less isolated. The patient's head and neck are moved only until the particular joint tested has come to the limit of its range.

Method: The starting position is identical with that described for flexion/extension. The purpose of this method is to achieve lateral flexion at the particular joint being tested, and therefore the head does not laterally flex but rather is displaced upwards. Lateral flexion is produced by the physiotherapist lifting the patient's head with a hugging grip of his head, the majority of the lift being achieved by the ulnar border of her left hand against the underside of his cervicothoracic junction (Fig. 5.24). To test lateral flexion in the opposite direction, the patient must lie on his other side. The palpating finger feels for movement between the two adjacent spinous processes. The upper process moves first, and when the lower process starts to move this will signal the extent of the lateral flexion at this particular intervertebral level.

Method: The starting position is again the same as for flexion/ extension. To produce the rotation properly, it is necessary to concentrate on moving the joint being examined without causing any tilting or flexing of the head and neck. Movement of the upper spinous process in relation to its distal neighbour is palpated through the pad of the physiotherapist's index or middle finger, which is facing upwards against the underside of the interspinous space.

With the patient's head cradled between the physiotherapist's left forearm and shoulder, and his lower neck firmly gripped in the ulnar border of her hand between the little finger and the hypothenar eminence, she rotates his lower cervical spine towards her. This is achieved by elevating her scapula to its highest point while maintaining a stable thorax (Fig. 5.25). As the movement is difficult to achieve accurately, more care is needed than with the other movements tested in this area.

Starting position: The patient sits with his hands clasped behind his neck while the physiotherapist, standing by his left side, places her left arm under his left upper arm and grasps his right upper arm in her supinated hand. She places her right hand across his spine just below the level being tested, and the pad of the tip of the middle finger in the far side of the interspinous space to feel adjacent spinous processes.

Method: While the patient relaxes to allow his thorax to be flexed and extended, the physiotherapist takes the weight of his upper trunk on her left arm.

To test flexion, she lowers his trunk from the neutral position until movement can be felt to have taken place at her right middle finger; the patient is then returned to the neutral position by lifting under his arms. The oscillatory movement through an arc of approximately 20° of trunk movement is facilitated if the patient is held firmly and if the physiotherapist laterally flexes her trunk to the left as she lowers the trunk into flexion. This makes the return movement one of laterally flexing her trunk to the right rather than lifting with her left arm.

The extension part of the test is carried out in much the same way, except that the physiotherapist assists the trunk extension with the heel and ulnar border of her right hand. In doing this she must be careful to keep the pad of her middle finger in a constant position between the adjacent spinous processes. Movement of the patient's trunk is from the neutral position into extension. It is important to remember that it is movement at only one joint that is being examined, and therefore large trunk movements are not necessary; in fact they detract from the examination.

Starting position: The patient sits and holds his hands behind his neck or crosses his arms across his chest while the physiotherapist stands side-on behind his right side reaching with her right arm to hold high around and behind his left shoulder. She grips his trunk firmly between her right arm and her right side in her left axilla. This high grasp with the right hand is necessary for examination of the higher levels; as the examination extends below T8, so the grasp needs to be taken down to the lower scapular area. She places the heel of her left hand on the right side of his back at the level being examined, spreads her fingers for stability, and places the tip of the pad of her flexed middle finger in the far side of the interspinous space of the joint to be tested (Fig. 5.26).

Starting position: Although rotation can be tested in the sitting position, it is more easily and more successfully tested when the patient is lying down. The patient lies on his left side with his hips and knees comfortably flexed while the physiotherapist, standing in front of the patient, leans over his trunk to cradle his pelvis between her left side and her left upper arm. This position stabilizes the patient's pelvis. The physiotherapist's forearm is then in line with the patient's spine, and her hand reaches the level where movement is to be examined. She then places her left hand on his spine with the pad of her middle finger facing upwards against the under-surface of the interspinous space to feel the bony margins of the adjacent spinous processes. With her right hand, she grasps as far medially as possible over the patient's suprascapular area and places her forearm over his sternum or grasps the patients elbow over his sternum (Fig. 5.27).

Method: The patient's trunk is repeatedly rotated back and forth by the physiotherapist's right forearm and hand through an arc of approximately 25°. Care must be taken to ensure that the movement does not include scapulothoracic movement. To examine movement in the upper thoracic intervertebral joints, the arc of movement should be performed just behind the frontal plane. As lower intervertebral joints are examined, the arc of rotation used to assess movement moves backwards until an arc of rotation between 40 and 60° from the frontal plane is used to examine the movement between T10 and T11. The palpating finger must follow the patient's trunk movement, and when movement occurs at the joint being examined, the upper spinous process will be felt to press into the pad of the middle finger, which is facing upwards. When the lower spinous process starts to move, this is the extent of rotation at the intervertebral level.

