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Manual Techniques for the Cervicothoracic Spine

Original Editors - Dana Tew

Top Contributors - Shailly Yadav, Kristen Holeman, Alexandra Stead, Kim Jackson, Ruchita Parikh, Dana Tew, Mariam Hashem, Vidya Acharya, Abbey Wright, Aya Alhindi and Samuel Winter


This article is currently under review and may not be up to date. Please come back soon to see the finished work! (27/10/2026)


Introduction

The cervicothoracic (CT) junction is the transitional region where the mobile, lordotic cervical spine meets the stiffer, kyphotic thoracic spine, It centres on the C7-T1 motion segment.[1] This change in curvature and stiffness is thought to make the junction a common site of reduced mobility.[2] Reduced CT junction mobility has been associated with neck and shoulder pain.[3] [4]

The rationale for treating this region rests on two models. Regional interdependence, which proposes that impairments in one region can contribute to symptoms in another, so improving CT and thoracic mobility may reduce movement demands on the mid and lower cervical segments.[2][5] The neurophysiological model proposes that manual therapy triggers pain-modulating responses that are not confined to the segment treated.[6][7]

Manual therapy techniques for cervicothoracic spine consists of mobilisation and manipulation, which are skilled passive movements applied at varying speeds and amplitudes. They range from low-velocity oscillations to high-velocity, low-amplitude thrust (HVLAT) techniques, and aim to reduce pain and improve range of motion.[8]

International clinical practice guidelines consistently recommend mobilisation or manipulation for neck pain, often combined with exercise.[9][10] Thoracic techniques are often chosen because they are perceived as lower risk than cervical techniques.[11] [12]

Anatomy of the Cervicothoracic Spine

The lower cervical spine has little bony stability and relies mainly on ligamentous support, which allows comparatively free movement.[13] The thoracic spine contributes rigidity and decreased mobility to this region due to its connection to the chest, including the scapulae, clavicles, ribs, and sternum.[1][13]

Bony anatomy also changes across the junction, from cervical lateral masses to thoracic transverse processes. Below C6, spinal rotation is limited to a range of 4-8, while lateral bending demonstrates a range of 6-8° between C5 and T6,[13] and the spinal canal is relatively narrow at this level.[1]

Due to the considerable difference in mobility between the two regions, the junction is exposed to translational forces, excessive flexion stress and high axial load transfer.[13] The knowledge of regional anatomy supports safe technique selection.[14]

Indications

After individual assessment and screening, cervicothoracic or thoracic mobilisation and manipulation may be considered, usually as part of a multimodal programme that includes exercise.[9]

Indications for this type of treatment include:

Indication Supporting evidence
Neck pain with mobility deficits (mechanical neck pain), including reduced cervical range of motion Recommended in the 2017 neck pain guideline, with moderate to weak strength of evidence depending on the stage of the condition.[9] Thoracic manipulation reduced pain more than thoracic or cervical mobilisation in the short term (mean difference −13.6 on a 100-point scale, 95% CI −21.8 to −5.5) but was no better than cervical or sham manipulation.[15] Later meta-analyses report similar short-term gains in pain and disability.[16][17] An umbrella review of seven systematic reviews rated confidence in these findings as low to critically low, so thoracic manipulation is best used as a short-term adjunct rather than a stand-alone treatment.[15]
Cervicogenic headache The 2017 guideline recommends cervical or cervicothoracic manipulation or mobilisation, combined with exercise, for neck pain with headache.[9] A 2024 network meta-analysis ranked combined approaches that included spinal manipulation highest for short-term reductions in headache intensity and frequency, although certainty was low and the review was not specific to the CT junction.[18]
Shoulder pain, particularly subacromial pain syndrome In a meta-analysis of 10 randomised trials, thoracic manual therapy reduced pain and disability, mainly in the short term, with a moderate effect on disability compared with placebo (standardised mean difference −0.75, 95% CI −1.18 to −0.32).[19] A second systematic review reached a similar conclusion for thoracic manual therapy with or without exercise.[20]
Thoracic spine pain Frequently managed with manual therapy in clinical practice, although direct trial evidence for thoracic spine pain is limited.[14]


Techniques of Cervicothoracic Spine Mobilisation

Mobilisation (non-thrust) and manipulation (thrust) differ in velocity and amplitude, and so require different training and screening.[8]

