Manual Therapy for

Thoracic Spine
Parta Kinandana
Reference
• Maitland GD, Hengeveld E, Banks K, English
K. 2005. Maitland’s Vertebral Manipulation.
Seventh edition. London. Elsevier. Please
Read P : 301-335

Others :
• Olson KA. 2009. Manual Physical Therapy of the Spine.
Second Edition Philadelphia. Elsevier. Please Read P : 199-
243
Principle of Manual Therapy
Type Description
Grade I Oscillation Small amplitude movement performed near starting
position of range
Grade II oscillation Large amplitude movement performed within range but
not reaching limit of range; can occupy any part of
range that is free of stiffness or muscle guarding
Grade III oscillation Large amplitude movement performed up to limit of
range and moves into stiffness or muscle guarding
Grade IV oscillation Small amplitude movement performed at limit of range
stretching into stiffness or muscle guarding
High velocity thrust High velocity, low amplitude therapeutic movements
within or at end range of Motion
Isometric Where patient’s muscles are used to mobilize joint by
performing isometric contraction against operator’s
resistance
 A, Depiction of range of movement. B, Grades in normal range with hard end
feel. C, Grades in hypermobile joint. L, Pathologic limit of range (hard end feel).
 D, Grades in relation to hypermobile asymptomatic range. B, Range of
movement beyond normal average range; N, normal hypermobile range. E,
Grades in hypermobile range with slight limitation and hard end feel. F, Depiction
of soft end feel. R, Beginning of resistance.
G, Grades III and IV under soft end feel. H, Depiction of techniques taken into
resistance in grades III and IV under soft end feel. I, Grade II movements are
always resistance-free movements
Red Flags, Absolute & Relative
Contraindication
Red Flags
• Trauma
• Penurunan berat badan
• Riwayat Kanker
• Demam
• Penggunaan obat intravena
• Penggunaan Steroid
• Pasien >50 Tahun
• Nyeri yang diperburuk ketika berbaring
Red Flags, Absolute & Relative
Contraindication
Absolute Contraindication
• Menurunnya integritas ligamen akibat trauma atau penyakit
• Unstable fracture
• Tumor tulang
• Penyakit infeksi
• Osteomyelitis
• VBI (Cervical Spine)
• Rheumatoid Arthritis (Upper Cervical Spine)
• Penggunaan obat-obatan anti koagulan
Red Flags, Absolute & Relative
Contraindication
Relative Contraindication
• Osteoporosis
• HNP dengan Radikulopati
• Tanda-tanda instabilitas vertebra
• Rheumatoid Arthritis
Mobilization Vs Manipulation
• Manipulasi jarang dipakai pada awal treatment.
• Hindari manipulasi dalam keadaan painfull joint
atau spasme otot.
• Manipulasi merupakan lanjutan dari mobilisasi.
• Manipulasi merupakan grade V
• Manipulasi dipakai ketika keterbatasan disertai
nyeri yang sedikit atau tidak disertai dg nyeri
 Thoracic Region

Unilateral Bilateral Symptoms

Symptoms

Postero-anterior central Postero-anterior central vertebral

vertebral pressure pressure

Transverse vertebral Transverse vertebral pressure (2

pressure sides)

Postero-anterior unilateral
Traction
vertebral pressure

Traction
Thoracic Spine
Treatment Technique
Parta Kinandana
Posterio-Anterior Central Vertebral
Pressure (PACVP) Mobilization
Posterio-Anterior Central Vertebral Pressure
(PACVP)
Transversal Vertebral Pressure
Mobilization

Transversal Vertebral Pressure (TVP)

Transversal Vertebral Pressure
Mobilization

TVP (alternative Hand 1) TVP (Alternative Hand 2)

Postero-Anterior Unilateral Vertebral
Pressure Mobilization
PAUVP Costovertebral Joint
PAUVP Costovertebral Joint (Alternative hand)
Intervertebral Rotational Mobilization

Intervertebral Rotation Intervertebral Rotation

Mobilization Mobilization (Skeleton view)
Lateral Flexion Manipulation Cervicothoracal Lateral
of IV Joint (C7-T3) Flexion Manipulation

Hand Placement of IV C7-T3

Upper Thoracic Gapping Manipulation

Upper Thoracic Gapping Upper Thoracic Gapping

Manipulation Manipulation (Sitting)
Intervertebral PA Manipulation

Postero-Anterior Manipulation Postero-Anterior

of IV T3-T10 (Hand Placement) Manipulation of IV T3-T10
Intervertebral PA Manipulation

Postero-Anterior Manipulation of IV T3-T10

(end position)
 Longitudinal Gapping Manipulation

Longitudinal Manipulation of IV
T3-T10 (Nelson’s Traction Thrust) Towel Placement
Longitudinal Gapping Manipulation

Nelson’s Traction Thrust Nelson’s Traction Thrust

Movement for Upper Thoracic Movement for Lower Thoracic
Intervertebral Lateral Flexion
Manipulation
Lateral Flexion Manipulation of Lateral Flexion Manipulation
IV T3-T10 in Prone (Hand
Position) of IV T3-T10 in Prone
Intervertebral Rotational Manipulation

Rotational Manipulation of
IV Joint T3-T10 (Supine) Specified Hand Placement
Intervertebral Rotational Manipulation

Rotational Manipulation of IV Rotational Manipulation of IV

Joint T3-T10 (Mid-Thoracic) Joint T3-T10 (Lower-Thoracic)
Rib Mobilization and Manipulation

First Rib Mobilization PA w/ First Rib Mobilization PA w/

Inferior Inclination (Altrn
Inferior Inclination Position)
Rib Mobilization and Manipulation

First Rib Mobilization AP w/ First Rib Mobilization AP w/

Inferior Inclination 1 Inferior Inclination 2
Rib Mobilization and Manipulation

Postero-Anterior
Manipulation of Rib
Rib Mobilization and Manipulation

Rib Exhalation Manipulation

Rib Exhalation Manipulation w/ Upper Extremity Leverage
Terimakasih
Om Shanti, Shanti, Shanti, Om