Starting position: The patient lies prone, either with his forehead resting on the backs of his hands or with his head comfortably turned to one side and his arms lying by his sides on the couch. The position depends on the amount of chest tightness created by the ‘arms up’ position, which is usually reserved for upper thoracic mobilization.

If the patient is on a low couch, the physiotherapist's position for mobilizing the upper thoracic spine (approximately T1–5) needs to be at the head of the patient with her shoulders over the area to be mobilized to enable the direction of the pressure to be at right angles to the surface of the body. The pads of the thumbs are placed on the spinous process, pointing transversely across the vertebral column, and the fingers of each hand are spread out over the posterior chest wall to give stability to the thumbs. As the spinous processes are large, the thumbs may be positioned tip to tip or with the tips side by side in contact with the upper and lower margins of the same spinous process. To gain the best control and feel of movement with the least discomfort to the patient, the pressure should be transmitted through the thumbs so that the interphalangeal joints are hyperextended. This enables the softest part of the pad to be flat over the spinous processes, with a slight degree of flexion in the metacarpophalangeal joints. Not only is this more comfortable for the patient, but it hinders the physiotherapist's intrinsic muscles from producing the pressure.

To mobilize the mid-thoracic spine (T5–9), the physiotherapist should stand at the patient's side with her thumbs placed longitudinally along the vertebral column so that they point towards each other. The fingers can then spread out over the posterior chest wall, to each side of the vertebral column above and below the thumbs.

It may be more comfortable (and this is far easier to do if the patient is lying on a low couch) for the physiotherapist to stand to one side of the patient, approximately at waist level and facing his head, and place the pads of the thumbs on the spinous process pointing across the vertebral column. The fingers of each hand can then spread over opposite sides of the posterior chest wall for stability.

For the lower thoracic spine (T10–12), the physiotherapist's position depends upon the shape of the patient's chest. Either of the latter two positions described above may be used, but the essential factor is that the direction of the pressure must be at right angles to the body surface at the level. This means that the shoulders may need to be anywhere between vertically above the lower thoracic spine and vertically above the sacrum (Fig. 5.28). If the patient has difficulty lying prone because extension is painful, a small pillow under the chest will assist. The physiotherapist's position must also allow pressure to be applied to the spinous process using the anteromedial aspect of the fifth metacarpal, similar to that described in Chapter 6, for the lumbar spine. However, it may be essential to avoid direct contact between the pisiform and the spinous process for the sake of comfort (Fig. 5.28).

Method: The mobilizing is carried out by an oscillating pressure on the spinous processes, produced by the body and transmitted through the arms to the thumbs. It is important that this pressure is applied by the body weight over the hands and not by a squeezing action with the thumbs themselves. The fingers, which are spread out over the patient's back, should not exert any pressure but act only as stabilizers for the thumbs. It is easy to dissipate the pressure and lose the effectiveness of the thumbs by faulty use of the fingers.

If the physiotherapist's elbows are kept slightly flexed and the thumbs maintained in the position of hyperextension of interphalangeal joints and slight flexion of metacarpophalangeal joints, the pressure can be transmitted to the pads of the thumbs through this series of strong springs. This springing action at the joints can readily be seen as the body weight is applied during the mobilizing.

Local variations: The degree of pressure required in the upper thoracic spine to produce movement is far greater than that required in the cervical spine, and slightly stronger than that required for the remainder of the thoracic spine.

The degree of movement possible in the middle and lower thoracic spine is considerable, and it is here that it is easiest to learn a feeling of movement. The degree of movement possible in the upper thoracic spine is considerably limited, and this is particularly so between T1 and T2.

Uses: Posteroanterior central vertebral pressure is as useful for the thoracic spine as rotation is for the cervical spine. In all symptoms arising from the thoracic vertebrae, it is worth trying this procedure first.

‘Central pressure’ is more likely to be successful with symptoms that are situated in the midline or evenly distributed to each side of the body, but it should also be tried for unilateral symptoms, particularly if they are ill-defined or widespread in their distribution.

Examples of treatment include: glove distribution symptoms, page 186 and Figure 5.14; thoracic backache, page 174 and Figure 5.1; and traumatic girdle pain, pages 185–186.

