Top 5 Fridays! 5 More Reasons to Treat the Thoracic Spine | Modern Manual Therapy Blog

Top 5 Fridays! 5 More Reasons to Treat the Thoracic Spine

This goes along perfectly with Monday's post, "No Pain, No Patient?"
You don't see too much literature or reports out there on the debilitating thoracic spine conditions keeping people out of work and costing bajillions of dollars. Nevertheless, you should treat it because it is often dysfunctional. Here are 5 More Reasons to Treat the Thoracic Spine

1) It helps the cervical spine
  • thrust manipulation to the upper and mid thoracic spines has been demonstated to help the cervical spine according to a few CPRs
  • often the neck can be a controversial place to manipulate and some groups are diametrically opposed to it
  • no matter, manipulation of the thoracic spine seems to have the same and less dangerous effects!
  • an added benefit is treating an area that is DN, for a DP complaint of cervical spine pain
    • if the patient is adverse to touch or movement of the cervical spine, treating an area that they are not apprehensive may be a gateway to cervical work 
2) It helps headaches
  • as many mechanical HA seem to be cervicogenic in origin, manipulation/mobilization to the upper and mid thoracic spines again also help headaches by extension
3) Apparently no risk for manipulation
  • lumbar manipulation risk for adverse events estimated at less than 1 in 10,000,000 and cervical spine anywhere between 1 and 100,000 to 1 in 1,000,000
  • thoracic spine? Not really studied, as in it's not happening
  • there is apparently a risk of fracture but it's a stable area with at least 8 facets per spinal level
  • less yacking, more cracking as Homer would say!
4) It helps the shoulder
  • thoracic manipulation should improve thoracic mobility which is a necessary component of shoulder girdle mobility
  • it has been demonstrated to improve frozen shoulder mobility, again, treating the DN adjacent area of a DP complaint 
5) It helps breathing
  • breathing requires proper rib expansion, a component of thoracic mobility
  • breathing pattern disorders have been demonstrated in chronic HA, cervical pain, and lumbar pain
  • other than teaching proper breathing techniques, thoracic manual therapy may assist, along with diaphragm release and inhibition of sternal elevators using gentle STM or reciprocal inhibition techniques

Just whip it!

Upper thoracic thrust for HA

My favorite thoracic manipulation technique

Keeping it Eclectic!


  1. Ironically this popped up on my RSS feed reader today also

    We still need to remember thoracic pain is a red flag, and patient selection for intervention is important!!

  2. Hi! For end-range thoracic whips, what prevents the patient from using a hypermobile lumbar ROM to accomplish this exercise? Does this risk increased pressure through the discs, especially of the lumbar spine? What outcomes are you measuring and when are you using this intervention (i.e. acutely, as soon as FN, forever)? Thank you!

  3. Hi Lee. Don't worry about the lumbar spine. Always use the stoplight rule. If the condition remains worse after reps stop immediately. If it's only uncomfortable, but doesn't last after reps it's ok to proceed with caution. I'm measuring pain and thoracic ROM, typically limited to the ipsilateral side of pain.

  4. Yes, but the most important red flag would be previous history of cancer combined with failure to improve within 3-4 weeks. True red flags are rare and especially thoracic pain is much less prevalent than cervical and lumbar

  5. Dr. E,
    I totally agree with treating the T-spine. I do teach manipulation to my interns and if they seem to get the T-spine ones very well but are hesitant to perform C/S. There are probably tens to hundreds of studies showing the benefits of working at this level for a majority of conditions.

    As for the risks, I teach that the ribs/t-spine can have higher risk for fracture if you don't use clinical reasoning. You should pick out individuals at higher risk, the middle-age females that are petite especially.

    From my knowledge, the only case reports available that show a fracture following T-spine manipulation had one common feature: All had a prior history of CA. It is safe if you perform a thorough history and the technique matters.

    Thanks for sharing,

  6. Thanks for your insight HV. I do stay away from the middle aged ectomorphic females for manipulation or just use the general guidelines of 65 yo for thrust manipulation.