Maitland Concept

The Maitland Concept is a patient-centred approach built on continuous assessment. The therapist selects passive accessory or physiological movements according to the person's pain, stiffness and irritability. A comparable sign is reassessed after each technique to judge its effect.[21]

Movements are graded by amplitude and position in range:[21]

Grade I : small amplitude movement at the beginning of the available range of movement

Grade II : large amplitude movement within the available range of movement

Grade III : large amplitude movement that moves into stiffness or muscle spasm

Grade IV : small amplitude movement stretching into stiffness or muscle spasm

Grade V : high-velocity, low-amplitude thrust (HVLAT) manipulation, which requires specific additional training

Grades I and II are generally used when pain dominates, and grades III and IV when stiffness dominates.[21]

Prone Mid-Thoracic PA Mobilisations

[22]

Technique:

  • Position: Patient lies prone on a treatment table
  • Contact: The therapist places the 2nd and 3rd finger on each transverse process of the same level while the opposite hypothenar eminence rests on top to apply the PA mobilisation.
  • Force: With therapist's weight over the segment of mobilisation, apply oscillatory PA pressure in line with the facet joints.[21]

Benefits: Central or unilateral PA mobilisation at C7–T1 produced immediate improvements in neck pain and cervical range of motion in people with mechanical neck pain and CT junction dysfunction.[2]

Mulligan Concept: Sustained Natural Apophyseal Glide (SNAG)

The Mulligan Concept combines a therapist-applied accessory glide with movement. In a SNAG, the therapist sustains a glide along the facet plane while the patient moves actively, and the technique must be pain-free. [23]

The application is guided by two principles - The first is the PILL response:[23]

  • P: Pain-free
  • I: Instant result
  • LL: Long-Lasting

A technique that does not produce a PILL response should not be continued.

The second principle is CROCKS:[23]

  • C: Contraindications (no PILL response is itself a contraindication)
  • R: Repetitions (only three repetitions on day one)
  • O: Overpressure
  • C: Communication (between clinician and patient throughout)
  • K: Knowledge (of treatment planes and pathologies)
  • S: Sustain the mobilisation throughout the movement
Mid Cervical/Upper Thoracic SNAGS

[24]

Technique:

  • Position: Patient in sitting with upright posture
  • Contact: Medial border distal phalanx of one thumb on the articular pillar, opposite thumb contacts other side of first thumb to provide the mobilisation force. With mid cervical/upper thoracic SNAGS, the therapist contact may be central over the spinous process (for Central SNAG), or ipsilateral over the articular pillar (for an Ipsilateral SNAG). It is recommended to start with application of forces over the area of pain regardless of the direction of the problematic movement.
  • Force: Directed anteriorly and superiorly along the plane of the facet, toward the patient's eye on the ipsilateral side.
  • Movement. Patient actively flexes, extends, rotates, or side-bends and provides overpressure with hand on cheek while clinician maintains glide through the entire movement.[23]
Cervicothoracic Reverse NAG

A reverse natural apophyseal glide (NAG) is a passive oscillatory technique. It differs from a SNAG, in which the patient moves actively.[23]

[25]

  • Position: Patient in sitting with upright posture
  • Contact: Standing to the side of the patient, utilising a wide base key grip with the spinous process in between the index finger and the thumb with the contact points being at the transverse processes of the vertebra. The other arm will hold the patient's head in order to control flexion or extension as well as providing control and a counterforce for the mobilisation.
  • Force: Directed anteriorly and superiorly along the plane of the facet.
  • Movement. the patient stays relaxed while the therapist applies rhythmic, pain-free oscillations in an anterosuperior direction.[23]

Benefits: Mulligan techniques may improve outcomes in chronic non-specific neck pain when combined with other treatment. [23][24]

Cervicothoracic Spine Manipulation

The HVLAT of the spine is a technique that addresses the functional and segmental restriction of range of movement. A thorough examination must be performed, using clinical reasoning in order to ensure appropriateness of treatment and reduce risk of an adverse event from occurring.[26] With uncertainty regarding screening tools, clinicians must use additional strategies (e.g. red flags) for decision-making when choosing to use an HVLAT.[27]

Cervicothoracic Junction Manipulation in prone

[1]

Cervicothoracic Junction Manipulation can be completed in prone.[28]

Technique:

  • Contact: The therapist places the radial border of the proximal phalanx on the arch of C7-T1, with the elbow at 90° aligned in the direction of thrust. The cradle hand is positioned at the posterior/lateral temporal bone.
  • Barrier creation: The short leverage hand establishes the barrier at the C7-T1 articular pillar. The long leverage hand then introduces ipsilateral side-bending, contralateral rotation, and PA extension to engage the segment.
  • Thrust: The short leverage hand delivers a lateral break directed toward the opposite axilla, while simultaneously the opposite forearm rapidly introduces rotation and side-bending to complete the impulse.