Starting position: The patient lies prone with his arms by his side while the manipulative physiotherapist stands alongside the patient (in this case by his right side). She places her right hand between the spine and his right scapula, and her left hand between the spine and his left scapula, and transmits pressure through the lateral surface of the hypothenar eminence near the pisiform bone. To reach the final position, the first step is to place the ulnar border of each hand in a line across the patient's back in parallel lines, the right hand being slightly caudad to the joint to be mobilized and the left hand slightly distal to the joint to be mobilized. At this preliminary stage the physiotherapist's forearms are also directed across the patient's back at right angles to the vertebral column, and her pisiform bone is tucked into the space between the paravertebral muscles and the spinous processes. The next step entails taking up the slack in the soft tissues. This is achieved by applying both posteroanterior and rotary pressures; the rotary pressure is achieved by changing the direction of the forearms, in a swinging or twisting fashion, from across the body to somewhat caudad (the right arm) and cephalad (the left arm) as well as laterally. The final stage is that of being certain that all of the slack has been taken up and that the pisiform bones are now opposite each other at the same intervertebral level (T6/7; Fig. 5.29A).

Method: When used as a mobilization, the technique consists of an oscillatory movement with three directions; posteroanterior, cephalad and caudad, and lateral. It can be performed as a very localized movement by using the pisiform as the main contact point through which the pressure is transmitted, or it can be performed much more comfortably over a wider area by utilizing the base of the palm of the hand together with the thenar and hypothenar eminences.

The technique can be performed rhythmically with increasing and decreasing posteroanterior pressure in time with the patient's breathing rhythm.

It can also be used as a manipulative thrust, usually at the end of the patient's expiration. There are times when the technique can be usefully employed in the lumbar spine.

Uses: The technique can be selected when movement is desired in a posteroanterior direction but the spinous processes are too tender for direct contact.

The ranges of movement of single costovertebral, costotransverse and intervertebral joints are quite small, and yet if this technique is performed through the palm of the hand as described above, quite considerable movement between three or four contiguous levels can be achieved. This can produce immediate comfort and improvement in movement (Fig. 5.29B).

Starting position: When the middle and lower thoracic vertebrae are to be mobilized with transverse pressures, the patient lies prone with his arms hanging over the sides of the couch or by his side to aid relaxation of the vertebral column. The head should be allowed to rest comfortably by being turned to one side, preferably towards the side where the physiotherapist stands. However, as this head position tends to produce some degree of rotation in the upper thoracic vertebrae, it is better for the patient to adopt the ‘forehead rest’ position when these vertebrae are to be mobilized in order to eliminate any rotation. Alternatively, some couches have a hole to allow the head to remain centrally placed. In some cases it may be useful to rotate or derotate the spine using the head position to produce the movement. If the mobilization technique needs to be performed strongly as a Grade IV1, it may help to ask the patient to face towards the manipulative physiotherapist.

The physiotherapist stands at the patient's right side at the level of the vertebrae to be mobilized, and places her hands on the patient's back so that the pads of the thumbs are adjacent to the right side of the spinous processes while the fingers are spread over the patient's left ribs. The left thumb acts as the point of contact and is fitted down into the groove between the spinous process and the paravertebral muscles, so that part of the pad of the thumb is pressed against the lateral aspect of the spinous process on its right-hand side. It is essential to have as much of the pad in contact with the spinous process as is possible. To prevent the thumb sliding off the spinous process, the palmar surface of the metacarpophalangeal joint of the index finger must be firmly brought down on top of the interphalangeal joint of the thumb. This is a valuable position to learn to adopt, as its stability is of value in other techniques. The right thumb, acting as reinforcement, is placed so that its pad lies over the nail of the left thumb. This thumb relationship is chosen because considerable effort is required to keep a single thumb comfortably against the spinous process.

The fingers of both hands should be well spread out over the chest wall to stabilize the thumbs, and the wrists need to be slightly extended to permit the pressure to be transmitted through the thumbs in the horizontal plane. Because of the slightly different functions required of the left and right thumbs, the left forearm is not as horizontal as the right forearm (Fig. 5.30).

Method: The pressure is applied to the spinous process through the thumbs by the movement of the trunk; alternate pressure and relaxation is repeated continuously to produce an oscillating type of movement of the intervertebral joint. For the gentler grades of mobilizing, very little pressure is needed. When stronger mobilizing is used, movement of the patient's trunk is involved and timing of pressures should coincide either with the patient's rolling or, in order to make the technique stronger, to go against the rolling.

Local variations: The upper thoracic spinous processes (T1–3/4) are readily accessible but have a limited amount of movement, T1 being almost immovable. The lower thoracic vertebrae (T8/9–12) are more easily moved and do not require great pressure. Local tenderness in these two areas is comparatively negligible. Mobilization of the mid-thoracic spine is made difficult by the relative inaccessibility of the spinous processes and natural tenderness, and when a painful condition is superimposed on this natural tenderness, adequate mobilization may be very difficult. Where stronger techniques are required to be performed for longer periods, better effect may be gained by reinforcing the contact thumb with the pisiform of the opposite hand rather than with the opposite thumb pad. In this way, the fingers can be spread over the chest wall and the movement can be produced through the thumb and hand via the therapist's trunk.

