1st Rib Thrust Manipulation

Body Region: Thoracic Spine

Technique Name: 1st Rib Thrust Manipulation

Indications: mechanical neck pain (MNP), cervical radiculopathy (CR), thoracic pain, shoulder pain

Instructions:

Patient Position:

• The patient is seated in the center of the treatment table with their legs hanging over the side.

Clinician Position:

• Stand behind the patient with one foot on the plinth and your thigh next to the patient’s unaffected side
• The patient’s arm is supported on the your thigh (this takes tension off the brachial plexus)
• Gently place your contralateral hand on the patient's head, with your elbow resting gently across the contralateral upper trapezius and clavicle.
• Gently push your hip into the patient’s back, which will force the spine into slight extension.

Technique Description:

• Using the 2nd metacarpo-phalangeal (MCP) joint on the ipsilateral hand, the locate the shaft of the 1st rib. A lumbrical grip (MCP flexion and IP extension) is maintined on the 1st rib by moving the trapezius posteriorly.
• The patient’s head is side-bent toward the affected side and rotated away
• Impart a gradual, progressive mobilizing force to the patients 1st rib to produce depression. The direction should be toward the midline of their body.
• When the restrictive barrier is engaged, deliver a high-velocity, low-amplitude thrust inferiorly and towards midline. (attempting to reach the opposite axilla).

Key Points:

• Use your entire body to translate the patient's cervical / thoracic spine until the restrictive barrier is engaged
• Ensure the patient can tolerate the pressure you are applying with your manipulating hand prior to thrusting

Manual therapy interventions for the thoracic spine have been associated with improvements in pain, function and disability in individuals with mechanical neck pain (MNP), cervical radiculopathy (CR), and shoulder pain.

Mechanical Neck Pain (mnp):

Thoracic spine thrust manipulation (TSM) has been shown to be effective in improving pain, neck function and disability levels in individuals with acute and chronic neck pain over the short and long term (6-month) time frames.  TSM plus exercise has been shown to be superior to exercise alone.  TSM plus thermo-modalities (i.e. moist heat, infra-red therapy, electrotherapy) has been shown to be more beneficial than thermo-modalities alone.

Cleland and colleagues developed a clinical prediction rule (CPR) to identify individuals with neck pain who were likely to respond to thoracic spinal manipulation (TSM). Six variables were identified as predictors and together formed the CPR.  A follow-on validation study found that this CPR was not helpful in identifying individuals with neck pain to respond to TSM.  However, individuals receiving TSM and exercise experienced superior outcomes to individuals receiving exercise alone regardless of their status on the CPR, indicating that TSM is a beneficial intervention for the majority of individuals with MNP.  

• Cleland, 2005, Man Ther
• Cleland, 2007, Phys Ther
• Vernon, 2007, J Manipulative Physiol Ther
• Gonzales-Iglesias, 2009, J Orthop Sports Phys Ther
• Cleland, 2010, Phys Ther
• Mintken, 2010, Phys Ther
• Lau, 2010, Man Ther

Shoulder Pain:

The addition of manipulative therapy to the cervical-thoracic spine and rib cage to usual medical care (UMC) has been shown to produce superior clinical outcomes to UMC alone in individuals with non-specific shoulder pain.

Mintken and colleagues developed a clinical prediction rule (CPR) to identify individuals with subacromial impingement syndrome (SIS) who were likely to respond favorably to thoracic spinal manipulation. Five variables were identified as predictors and together formed the CPR. The variables were:

1. Pain-free shoulder flexion <127°

2. Shoulder internal rotation <53 degrees at 90 degrees of abduction

3. A negative Neer test

4. Not taking medications for their shoulder pain, and

5. Duration of symptoms less than 90 degrees.

The CPR demonstrated a positive likelihood ratio of 5.5, indicating that individuals who were positive for at least three of the five variables increased their likelihood of a successful outcome with thoracic manipulation from 61% (pre-test probability) to 89% (post-test probability). This CPR must be further tested in a broader patient population with a comparison group and long-term follow up in order to validate the findings of this preliminary study.

• Bergman, 2004, Ann Int Med
• Mintken, 2010, Phys Ther
• Bergman, 2010, BMC Musculoskeletal Disord
• Bergman, 2010, J Manipulative Physiol Ther

Cervical Radiculopathy (cr):

There are no studies that explicitly examine the effectiveness of thoracic spine manual therapy (MT) interventions in individuals with CR. Thoracic spine MT has been included in multi-modal (traction, exercise, thoracic MT and cervical MT) treatment protocols associated with good outcomes in individuals with CR, however, there are no placebo-controlled trials investigating this management approach. Because of these factors, the benefit of thoracic spine MT for individuals with CR is currently unknown.

• Cleland, 2005, J Orthop Sports Phys Ther
• Cleland, 2007, J Orthop Sports Phys Ther
• Young, 2009, J Orthop Sports Phys Ther

Other Clinical Evidence:

• Rose, 2003, J Manipulative Physiol Ther
• Pho, 2004, J Orthop Sports Phys Ther
• Waldrop, 2006, J Orthop Sports Phys Ther
• Fernandez-de-las-Peñas, 2007, J Manipulative Physiol Ther
• Krauss, 2008, J Man Manip Ther

Other Relevant Evidence:

• Campbell, 2010, J Orthop Sports Phys Ther
• Bishop, 2011, Spine J