Benefits: Thoracic thrust manipulation, mostly applied to the mid-thoracic spine, has reduced short-term pain and disability in mechanical neck pain more than mobilisation or standard care,[15][16] and thrust techniques applied to the cervical or thoracic spine appear to increase cervical range of motion.[26]

Precautions and Contraindications

The contraindications and precautions listed below refer predominantly to thoracic thrust manipulation.[12] Screening for serious spinal pathology and vascular risk applies equally before mobilisation,[29][30] but whether a listed condition also rules out mobilisation depends on the condition and the grade of technique, and should be decided through individual clinical reasoning.[27]


Contraindicaitons include:[12][29][30]

  • Bony pathology or structural compromise
    • Tumour (for example metastatic disease)

◦    Infection (for example tuberculosis, osteomyelitis)

◦    Metabolic bone disease (for example osteomalacia, established osteoporosis)

◦    Congenital conditions (for example dysplasias, congenital fusions)

◦    Iatrogenic causes (for example long-term corticosteroid use, recent surgery, surgical fusion)

◦    Active inflammatory disorders (for example rheumatoid arthritis, ankylosing spondylitis, connective tissue disease, synovial cysts)

◦    Traumatic injury (for example fracture, dislocation, ligamentous rupture, instability)

•    Neurological pathology

◦    Acute cervical, thoracic or lumbar myelopathy

◦    Spinal cord compression

◦    Cauda equina syndrome

◦    Progressive nerve root compression with neurological deficit

◦    Bilateral hyperreflexia or sensory loss

•    Vascular and visceral pathology

◦    Suspected vascular pathology of the neck, such as cervical artery dissection (previously termed vertebrobasilar insufficiency or cervical arterial dysfunction)[29]

◦    Aortic aneurysm

◦    Bleeding disorders or anticoagulant therapy

◦    Angina pectoris

◦    Untreated cardiac insufficiency or dysrhythmia

◦    Acute abdominal pain with guarding


Precautions include: [12]

•    Adverse reaction to previous manipulation

•    Inflammatory joint disease that is not currently active

•    Low bone density without fragility fracture

•    Disc herniation or protrusion

•    Spondylolisthesis

•    Hypermobility or ligamentous laxity

•    Arterial calcification

•    Arterial hypertension

•    Advanced degenerative joint disease

•    Children and adolescents with open growth plates or developing ossification centres

•    Marked kyphosis or scoliosis

•    Herpes zoster affecting the thoracic region

•    Vertigo

•    Systemic infection

•    Reliance on manipulation as the main form of treatment

•    Prominent psychosocial factors that passive treatment may reinforce

No change or worsening of symptoms after repeated manipulation

Conclusion

Cervicothoracic mobilisation and manipulation are widely used, guideline-recommended options for neck pain, with supporting evidence for subacromial shoulder pain.[9][10][19] The benefits shown are mainly short-term improvements in pain, disability and range of motion, and confidence in the evidence is low to critically low.[15][11] Thoracic manipulation has not outperformed sham or cervical manipulation, and results do not appear to depend on treating a specific segment.[11][31][32]

Techniques should therefore be selected through assessment, clinical reasoning and shared decision-making, with screening and informed consent completed first.[29][30] Manual therapy is best used as one part of a broader rehabilitation programme that includes exercise.[9] Higher-quality trials with longer follow-up, and trials specific to the CT junction, are needed.[2][15]