Uses: This technique is particularly useful for pain of unilateral distribution in the thoracic area. In such cases the pressure is best applied against the side of the spinous process that is away from the pain, applying the pressure towards the patient's painful side. When using this technique it is frequently necessary to mobilize the ribcage by a posteroanterior pressure directed through the angle of the rib. If progression is needed, the manipulative physiotherapist may need to clear the joint signs by using pressure on the spinous process on the painful side and towards the pain-free side.

Examples of treatment include pain simulating cardiac disease, page 175; scapula pain, page 176; thoracic backache; traumatic girdle pain, page 185; and abdominal pain and vague pains, page 175.

Starting position: The patient lies prone with his head turned to the left and his arms hanging loosely over the sides of the couch or by his side.

To mobilize the left side of the middle or lower thoracic spine (approximately T5–12), the physiotherapist stands on the left side of the patient and places her hands on the patient's back so that the pads of the thumbs, pointing towards each other, lie over the transverse processes. The fingers of the left hand spread over the chest wall pointing towards the patient's head, while the fingers of the right hand point towards his feet and the thumbs are held in opposition. By applying a little pressure through the pads of the thumbs, they will sink into the muscle tissue adjacent to the spinous processes until the transverse process is reached. The metacarpophalangeal joint of the thumb needs to be slightly flexed and the interphalangeal joint must be hyperextended to enable the pad of the thumb to transmit the pressure comfortably. When a much finer degree of localization of the pressure is required, the thumbnails should be brought together so that the tips of the thumbs make a very small but comfortable point of contact. In this position, the metacarpophalangeal joints of the thumbs are brought much closer together to lie directly above the thumb tips. The physiotherapist's shoulders and arms, with slightly flexed elbows, should be in the direct line through which the pressure is to be applied, and this is at right angles to the plane of the body surface.

Because of the curve of the thoracic spine, it is necessary when mobilizing the upper levels (T1–4) to stand either at the patient's head or towards the shoulder of the side being mobilized to accommodate the necessarily altered angle of the physiotherapist's arms. It is advisable to use the largest amount of the pad of the thumb that can be brought into contact with the transverse process, to enable the pressure to be administered as comfortably as possible (Fig. 5.31).

Method: A very steady application of pressure is necessary to be able to move some of the muscle belly out of the way and make bone-to-bone contact. As this procedure can be quite uncomfortable for the patient, care must be given to the position of the arms and hands to enable a spring-like action to take place at the elbows and the thumbs. This reduces the feeling of hardness and soreness between the physiotherapist's thumbs and the patient's transverse process that is present if the pressure is applied by intrinsic muscle action.

Once the required depth has been reached, the oscillating movement at the intervertebral joint is produced by increasing and then decreasing the pressure produced by trunk movement.

Local variations: Because of the structure and attachments of the ribcage, it is not possible to produce very much movement with this mobilization.

Some people may find it easier to carry out the mobilization using the hands (as described for the lumbar spine) instead of the thumbs, but this should be discouraged as the thumbs have a greater degree of ‘feel’ and can localize the mobilization more accurately. They also cause much less discomfort to the patient – a factor of considerable importance. When the hands are used, the technique is frequently more vigorous than is required.

Uses: Posteroanterior unilateral vertebral pressure is used, almost entirely, for unilateral distributed pain arising from the thoracic spine, and the technique is done on the painful side. Unless the patient's pain is severe, it is less likely to produce a favourable change in the patient's signs and symptoms if it is done on the side away from the pain. When this technique is used in the presence of spasm the pressure must be steadily applied and not hurried, in order to allow time for the spasm to relax.

Starting position: The patient lies prone with his arms by his side or hanging over the sides of the couch, and the physiotherapist stands at the side of the patient where the mobilization is to be effected. The physiotherapist's thumbs are placed along the line of the rib at its angle so that the maximum area of contact can be made between the thumbs and the rib (Fig. 5.32A). Alternatively, the whole ulnar border of the hand and little finger may be used to produce the movement (Fig. 5.32B).

Method: An oscillatory movement is transmitted to the rib by the thumbs or hands, and the range of movement produced at one rib angle is compared with that produced at the rib angles above and below. The pain produced by the movement of the faulty rib is also compared with the pain (if any) produced at the rib above and the rib below. Similarly, both the range of the movement and the pain should also be compared with the ribs on the opposite side of the body.

Local variations: First rib. Examination of the first rib is somewhat different from that of the other ribs as the technique can be applied in three ways due to a greater area of the rib being palpable.

