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Spine Thrust Manipulation Techniques
SI Region Manipulation
Patient position: Patient is in the supine position with their hands interlaced cradling their neck.
Therapist position: Standing on the opposite side of the SI joint that is going to be
manipulated. For example if the side to be manipulated is the right SI joint, the examiner will
stand on the left side of the table facing the patient’s right SI joint.
Method: First, the examiner maximally side bends the patient by translating the pelvis towards
the examiner, and then side bending the extremities and the trunk away from the examiner. For
example, if the side to be manipulated is the right SI joint, the examiner will translate the pelvis
towards them and then will side bend the extremities and the trunk to the right. Without losing the
side bending, lift and rotate the trunk away from the side to be manipulated (rotate left if manipulating the
right SIJ) so the patient rests on their shoulder. The examiner will then thread their cranial hand and
forearm through the patient’s arms; the examiners fingertips can rest on the patient’s sternum or
the table. The examiner then stands upright and takes up the slack by rotating the patient’s trunk
away from the side to be manipulated (rotate left if manipulating the right SIJ). The examiner
needs to maintain right side bending with the added component of trunk rotation. Trunk rotation
will cause the ASIS on the side to be manipulated to rise off the table. As the ASIS raises off the
table, the examiner then places their caudad hand over the patient’s ASIS of the side to be
manipulated. Perform a smooth high-velocity, low-amplitude thrust in an anterior to posterior direction.
Alternative Method:
1. The examiner can grasp the top shoulder and scapula OR can use the cranial forearm and hand across
the scapula, thoracic, and lumbar spine to maintain the locked spinal position.
Indications: (Flynn et al., 2002) Flynn and colleagues found
that subjects who had the following examination findings
responded with dramatic success to this particular
manipulation:
Fear Avoidance Behavior Questionnaire work subscale score
<18.
Duration of symptoms 15 days or less.
No symptoms distal to the knee.
Lumbar spine hypomobility at any level.
Either hip with greater than 35 degrees of internal rotation.
Successful response to the manipulation was defined by a 50% reduction in the Oswestry score in less
than 5 days: Patients with 4 or more of these findings have a high likelihood of dramatic success. These
subjects had severe LBP with Oswestry scores >30 but did not have significant sensory and/or motor loss.
While the 4 or more findings predicted dramatic success, patients with fewer findings may respond more
favorably than the passage of time. This clinical prediction rule has recently been validated by another
study using a different sample of patients and clinicians (Childs et al., 2004; Flynn et al., 2002; Fritz et
al., 2004).
*Side closest to you that is sidebended toward you has the foot on top when cross feet
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**Contraindications:
Pregnancy, osteoporosis (severe), instability (SI and Lumbar), RA, Fracture, Cauda Equina, Cancer,
Tumor, Infection
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Lumbar Rotation Manipulation (description of left rotation of L4-5 segment)
Patient Position: The patient is lying on their right side with head supported on a pillow and
their knees and hips comfortably flexed.
**PAINFUL SIDE IS UP
Therapist Position/ Set-up: The examiner stands facing the patient at the level of the pelvis.
The examiner places the patient’s bottom leg into approximately 30 degrees of hip flexion such
that the patient’s knee and proximal lower leg are resting on the table. The examiner uses the
cranial hand to palpate the interspinous space of the level that is going to be manipulated (L4-5)
with the pad of the third digit and palpates the interspinous space of the level below (L5-S1) with
the pad of the 2nd digit. The examiner uses their caudad hand to flex the patient’s upper leg to
position the lumbar spine in flexion up to the level that is to be manipulated. Once this position
is reached, hook the patient’s top foot behind the popliteal fossa of the bottom leg. The examiner
will now switch the position of their hands such that the caudad hand will palpate the
interspinous space of the level that is going to be manipulated (L4-5) with the pad of the third
digit and palpates the interspinous space of the level above (L3-4) with the pad of the 2nd digit.
The examiner uses their cranial hand to rotate and flex the patient’s trunk by lifting the patient’s
right arm or scapula up and forward, feeling for the beginning of rotation of L4-5. The examiner
places the patient’s left forearm and hand across the abdomen. The examiner can either place the
patient’s right arm behind their head or fold it on top of the patient’s left forearm/ hand. The
examiner then weaves their cranial hand through the triangle made between the patient’s left arm
and trunk. The examiner places their cranial thumb on the left side of the L4 spinous process.
