What Does the Evidence Say About Treating Neck Pain? Target The Thoracic Spine.

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What Does the Evidence Say About Treating Neck Pain? Target The Thoracic Spine.

Interventions applied to the thoracic spine and ribs may help provide more insight into how it could potentially lead to treating individuals with neck pain. Cleland et al1 introduced a study to investigate the predictive validity of how patients with neck pain would respond to thoracic thrust manipulations in comparison to therapeutic exercise.2 The study derived a clinical prediction rule in which patients who met 3+ items 86%, 4+ items 93%, and 5+ items 100% probability of success:2

  • Symptoms <30 days
  • No symptoms distal to the shoulder
  • Looking up does not aggravate symptoms
  • FABQ-PA score <12
  • Diminished upper thoracic spine kyphosis
  • Cervical extension ROM <30

The data did not support the validity of the clinical practice rule; however, the study demonstrated how the use of thoracic thrust manipulations and exercise provided short- and long-term benefits in comparison to those who received exercise only.2 Individuals with mechanical neck pain who received thoracic thrust manipulation have shown decreased pain and range of motion compared to those receiving interventions consisting of electro/thermal therapy.3 Cervical and thoracic manipulations may influence pressure pain sensitivity, neck pain, and cervical range of motion.4 Thoracic thrust manipulation may be beneficial for those who present with acute and subacute neck pain.5 Thoracic manipulations may also help improve range of motion and reducing pain in individuals presenting with chronic neck pain.6

Manual Therapy

High velocity low amplitude thrusts at the upper cervical and thoracic spine have demonstrated short term relief for individuals presenting with mechanical neck pain.7 Dunning et al in 20168, demonstrated how upper cervical and thoracic manipulations were more effective in comparison to mobilizations and exercise in patients with cervicogenic headaches. Performing manipulations to the thoracic spine seems to have less risk in comparison to manipulations to the cervical spine.9

Examining dysfunction in the upper ribs could contribute to patients demonstrating with neck pain. Performing a cervical rotation flexion test may indicate 1st rib hypomobility that could lead to cervical pathology.10 Dysfunction in the ribcage may decrease thoracic range of motion that could contribute to generated symptoms.11 Non thrust manipulations to the upper ribs can help improve functional mobility and cervical range of motion.11

Manual Therapy and Exercise

Utilizing a multimodal approach to treating neck pain should also incorporate therapeutic exercise to improve posture, strengthening, and coordination.12 Patients with neck pain have generally high expectations especially about manual therapy and exercise.13 The implementation of manual therapy and exercise demonstrated improved short- and long-term improvements for patients with mechanical neck pain; Those who were in a manual therapy and exercise group (49%) perceived expectations statistically better than the minimal intervention group (32%).14 Patients with neck pain exhibiting mobility deficits may include thoracic and/or cervical manipulation or mobilization, therapeutic exercise including coordination and postural reeducation, and the use of modalities such as dry needling, laser, or intermittent mechanical/manual traction.12

Treating the thoracic spine for neck pain is not the only course of treatment recommended. The use of manual therapy and exercise seems to warrant the most merit when treating individuals with neck pain. It is important to consider other potential factors to determine the most appropriate plan of care.

Article Written By Eric Trauber, PT, DPT, OCS, CSCS, FAAOMPT


  1. Cleland JA, Childs JD, Fritz JM, Whitman JM, and Eberhart SL. (2007). Development of clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education, Physical Therapy Journal, Volume 87, Number 1: pp. 9-23.
  2. Cleland JA, Mintken. PE, Carpenter K, Fritz JM, Glynn P, Whitman J, and Childs JD. (2010). Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a general cervical range of motion exercise: multi center randomized clinical trial, Physical Therapy Journal, Volume 90, Number 9: pp. 1239-1250.
  3. Gonzalez-Iglesias J, Fernandez-de-as-Penas C, Cleland JA, Del Rosario Gutierrez M. (2009). Thoracic spine manipulation for the management of patients with neck pain: a randomized clinical trial, Journal of Orthopaedic and Sports Physical Therapy, Volume 39, Number 1: pp. 20-27.
  4. Martinez-Segura R, De-La-Llave-Rincon AI, Ortega-Santiago R, Cleland JA, and Fernandez-de-las-Penas C. (2012).  Immediate changes in widespread pressure pain sensitivity, neck pain, cervical range of motion after cervical or thoracic thrust manipulation in patients with bilateral chronic mechanical neck pain: a randomized clinical trial Journal of Orthopaedic and Sports Physical Therapy, Volume 42, Number 9: pp. 806-814.
  5. Cross KM, Kuenze C, Grindstaff T, and Hertel J. (2011). Thoracic spine thrust manipulation improves pain, range of motion, and self-reported function in patients with mechanical neck pain: a systematic review, Journal of Orthopaedicc and Sports Physical Therapy, Volume 41, Number 9: pp. 633-642.
  6. Lau HMC, Chiu TTW, and Lam TH. (2011). The effectiveness of thoracic manipulation on patients with chronic mechanical neck pain – a randomized controlled trial, Manual Therapy, 16:141-147.
  7. Dunning JR, Cleland JA, Waldrop MA, Arnot C, Young I, Turner M, and Sigurdsson G. (2012). Upper cervical and upper thoracic thrust manipulation versus non thrust mobilization in patients with mechanical neck pain: a multi center randomized clinical trial, Journal of Orthopaedic and Sports Physical Therapy, Volume 42, number 1: pp. 5-18.
  8. Dunning JR, Butts, R, Mourad F, Young I, Fernandez-de-las Penas C, Hagins M, Stanislawski T, Donley J, Buck D, Hooks TR, and Cleland JA. (2016). Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial, BMC Musculoskeletal Disorders, Volume 17, Number 64: pp. 1-12.
  9. McDevitt A, Young J, Minkten P, Cleland J. (2015).  Regional interdependence and manual therapy directed at the thoracic spine, Journal of Manual and Manipulative Therapy, Volume 23, Number 3: pp. 139-146.
  10. Lindgren KA, Leino E, Hakola M, Hamberg J. (1990). Cervical spine rotation and lateral flexion combined motion in the examination of the thoracic outlet, Archives of Physical Medicine Rehabilitation, Volume 71, Number 8:582.
  11. Egan W, Burns S, Flynn TW, and Ojha H. (2011). The thoracic spine and rib cage: physical therapy patient management utilizing current evidence, Current Concepts of Orthopaedic Physical Therapy, 3rd Edition: pp. 1-31.
  12. Blanpied PR, Gross AR, Elliot JM, Devaney LL, Clewley D, Walton DM, Sparks C, and Robertson EK. (2017). Clinical practice guidelines – neck pain: revision. clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopedic section of the american physical therapy association, Journal of Orthopaedic and Sports Physical Therapy, Volume 47, Number 7: A1-A83.
  13. Bishop MD, Mintken P, Bialosky JE, and Cleland JA. (2013). Patient expectations of benefit from interventions for new pain and resulting influence on outcomes, Journal of Orthopaedic. and Sports Physical Therapy, Volume 43, Number 7: pp. 457-46.
  14. Walker MJ, Boyles RE, Young BA, Struence JB, Garber MB, Whitman JM, Deyle G, and Wainner RS. (2008). The effectiveness of manual physical therapy and exercise for mechanic neck pain: a randomized clinical trial, Spine, Volume 33, Issue 22: pp. 2371-2378.