Other ribs. All of the ribs can be examined throughout their entire length by thumb palpation, including the costochondral junctions and the junction with the sternum. The freedom of movement between adjacent ribs can also be tested, but as these are not part of the vertebral column they are not described in this book. They are, however, described in Peripheral manipulation (Maitland 1970).

A technique performed with the patient supine is described below.

Uses: Whenever treatment is applied to the thoracic intervertebral joints, the inclusion of mobilization of the ribs should be considered for two reasons:

If pain is in a referred area of the ribcage, the symptoms may be arising from some abnormality between adjacent ribs. Palpation will reveal abnormalities of position and of movement between adjacent ribs. This aspect of treating costal pain is described in Peripheral manipulation (Maitland 1970).

Starting position: The patient lies supine with his arms folded across his chest, resting his hands on the opposite shoulders (Fig. 5.36). The physiotherapist stands on the right-hand side of the patient, taking hold of the left shoulder with the left hand and the left iliac crest with the right hand (Fig. 5.37). The trunk is then rolled towards the therapist so that the left shoulder comes off the couch, exposing the thoracic spine. The right hand is then placed so that the flexed interphalangeal joint of the thumb is placed over the transverse process of the thoracic vertebrae to be rotated, allowing the fingers to lie across the thoracic spinous process.

The contact hand is positioned in such a way as to allow the thumb to be flexed at the interphalangeal joint and adducted and slightly opposed at the metacarpo-interphalangeal joint so that it lies in contact with the palm of the hand, the proximal phalanx being in line with the index finger.

The index finger of the right hand is placed over the spinous process of the vertebrae being rotated (Fig. 5.38). The patient's trunk is then rolled backwards over the right hand, and the therapist leans over the patient so that the patient's flexed forearms are tucked into the physiotherapist's chest (Fig. 5.39).

Method: The mobilization is then carried out by the physiotherapist rolling the patient's trunk over the right hand. This is done in an oscillating manner.

Starting position: The patient lies on his back with one or two pillows under his head to flex the neck until the intervertebral level to the treated is positioned midway between flexion and extension. A cervical halter is then applied in the same way as has been described for cervical traction in flexion. If a lower level is to be treated and if the strength of the traction needs to be very firm, it may become necessary to apply some form of counter-traction. A belt is fitted around the pelvis and is attached to the foot end of the couch to stabilize the distal end of the vertebral column. The halter is then attached to its fixed point so that the angle of the pull on the neck will be approximately 45° to the horizontal. The actual angle used varies with the amount of kyphosis present in the upper thoracic spine, and it should be an angle that will allow the thoracic intervertebral joint to be moved longitudinally while in a position midway between its limits of flexion and extension. To relieve strain on the patient's lower back during the period when the traction is being applied, his hips and knees may be flexed (Fig. 5.41).

Method: The traction can be adjusted from either end or from both ends, but whichever method is used, care must be taken to ensure that friction between the patient's trunk and the couch is reduced to a minimum. This can be done while the traction is being applied by gently lifting the weight of the patient's thorax or pelvis off the couch and allowing it to relax back into a new position. Friction is almost completely eliminated by a couch whose surface is in two halves that are free to roll longitudinally. Releasing the traction does not present any problem, but it is advisable to release slowly.

Starting position: For the lower thoracic spine, a thoracic belt similar to that used for lumbar traction is used in place of the cervical halter. Traction is usually more effective if it is carried out with the patient supine, but it can be done with him prone.

The thoracic belt is applied to hold the chest above the level of the spine to be treated, and it is then attached to its fixed point. After this the pelvic belt is applied and attached to its fixed point. The direction of the pull is then longitudinal in the line of the patient's trunk, but pillows may be needed to adjust the position of the spine so that the joint being moved is relaxed midway between flexion and extension (Fig. 5.42).

Method: Traction is applied from either end or from both ends, but again care is required to reduce friction to a minimum both at thoracic and at pelvic levels. As mentioned previously, a roll-top couch eliminates friction. A simple, cheap and extremely effective roll-top couch is described below.

Releasing the traction should be done steadily, and the patient should rest for a short time before standing.

Intermittent variable traction can also be used in this area of the spine, and the details of times for ‘rest’ and ‘hold’ periods are the same as have been discussed for the cervical spine.

Local variations: The thoracic kyphosis varies considerably from person to person, and the positioning of the patient is controlled by this curve. Theoretically, the direction of the pull may be thought of as being at right angles to the upper and lower surfaces of the intervertebral disc at the level that is being moved. The kyphosis usually influences the position for upper thoracic traction more than for the lower thoracic spine.

Precautions: A check must be kept on the patient to ensure that the traction does not cause any low-back pain.

As with the cervical traction in flexion, it is possible for the head halter in upper thoracic traction to cause occipital headache, but this can be eliminated by the means already described.