References

  1. ↑ 1.0 1.1 1.2 1.3 Dash C. Cervicothoracic junction fractures management: an overview of literature. Indian J Neurotrauma. 2019;16(1):27–32. doi:10.1055/s-0039-1700621. Cite error: Invalid <ref> tag; name ":1" defined multiple times with different content
  2. ↑ 2.0 2.1 2.2 2.3 Joshi S, Balthillaya G, Neelapala YVR. Immediate effects of cervicothoracic junction mobilization versus thoracic manipulation on the range of motion and pain in mechanical neck pain with cervicothoracic junction dysfunction: a pilot randomized controlled trial. Chiropr Man Therap. 2020;28:38. doi:10.1186/s12998-020-00327-4.
  3. ↑ Norlander S, Gustavsson BA, Lindell J, Nordgren B. Reduced mobility in the cervico-thoracic motion segment: a risk factor for musculoskeletal neck-shoulder pain: a two-year prospective follow-up study. Scand J Rehabil Med. 1997;29(3):167–174. doi:10.2340/16501977199729167174.
  4. ↑ Norlander S, Nordgren B. Clinical symptoms related to musculoskeletal neck-shoulder pain and mobility in the cervico-thoracic spine. Scand J Rehabil Med. 1998;30(4):243–251. doi:10.1080/165019779830243251.
  5. ↑ McDevitt A, Young J, Mintken P, Cleland J. Regional interdependence and manual therapy directed at the thoracic spine. J Man Manip Ther. 2015;23(3):139–146. doi:10.1179/2042618615Y.0000000005.
  6. ↑ Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009;14(5):531-538. doi:10.1016/j.math.2008.09.001. PMID:19027342; PMCID:PMC2775050.
  7. ↑ Bialosky JE, Beneciuk JM, Bishop MD, Coronado RA, Penza CW, Simon CB, et al. Unraveling the mechanisms of manual therapy: modeling an approach. J Orthop Sports Phys Ther. 2018;48(1):8–18. doi:10.2519/jospt.2018.7476.
  8. ↑ 8.0 8.1 Mintken PE, DeRosa C, Little T, Smith B. AAOMPT clinical guidelines: a model for standardizing manipulation terminology in physical therapy practice. J Orthop Sports Phys Ther. 2008;38:A1–A6. doi:10.2519/jospt.2008.0301
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 Blanpied PR, Gross AR, Elliott JM, Devaney LL, Clewley D, Walton DM, et al. Neck pain: revision 2017 clinical practice guidelines linked to the International Classification of Functioning, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2017;47(7):A1–A83. doi:10.2519/jospt.2017.0302.
  10. ↑ 10.0 10.1 Peters R, Hallegraeff J, Koes B, van Trijffel E. Recommendations for Mobilization and Manipulation Treatment and Screening for Vascular Complications in Clinical Practice Guidelines for Neck Pain: A Systematic Review. Phys Ther. 2025 Feb;105(2):pzae179. doi: 10.1093/ptj/pzae179.
  11. ↑ 11.0 11.1 11.2 Masaracchio M, Kirker K, States R, Hanney WJ, Liu X, Kolber M. Thoracic spine manipulation for the management of mechanical neck pain: a systematic review and meta-analysis. PLoS One. 2019;14(2):e0211877. doi:10.1371/journal.pone.0211877.
  12. ↑ 12.0 12.1 12.2 12.3 Heneghan NR, Puentedura EJ, Arranz I, Rushton A. Thoracic thrust joint manipulation: an international survey of current practice and knowledge in IFOMPT member countries. Musculoskelet Sci Pract. 2020;50:102251.
  13. ↑ 13.0 13.1 13.2 13.3 Amenta PS, Harrop JS. Pathology of the cervicothoracic junction: evaluation and treatment. In: Winn HR, editor. Youmans and Winn neurological surgery. 7th ed. Philadelphia (PA): Elsevier; 2017.
  14. ↑ 14.0 14.1 Puentedura EJ, O'Grady WH. Safety of thrust joint manipulation in the thoracic spine: a systematic review. J Man Manip Ther. 2015;23(3):154–161. doi:10.1179/2042618615Y.0000000012.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 Masaracchio M, Kirker K, Dewan B, Caronia S. Effectiveness of thoracic spine manipulation for the management of neck pain: a systematic umbrella review with risk of bias and methodological and reporting quality. Healthcare (Basel). 2026;14(2):240. doi:10.3390/healthcare14020240. PMID:41595376; PMCID:PMC12841215.
  16. ↑ 16.0 16.1 Tsegay GS, Gebregergs GB, Weleslassie GG, Hailemariam TT. Effectiveness of thoracic spine manipulation on the management of neck pain: a systematic review and meta-analysis of randomized control trials. J Pain Res. 2023;16:597–609. doi:10.2147/JPR.S368910.
