Technique Highlight: Supine Thoracic Thrust Manipulation | Modern Manual Therapy Blog

Technique Highlight: Supine Thoracic Thrust Manipulation

This is my preferred technique for thoracic thrust manipulation. Most true thoracic patients should be resolved within 2-4 visits. I prefer the control of this technique over the simplicity of the prone P/A.

This is a variation on the "pistol-grip" which I had used prior to learning this. That technique is often as uncomfortable for the practitioner as it is for the patient. This technique uses a flat hand, fingers facing superiorly with the SP in between the thenar and hypothenar eminences.

Pt: Supine

PT: leverage hand fingers facing superiorly, the spinal level SP you want to perform the technique to between the thenar and hypothenar eminences.


  • first roll the patient toward you, to place you hand on the level you want to perform the thrust to
  • you may do some P/A springing in sidelying to confirm for restrictions and/or tenderness
  • over roll the patient over your leverage hand, as in more than 90 degrees as the first component
  • next, horizontally adduct your leverage hand UE to SB the patient away from you
  • the patient grasps their shoulders if possible placing their elbows as close to together as possible
  • your thrust hand is cupping the top elbow and your sternum is over your hand for leverage
  • take up all the slack of the shoulders and forearms by pushing them into GH extension
  • you can start to mobilize to get a feel for barrier
    • mobilization and thrust performed in the direction of the forearms, NOT A/P 
    • it is A/P and superior 
  • last component is the leverage wrist is extended, radially deviated, and forearm is pronated, which works really well as final components
  • the pt inhales, at start of exhale, bear down to take up all P/A, pull SB away UE closer to you
  • in between the middle of the exhale and end (don't wait until the end as pts tense) perform a quick abdominal thrust with a slight UE push in the A/P and superior direction
  • you may repeat this at several levels if needed
  • works well only from about T1-T6/7
  • For T1-3 you have to pull the patient's spine inferiorly and thus into flexion to flatten out the upper thoracic facets to get the same leverage on T3-6/7

Don't forget the HEP, which should clear up any true thoracic (only) complaints in 2-4 visits!
IASTM to the paraspinals and possibly around the bony contours of the ribs may help for persistent complaints.


  1. Nice touch with the wrist extension to take up the slack. I like the work. Gotta watch the elbows in the sternum though, I had a pointy elbow elevate my rib #4 anterior and it took weeks for that to calm down.

  2. Yeah, I actually get elbowed EVERY time I do this technique. Still, I feel I get better control than prone, and certainly better than having the pt end range flex their cspine and then mashing down on their arms as leverage.

  3. great post doc. I'm a chiro student and found your instructions clear (take out the slack, etc)...i find putting the fist really uncomfortable. Btw, the way we learned it for thoracic, continue to *flex* the patient's neck whereas the segment you want flattens. And apparently, there's a difference with regard to the lesion - to treat extension dysfunction, keep the patient flexed; whereas for flexion dysfunction, extend the patient (thrust in cephalad direction and patient's arms should move slightlt superiorly/caudally)?? thank you... the video is really useful. ben

  4. Thanks Ben! I was initially taught that as well, traiditional manual therapy theory speaks of flexion and extension lesions, in the end, only neurophysiologic resets and movement matter. Getting the patient to move after a manipulation, which is NEVER specific even according to chiro literature (at least 3-4 segments move and often the cavitations are made levels away from the contact points), is more important. Bottom line, manipulate and get them moving regardless of their movement dysfunction or loss. Different patients will need different techniques however depending on tolerance and the what they expect out of treatment.

  5. ok thanks for the tips doc. Btw, one of the standard advice for thrusts is for the xiphoid sternum to be in the same line of drive as the thrusting hand. So in this supine thoracic thrust, if the xiphoid process is really stacked on top of the bottom fist/hand, that would make the thrust an axial compression? Or it more accurate to say that since the therapist's body is diagonal/ oblique to the table, the xiphoid is obliquely aligned towards and thrusted (like a billiard cue) into the bottom fist/hand.