Uses: Traction is of greatest value in patients who have widely distributed areas of thoracic pain, particularly if they are associated with radiological degenerative changes in the thoracic spine. It is also of value for patients whose thoracic symptoms do not appear to be aggravated by active movements of the spine or when neurological changes are present. Similarly, it is the treatment of choice for patients with severe nerve-root pain. Whenever mobilizing techniques have been used in treatment without achieving the desired result, traction should be tried.

Sometimes a patient is able to guide the therapist as to what to do because his body tells him what it wants (and what it doesn't want). Figure 5.43 is a perfect example of such a case. The patient's disorder had been very difficult to help in that progress gained at a treatment session was not retained well enough. The disorder was at the level of T6/7, and had been responding to extremely gentle traction. One day the patient said that he needed the traction, but he also needed to have the vertebra pushed backwards and towards the left while having the levels above twisted to the right. Figure 5.44 shows how the position was obtained while the mobilizing was produced through the patient's sternum. He claimed that he was 60% better after the first of these treatments, and 80% better after the second. At his suggestion, treatment was discontinued, and on review 12 months later he showed no signs of recurrence.

• A force is applied to the patient at a specific joint or spinal segment.

• The direction of force is perpendicular to the surface of the joint.

• The magnitude of this force increases to a peak over a finite period of time (100–200 ms; Herzog 2000).

• The force applied (100–150N in the cervical spine; Herzog 2000) produces motion at the joint.

• The joint motion always included articular surface separation.

• The velocity of joint motion is variable.

• The sum displacement of the articulating bones is usually zero.

• Cavitations occur within the affected joint (the formation and activity of bubbles or cavities within synovial fluid, formed when tension is applied to the fluid as a result of local reduction in pressure; Evans & Breen 2006).

• Duration of symptoms less than 30 days

• No symptoms distal to the shoulder

• Looking up does not aggravate symptoms

• Fear-avoidance beliefs questionnaire (FABQPA) score less than 12

• Diminished upper thoracic kyphosis

• Cervical extension range less than 30°.

• Mechanical release of entrapped and painful intraarticular material

• Relaxation of hypertonic muscle

• Mechanoreceptor pain gating

• Descending pain suppression

• Stimulus re-interpretation

• Disruption of restrictive articular and periarticular adhesions

• ‘Unbuckling’ of motion segments.

• Is there segmental stiffness, which has not responded to strong mobilization?

• Is there evidence of locked segmental motion with active movement and with passive physiological and accessory movement testing?

• Careful and thorough assessment (C/O and P/E).

• Mobilize before manipulation.

• Never manipulate through protective spasm.

• Always inform the patient of your intentions and give them the choice to stop whenever they wish to.

• Avoid repeated manipulations over long periods of time.

Absolute contraindications:

Relative contraindications (at risk for adverse reactions):

Best practice involves the receiving of informed consent to carry out the intervention and should include information to the patient that clearly explains:

The manipulation procedure should include:

Starting position: The patient sits well back on a medium-height couch while the physiotherapist stands behind. To provide the patient with comfortable support, the physiotherapist places her left foot on the couch next to the patient's left buttock, rests the patient's left arm over her left thigh, and asks the patient to relax back against her. Localization of the manipulation is achieved by firmly placing the tip of the right thumb against the right side of the spinous process of the lower vertebra of the intervertebral joint. Pressure is applied horizontally in the frontal plane by this thumb, while the fingers spread forward over the patient's right clavicular area. These fingers also stabilize the vertebra. The next step is to flex laterally the patient's head to the right until the tension can be felt at the thumb. While maintaining the lateral flexion tension, the middle position between flexion and extension is found by rocking the neck back and forth on the trunk. After determining this position, rotation (face upwards) is added in small oscillatory movements until the limit of the rotary range is found. The therapist then positions both forearms to work opposite each other (Fig. 5.44).

Method: The manipulation consists of a sudden short-range thrust through the right thumb transversely across the body, while a counter-thrust is given by the operator's left hand against the left side of the patient's head.

