Regional interdependence and manual therapy directed at the thoracic spine

Abstract

Thoracic spine manipulation is commonly used by physical therapists for the management of patients with upper quarter pain syndromes. The theoretical construct for using thoracic manipulation for upper quarter conditions is a mainstay of a regional interdependence (RI) approach. The RI concept is likely much more complex and is perhaps driven by a neurophysiological response including those related to peripheral, spinal cord and supraspinal mechanisms. Recent evidence suggests that thoracic spine manipulation results in neurophysiological changes, which may lead to improved pain and outcomes in individuals with musculoskeletal disorders. The intent of this narrative review is to describe the research supporting the RI concept and its application to the treatment of individuals with neck and/or shoulder pain. Treatment utilizing both thrust and non-thrust thoracic manipulation has been shown to result in improvements in pain, range of motion and disability in patients with upper quarter conditions. Research has yet to determine optimal dosage, techniques or patient populations to which the RI approach should be applied; however, emerging evidence supporting a neurophysiological effect for thoracic spine manipulation may negate the need to fully answer this question. Certainly, there is a need for further research examining both the clinical efficacy and effectiveness of manual therapy interventions utilized in the RI model as well as the neurophysiological effects resulting from this intervention.

Keywords: Manual therapy; Neck; Physical therapy; Regional interdependence; Shoulder; Thoracic manipulation; Thoracic spine.

Figure 1.

Mechanisms of manual therapy comprehensive model.

Figure 2.

Supine middle thoracic spine thrust manipulation technique. The therapist uses her body to push down through the individual's arms to perform a high-velocity, low-amplitude thrust directed towards T5 through T8.

Figure 3.

Prone middle to lower thoracic spine thrust manipulation technique. The therapist achieves a ‘skin lock’ with the pisiforms of each hand over the transverse processes of the target vertebra pushing caudal with one hand and cephalad with the other. The therapist then uses her body to push down through her arms to perform a high-velocity, low-amplitude posterior to anterior thrust.