  17. ↑ Yang J, Zhao S, Zhang R, Huang C, Huang KY, Cheng Y, et al. Effectiveness and safety of thoracic manipulation in the treatment of neck pain: an updated systematic review and meta-analysis. Technol Health Care. 2024;32(S1):385–402. doi:10.3233/THC-248034.
  18. ↑ Jung A, Carvalho GF, Szikszay TM, Pawlowsky V, Gabler T, Luedtke K. Physical therapist interventions to reduce headache intensity, frequency, and duration in patients with cervicogenic headache: a systematic review and network meta-analysis. Phys Ther. 2024;104(2):pzad154. doi:10.1093/ptj/pzad154
  19. ↑ 19.0 19.1 Yu S, Chen S, Yang Z, Ma X, Huang J, Yang L. Effectiveness of thoracic spine manual therapy in treating subacromial impingement syndrome: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2025;106(12):1886–1898. doi:10.1016/j.apmr.2025.07.008.
  20. ↑ Robles-Pérez R, Vallejo-Martínez R, Carrasco-Uribarren A, Jiménez-del-Barrio S, Hernández-Lázaro H, Ceballos-Laita L. Thoracic manual therapy with or without exercise improves pain and disability in subacromial pain syndrome: a systematic review of randomized trials. Healthcare. 2025;13(19):2479. doi:10.3390/healthcare13192479.
  21. ↑ 21.0 21.1 21.2 21.3 Maitland GD, Hengeveld E, Banks K, English K. Maitland's vertebral manipulation. 8th ed. Edinburgh: Elsevier; 2013.
  22. ↑ Maitland techniques — all [Internet]. YouTube; [c2010; cited 2025 May 16]. https://www.youtube.com/watch?v=pncefI5qyog
  23. ↑ 23.0 23.1 23.2 23.3 23.4 23.5 23.6 Mulligan BR. Manual therapy: NAGS, SNAGs, MWMs, etc. 6th ed. Wellington (NZ): Plane View Services; 2010.
  24. ↑ 24.0 24.1 Physitrack Education. SNAGs (lower cervical spine C3–C7) for pain/stiffness in neck [Internet]. YouTube; [2019 Mar 12; cited 2025 May 16]. https://www.youtube.com/watch?v=fTKOoV5wHBU
  25. ↑ Thoracic spine mobilisation: reverse NAG, Mulligan mobilisation with movement technique MWM [Internet]. YouTube; [c2018; cited 2026 May 16]. https://www.youtube.com/watch?v=A8juGfCJOcc
  26. ↑ 26.0 26.1 Langenfeld A, Baechler M, Swanenburg J, Mühlemann M, Nyirö L, Streuli D, et al. Systematic review on biomechanical effects of high-velocity, low amplitude spinal manipulation. PLoS One. 2025;20(7):e0328048. doi:10.1371/journal.pone.0328048.
  27. ↑ 27.0 27.1 Cook C, George SZ, Reiman MP, et al. International framework for red flags for potential serious spinal pathologies. J Orthop Sports Phys Ther. 2020;50(7):350–372. doi:10.2519/jospt.2020.9971.
  28. ↑ McCoy RC, Bittencourt E, Clifton W. Cervicothoracic manipulation techniques reviewed utilizing three-dimensional spine model. Cureus. 2019;11(10):e5836. doi:10.7759/cureus.5836.
  29. ↑ 29.0 29.1 29.2 29.3 Rushton A, Carlesso LC, Flynn T, Hing WA, Rubinstein SM, Vogel S, et al. International framework for examination of the cervical region for potential of vascular pathologies of the neck prior to musculoskeletal intervention: International IFOMPT Cervical Framework. J Orthop Sports Phys Ther. 2023;53(1):7–22. doi:10.2519/jospt.2022.11147.
  30. ↑ 30.0 30.1 30.2 Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL, et al. International framework for red flags for potential serious spinal pathologies. J Orthop Sports Phys Ther. 2020;50(7):350–372. doi:10.2519/jospt.2020.9971
  31. ↑ Nim CG, Downie A, O'Neill S, Kawchuk GN, Perle SM, Leboeuf-Yde C. The importance of selecting the correct site to apply spinal manipulation when treating spinal pain: myth or reality? A systematic review. Sci Rep. 2021;11:23415. doi:10.1038/s41598-021-02882-z.
  32. ↑ Nim CG, Aspinall SL, Cook CE, et al. The effectiveness of spinal manipulative therapy in treating spinal pain does not depend on the application procedures: a systematic review and network meta-analysis. J Orthop Sports Phys Ther. 2025;55(2):109–122. doi:10.2519/jospt.2025.12707.
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