Starting position: The patient lies supine without a pillow and links his hands behind his neck while the physiotherapist stands by his right side. By grasping the patient's left shoulder in her right hand and both elbows in her left hand, the physiotherapist holds the patient in this position; she releases her hold on the shoulder and leans over the patient to palpate for the spinous process of the lower vertebra forming the intervertebral joint being manipulated. Still holding the patient in this position, the physiotherapist makes a fist with the right hand by flexing the middle, ring and little fingers into the palm but leaving the thumb and index finger extended. A small pad of material grasped in the fingers will give added support. This fist is then applied to the patient's spine (the thumb points towards the head) so that the lower spinous process is grasped between the terminal phalanx of the middle finger and the palmar surface of the head of the opposed first metacarpal. The patient is then lowered back until the physiotherapist's right hand is wedged between the patient and the couch. The weight of the patient's trunk is taken on the flat of the dorsum of the hand (not on the knuckles), and the forearm should project laterally to avoid interference with movement of the patient's trunk. If the surface of the couch is too hard, it will be difficult for the physiotherapist to maintain her grip on the spinous process. To achieve firm control of the patient's trunk, his elbows should be held firmly and pressed against the physiotherapist's sternum. However, when a patient has excessively mobile joints it may be necessary for him to grasp his shoulders with opposite hands while keeping the elbows in close apposition rather than clasping the hands behind the neck. The patient's upper trunk is then gently moved back and forth from flexion to extension in decreasing ranges until the stage is reached where the only movement taking place is felt by the underneath hand to be at the intervertebral joint to be manipulated (Fig. 5.45).

Method: Pressure is increased through the patient's elbows, causing stretch at the intervertebral joint, and the manipulation is then carried out by a downward thrust through his elbows in the direction of his upper arms. This thrust is transmitted to the patient's trunk above the underneath hand. The thrust may be given as the patient fully exhales.

Starting position: The patient sits well back on the couch and grasps his hands behind his neck, allowing his elbows to drop forwards. The physiotherapist stands behind the patient and threads her arms in front of his axillae to grasp over the dorsum of his wrists. When grasping his wrists, she encourages his elbows to drop forwards while at the same time holding his ribs firmly from each side with her forearms. She then turns her trunk slightly to one side to place her lower ribs against his spine at the level requiring manipulation. While feeling for movement with her ribcage, she flexes and extends his thoracic spine above the level to be manipulated until the neutral position between flexion and extension is found for the joint to be treated (Fig. 5.46).

Method: The physiotherapist lifts the patient's trunk in the direction of the long axis of the joint being treated, and makes a final adjustment of the flexion/extension position to ensure that the mid-position has been retained. The manipulation then consists of a short-amplitude sharp lift.

Some degree of extension may be added into this technique. This extra movement is achieved by a very small movement with the therapist's ribs against the patient's spine, performed at the same time as the lift is executed through the arms.

Starting position: If rotation to the left is to be performed, the patient sits on the edge of the couch near the right-hand end while the physiotherapist stands behind his right side. The patient hugs his chest with his arms and turns his trunk to the left. For the mid-thoracic area, the physiotherapist reaches with her left arm around his arms to grasp his right shoulder while placing the heel of her right hand along the line of the right rib above the joint to be manipulated. She cradles his left shoulder in her left axilla (Fig. 5.47A). For the lower thoracic levels, she grasps around his chest under his arms to reach his scapula. This time she places the ulnar border of her right hand along the line of the ribs (Fig. 5.47B). With both techniques she then takes the movement to the limit of the range, taking up all slack.

Method: The manipulation consists of a synchronous movement of the physiotherapist's trunk and an extra pressure through her right hand. With her trunk she carries out an oscillatory rotation back and forth at the limit of the rotary range. At the same time she maintains constant pressure with either the heel of her right hand or its ulnar border exerting an extra rotary push at the limit of the rotation. The manipulation consists of an over-pressure at the limit of the range, being done in a very small amplitude and very sharply.

Starting position: The patient lies supine. A pillow is not used unless the patient has a ‘poking-chin’ postural abnormality. The physiotherapist stands by his head and makes a broad contact medial to the transverse process of the vertebra to be mobilized with both thumbs. The thumbs should be used with care, as direct bone-to-bone contact can be uncomfortable. She spreads her fingers around the adjacent neck area for stability while positioning her shoulders above the joint being treated (Fig. 5.48A).

Method: The oscillatory anteroposterior pressures are performed very gently, and the movement must be produced by the physiotherapist's arms and trunk. Any effort to produce the movement with intrinsic thenar muscle action will produce discomfort immediately.

This technique is not a comfortable one to use unless great care is taken. Also, the muscles lying over the area make direct contact rather difficult, and care should be taken to see that the thumbs are positioned medial to the transverse process. This means that at some levels the muscle belly needs to be moved to one side.

Local variations: This technique can be performed either unilaterally or bilaterally, as is shown in the diagrams (Fig. 5.48A and 5.48B). The intervertebral level to which one can reach varies enormously from patient to patient. In the stocky, heavily built patient with a short, thick neck, extending down into the thoracic area is almost impossible. Conversely, in the long-necked, slim person enough space is allowed to reach down to approximately T3 (Fig. 5.48C). With all patients, the technique can be used as high as C1.

Anteroposterior movement can be produced with the patient lying prone. The patient rests his forehead in his palms, and the physiotherapist grasps around the sides of the neck to hook the palmar surface of the pads of her fingers medial to the transverse process area. It is easy to localize the joint to be mobilized by the accurate placement of the fingers (Fig. 5.48D).

