Thoracic manipulation with shoulder dysfunction
Original Editor - Carla Benton
Cervicothoracic manipulation for treatment of shoulder dysfunction
In the orthopedic physical therapy setting, shoulder pain and dysfunction is a common diagnosis. Whether the cause may be a rotator cuff, bursa inflammation, degenerative changes in the glenohumeral joint, or spurring, our choices of treatment are varied. Now there is evidence to support the use of manual therapy, that includes thoracic spine thrust manipulation (TSTM). Overall, there is limited but promising evidence supporting the use of cervico-thoracic (CT) mobilization and thrust manipulation for patients with shoulder pain. 
Possible mechanisms for the effectiveness of CT mobilization/manipulation include:
- Thoracic spine and scapular mobility- Thoracic spine forms a key link in the kinematic sequence of arm elevation. Thoracic side bending and rotation are caused by unilateral humeral motions. Thoracic rotation and ER indicate significant coupling of these segmental movements.  Another explanation for use of TSTM with shoulder patients by Bergman et al describes the relationship of restoring mobility between adjacent vertebrae which may be blocked by entrapment of a meniscoid. The relationship between reduced mobility of the cervicothoracic spine and shoulder pain could be explained by this reflexogenic mechanism. Abnormal biomechanical relationship between adjacent vertebra can also compress nerve roots, which can affect associated segmental muscular function, such as muscle spasms. This can cause abnormal movement patterns in the shoulder complex , including the scapulohumeral joint. Use of manipulative treatment can help our patients not only improve their shoulder mobility, but improve their overall functional performance.
- Postural dysfunctions- The upper crossed postural syndrome as explained by Janda in which the precense of weak deep neck flexors coupled with weak rhomboids and lower trapezius (LT) and Tight pecs coupled with tight upper traps. Other research has shown a relationship between scapular positional dysfunction and shoulder dysfunction and pathology (Kibler, 1998; Lukasiewicz et al, 1999; Ludewig and Cook, 2000; Laudner et al, 2006). So basically the position of the scapula on the thoracic wall affects posture, which could affect shoulder function.
- Regional Interdependance- The clinical rationale for the use of thoracic manipulation with shoulder patients is based on regional interdependence (Wainner et al, 2001). This basically states that one area directly affects another. If one area, such as the thoracic spine is dysfunctional, it may affect the mobility of the shoulder as well, and create shoulder pain and limitations in function of the upper extremity. 
- Increased scapular strength with manipulation- Improved LT strength following thoracic spine mobilization and thrust manipulation.
- Spinal level pain modulation- Immediate short-term reduction in numeric pain rating score (NPRS) and shoulder pain and disability index (SPADI) following cervico-thoracic spine manipulation. In a recent study performed by Boyles  et al 56 patients with shoulder impingement, were treated with thoracic spine thrust manipulation. Upon completion of the physical exam, all of the patients received a high velocity, low amplitude thoracic spine thrust manipulation with focus on the mid-thoracic and cervicothoracic junctional areas. These patients demonstrated statistically significant changes in pain and disability scores at 48 hours. It was mentioned above that regional interdependence may be one reason this intervention is so successful when used with shoulder patients; however another possible reason for changes may be the effects that thoracic posture has on shoulder pain (Bulloch et al, 2005; Lewis et al, 2005). It seems that postural correction in the thoracic spine decreases shoulder pain, and assists with increasing overall shoulder mobility. Another study initiated by Rainbow et al compared the effects of shoulder, cervical, and thoracic spine high velocity, low-amplitude (HVLA) chiropractic manipulative therapy in the treatment of frozen shoulder. Group 1 received HVLA chiropractic manipulative therapy for 6 weeks to the glenohumeral joint, cervical, and thoracic spines, along with were given home exercise program. Group 2 received grade 4 glenohumeral joint mobilization for 6 weeks with a home exercise program. Both groups were given the same home program. The outcome measure used to measure change was the Shoulder Pain and Disability Index (SPADI). Greater than a 10 point decrease in SPADI score is considered clinically significant and meaningful. Initial scores of SPADI for Group 1=68.3, and Group 2=65.2. After 6 weeks of treatment, the chiropractic manipulative treatment group decreased to 14.1, while the Mobilization group of glenohumeral decreased to 35. Both showed clinically meaningful changes in reduced pain and disability; however, the manipulative group improved by an additional 24 points compared to Group 2. Is there any difference in chiropractic manipulative therapy and physical therapy manipulative care? The final study that I wanted to discuss was a study by Menck et al that used the treatment of the thoracic spine in the management of patients who suffered from upper extremity Complex Regional Pain Syndrome Type I (CRPS-I). This was a case study in which a 38 year old woman suffered from a traumatic injury to her left hand. She was treated for 36 visits in 3 months with treatment other than thoracic manipulation. Then T3-4 vertebral manipulation was implemented and immediately there was a significant increase in the left hand’s skin temperature. Shoulder range of motion increased from 135 to 175 degrees, and the patient reported decreased pain from 6/10 to 3/10. The authors hypothesized that there may be a relationship between symptoms of the upper extremity CRPS and the thoracic spine. They , too, discuss the abnormal posturing caused by disuse of the upper extremity, leading to thoracic hypomobility. Thoracic joint manipulation improved spinal mobility, and also assisted in decreasing distal and autonomic symptoms. This helped to improve overall functional performance of this patient’s upper extremity. This patient was discharged with full return to independence .
One can distinguish from the evidence that our approach to treatment of the shoulder patient should include thoracic manipulation. Many physical therapists are not comfortable with manipulation; however, as one can see, it is becoming mandatory to gain these manual skills to deliver successful treatment for our patients. Attending continuing education courses, as well as completing residencies, such as Evidence in Motion, can help us stay up with the evidence, and continue to grow our profession as manual experts. The challenge is on for all of us, young and old, to become recognized as experts in the treatment of musculoskeletal dysfunctions. We cannot do this without continuing to learn and grow, and using the evidence to help guide our interventions.
- Rainbow DM, Weston JP, Brantingham JW, Globe G, Lee F. A prospective clinical trial comparing chiropractic manipulation and exercise therapy vs. chiropractic mobilization and exercise therapy for treatment of patients suffering from adhesive capsulitis/frozen shoulder. Journal of the American Chiropractic Association 2008; September/October: 12-28.
- Menck JY, Requejo SM, Kulig K. Thoracic spine dysfunction in upper extremity complex regional pain syndrome Type I. Journal of Orthopaedic and Sports Physical Therapy 2000; 30:401-409.
- Walser RF, Meseve BB, Boucher TR. The Effectiveness of Thoracic Spine Manipulation for the Management of Musculoskeletal Conditions: A Systematice Review and Meta-Analysis of Randomized Controlled Trials. J Man Manip Ther. 2009; 17(4): 237-246.
- Crosbie J, Kilbreathe SL, Hooman L, York S. Scapulohumeral rhythm and associated spinal motion. Clin Biomechan. 2008; 23: 184-192.
- Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come. J Ortho Sports Phys Ther. 2007; 37(11): 658-660.
- Boyles RE, Bradley BM, Miracle BM, Barclay DM, Faul MS, Moore JH, Koppenhaver SL, Wainner RS. The short-term effects of thoracic spine thrust manipulation om patients with shoulder impingement syndrome. Manual Therapy 2009; 14:375-380.