May 2013

Illinois Chiropractic Society Journal Article - June 2013

Research To Know: The Thoracic Spine and Neck Pain
Greg Markley, DC, MS, DACO

Do you remember the very first patient you saw after you graduated? I do. My first patient was a gentlemen in his mid-fifties who complained of anterio-lateral thigh pain. Of course, I took the most detailed patient history in the history of taking histories as well as performed the most extensive physical examination known to man, all for the diagnosis of meralgia paresthetica! I was so proud, I had nailed my very first diagnosis! After treating the patient I was patting myself on the back and discussing the “amazing” case I just had with my mentor. He, seeing my excitement let me basque in my glory for a while and then asked me a simple question.
“Why did you treat him with that protocol and how can you justify your treatment to that patient for that condition?”

You could hear crickets. I had no idea! Those two simple questions have had greatest impact on my career. It has lead me to search for the evidence that supports all of my clinical rational when treating patients. One particular example is I almost always address the thoracic spine with cervical complaints.

If a patient presents to your office with neck pain, do you evaluate and/or manipulate the thoracic spine? Why? What is the clinical justification of taking a patient with neck pain and expanding the area of treatment into the thoracic spine? Below, you will find two recent articles that I hope will assist in the explanation of why we should strongly consider addressing the thoracic spine in cervical complaints.

The effectiveness of thoracic manipulation on patients with chronic mechanical neck pain - A randomized controlled trial 1

The aim of this study was simple. What are the clinical effects of thoracic manipulation in the treatment of mechanical neck pain and determine if those clinical effects were significant at a later date. 120 patients with a diagnosis of chronic mechanical neck pain as diagnosed by there primary care physician were recruited. The patients were between 18-55 and had pain for 3 months or longer. Exclusions from the study included contraindications to manipulation
2, history of whiplash or cervical surgery, diagnosis of fibromyalgia, prior spinal manipulation in the previous 2 months or loss of standing balance.

Participants of the study were separated into 2 groups. Group A included thoracic manipulation (anterior-posterior approach in supine lying position), infrared radiation therapy for 15 minutes, and standardized educational materials with exercises (active neck mobilization, isometric neck muscle contraction for stabilization, stretching of the upper trapezius and scalene muscles and postural correction exercises). Group B was the control group and underwent the same treatment protocol minus thoracic manipulation. Both groups were treated 2 times per week for a total of 8 visits and evaluated/assessed at the baseline, immediately after the 8 sessions, 3 and 6 months post treatment.

The authors utilized the Numeric Pain Rating Scale (NPRS) scale and the Northwick Park Questionnaire (NPQ) as subjective measurements in addition to cervical range of motion and the craniovertebral angle for objective evaluation. Data from the subjective measurements revealed a significantly greater improvement in both the NPRS and NPQ immediately at the conclusion of treatment as well as the 3 and 6 months post treatment for the group who received the addition of thoracic manipulation. Data from the objective analysis revealed a significantly greater improvement in range of motion except for rotation at the 3 and 6 month follow up.

Normal kinematics of the neck: The interplay between the cervical and thoracic spines3

The purpose of this next study was to evaluate the relationship of the cervical, upper and lower thoracic spines in active neck movements in asymptomatic individuals. This study used 34 asymptomatic patients who had no history of neck pain in the 12 months prior to the study. Participants were excluded if they experienced any limitation in performing pain free neck movements actively, or had any neurological, orthopaedic, or vestibular conditions.

The manor in which the authors measured the movement of the thoracic spine during neck movements is rather elaborate. In the analysis of cervical range of motion (flexion, extension, left and right side bending and rotation), the authors measure the amount of motion in the cervical, upper and lower thoracic spine. For the purpose of this brief summary, I will skip the details and get right to the clinically relevant information. (I do recommend reading the article, however because this is not randomized clinical trial, I feel it is less important to detail the set up and the specific measurements of the subjects).

In the evaluation of the participants full range of motion, the findings revealed the greatest amount of motion came from the cervical spine, followed by the upper thoracic and lastly the lower thoracic spine. The amount of displacement or motion noted in the upper thoracic spine was greatest in the flexion, extension and rotational movements. In the side bending motion, the degree of displacement noted in the upper and lower thoracic spine was similar.

Take Home Points
  • The addition of thoracic manipulation in the typically treatment of mechanical neck pain provided a greater reduction of pain.
  • The addition of thoracic manipulation in the typical treatment of mechanical neck pain provided greater improvement in cervical range of motion.
  • Movements of the cervical and thoracic spine are highly coordinated, especially the cervical and upper thoracic spines.
  • If setting objective goals for your patient includes restoring active, full range of motion, you should strongly consider focused treatment to the thoracic spine.
  • Lau H, Chiu T, Lam T.. The Effectiveness of Thoracic Manipulation on Patients with Chronic Mechanical Neck Pain - A Randomized Controlled Trial. Manual Therapy 2011;16:141-147.
  • Gonzalez-Iglesias J, Fernandex-de-las-Penas C, Cleland JA, Gutierrez-Vega Mdel R. Thoracic spine manipulation for the management of patients with neck pain: a randomized clinical trial. The Journal of Orthopaedic and Sports Physical Therapy 2009a;39:20-7.
  • Tsang SMH, et al. Normal kinematics of the neck: The interplay between the cervical and thoracic spines. Manual Therapy (2013), http://dx.doi.org/10.1016/j.math/2013.03.002