Precautions: The only precaution necessary is to avoid discomfort from undue pressure.

Uses: Application of this technique is reserved for patients whose symptoms, felt anterolaterally, can be reproduced by anteroposterior pressure on the side of the pain. Pain referred to the ear or throat can often be reproduced by this technique. Anterior shoulder pain, scapula pain (Cloward 1959) and headache associated with irritation of the stellate ganglia of the sympathetic chain may also be reproduced by this technique. Under all these circumstances, the described technique could be the treatment of choice.

1. The patient is asked to sit well back until the posterior knee area is wedged against the edge of the examination couch so that uniformity of the test position is maintained. In this erect sitting position, he is asked to report any pain or discomfort (Fig. 5.49).

2. He is then asked to let his back slump through its full range of thoracic and lumbar flexion, while at the same time preventing his head and neck from flexing. Once he is in this position, gentle over-pressure is applied to the shoulder area to stretch the thoracic and lumbar spines into full flexion. The direction of pressure is a straight line from T1 to the ischial tuberosities, as though increasing the convexity of a bow by shortening its string (Fig. 5.50). Any hip extension that might take place, as would be the case if the convexity increased markedly, must be prevented by bringing the patient's shoulders closer to his knees. Any pain response in this position is noted (Fig. 5.51).

3. Having established a 90° hip flexion angle he is asked to flex his head and neck fully, approximating his chin to his sternum. Sufficient over-pressure is applied to the neck flexion position to ensure that the whole spine from head to ischial tuberosities is on equal stretch. The range with pain response is recorded (Fig. 5.52). Next, the over-pressure maintaining the head and neck flexion is maintained by the physiotherapist's chin (Fig. 5.53) and then her left hand is free to palpate his spine (Fig. 5.54).

4. With the whole spine maintained in flexion with over-pressure, he is asked to extend his left knee as far as possible, and while he is holding it in this position the range and pain response is noted (Fig. 5.55).

5. The next step is to add active dorsiflexion of the ankle to the knee extension and note the pain response (Fig. 5.56).

6. While the neck flexion to knee extension position is maintained, and being sure that the symptoms are stable and consistent, the physiotherapist retains the same over-pressure to thoracic and lumbar flexion while at the same time releasing some of the neck flexion, allowing the patient's head to be raised to the neutral position (Fig. 5.57) or extended (Fig. 5.58). He is asked to state clearly what happens to the symptoms. In the fully slumped position he may not have a full range of knee extension. If he is unable to extend his knee fully he is then asked, when neck flexion has been released, if he can extend his knee further. In this new position the range is noted and any pain response recorded (Fig. 5.59).

Starting position: The patient is positioned in side lying, trunk parallel to the edge of the bed, the leg to be tested in hip extension and knee flexion, the other leg being held by the patient in 90° of hip and knee flexion.

The therapist stands behind the patient level with the pelvis. With one hand the therapist stabilizes the patient's pelvis to prevent lumbar extension. The therapists other hand supports the patient's knee and lower leg (Fig. 5.62).

Method: Whilst stabilizing the patient's pelvis, the therapist extends the patient's hip to pain or limit and then adds medial rotation of the hip to pain or limit to tension the ilio-inguinal (and genitofemoral) nerve(s).

A change in the patient's symptoms and range of hip medial rotation with the addition and subtraction of cervical flexion will indicate involvement of the ilio-inguinal (genitofemoral) nerve (s) in the symptom response.

Starting position: The patient lies supine towards the side of the bed to be tested.

The therapist stands by the side of the patient at the level of the patient's knee, facing the patient's head. One of the therapist's hands keeps the knee in full extension whilst the other supports under the patient's heel.

Method: The therapist then lifts the patient's straight leg with the hip in neutral adduction/abduction and neutral rotation with the foot relaxed. On reaching the point of onset of back or thoracic pain or the limit of SLR, the patient's leg is then rested on the therapist's shoulder. The therapist then dorsiflexes the patient's ankle. A change in back or thoracic pain with this manoeuvre of the foot will support the hypothesis that neural tissue is involved in the symptom response (Fig. 5.63).

Starting position: The patient lies supine near the edge of the bed on the side to be treated. The therapist stands by the side of the bed at the level of the sternochondral/costochondral joint to be mobilized. The therapist's thumbs are placed adjacent to each other across the line of the sternochondral/costochondral joint. The therapist's fingers spread out over the chest for added stability.

Method: The therapist leans over the patient. The therapist's elbows are slightly bent and tucked in. The therapist's body produces the movement through the therapist's thumbs to the joint (Fig. 5.64).