The right middle finger grasps beneath on the right side of the spinous process of L5 pulling
upward. The examiners caudad forearm is behind the patient’s hip. At this point, the examiner
should have firm contact against the patient’s abdomen, left hand/ forearm with the cranial leg
stepped in towards the patient and the caudal leg behind.
Method: The examiner will take up the soft tissue slack and gradually oscillate to the end of
available movement by using the cranial thumb (left thumb) to press downwards on the L4
spinous process as the caudad middle finger (right finger) pulls the L5 spinous process upwards.
In addition, the examiner will use the contact of their cranial forearm on the patient’s anterior
shoulder and chest and the contact of their caudad forearm on the patients posterior hip and
pelvis to take up the soft tissue slack. The examiner will perform a high-velocity, low-amplitude
thrust by dropping their body and forearm toward the table.
Alternative Method: There are alternate positions in which the examiner can place their caudad
hand/ arm to assist with greater leverage and to further lock the spine.
Indications: This technique is used to improve mobility of a selected segment in the direction of
rotation and or flexion. This technique can be used in the treatment of patients with DJD/ DDD,
unilateral facet joint dysfunction, chronic nerve root irritation related to segmental dysfunction.
It may be indicated to begin with gentle mobilizations and implement this technique when more
vigorous manipulation is warranted. Acute disc involvement, spondylolysis, or spondylolisthesis
are considered precautions for this technique.
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Thoracic Spine: Supine Flexion/ Opening Manipulation (T3-T10)—Technique
described for T4-5
**stand opposite painful sign
Patient Position: The patient is supine with arms across chest. The arm closest to the therapist
should be crossed underneath (right above the left).
Therapist Position: The examiner stands on the left side of the patient’s body. The examiner
will use the cranial hand (right) to roll the patient slightly towards the left side of the table. The
examiner will use the index finger of the caudal hand (left) to palpate the specified segment (T45). Once the segment is located, the examiner will flex the DIP and PIP joints of the 3rd, 4th and
5th digits. The examiner places the thenar eminence of their caudal hand (left hand) on the
transverse process of the inferior vertebra. The therapist places the dorsal aspect of the middle
phalanx of the 3rd digit on the transverse process of the cranial member of the segment. Gently
roll the patient back into the supine position onto the caudal hand. The examiner places their
cranial hand/ forearm (right) to support the patient’s upper body, head, and neck.
Method: Localize motion through the patient’s arms by flexing, left side-bending and left
rotation from above down to the dysfunctional segment. Coordinate the manipulation with the
patient’s breathing, progressively oscillating into slightly more rotation each time. Once the
barrier is engaged, apply a high velocity, low
amplitude thrust with your body in an anterior to
posterior direction.
Alternative Method:
 The examiner can use a small towel roll to help
maintain flexion of the 3rd, 4th and 5th DIP and
PIP joints during the set-up/ thrust.
 Alternative hand placement for the cranial hand
(right) is to place the examiner’s forearm over
the patient’s elbows.
Indications: Indication for use of this technique is
decreased rotation/ side-bending of a specific thoracic segment (T3-T4 through T10-T11). The
thrust introduces a flexion moment to open the right zygapophyseal joint.
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Thoracic Spine: Prone Thoracic Side bending Manipulation (T3-T10)
described for closing left facet.
Patient Position: Patient is lying in the prone position with lower legs supported with a pillow
and head face down if possible.
Therapist Position: The examiner places the
hypothenar eminence of the cranial hand
(right) over the right transverse process of the
superior vertebra; rotate hand into a caudal
direction to obtain a “skin lock” and introduce
a caudal and anteriorly directed force with the
right hand. The examiner places the
hypothenar eminence of caudal (left) hand on
the left transverse process of the same vertebra;
rotate hand into a cranial direction to obtain a
“skin lock” and engage the restrictive barrier by introducing a cranial and anteriorly directed
force.
Method: Apply a high velocity, low amplitude posterior to anterior thrust into the restrictive
barrier. Consider combining this technique with breathing.
Alternative Method: Can place a pillow under the patient’s chest.
Indications: To manipulate a specific thoracic segment (T3-T4 to T10-T11) into side-bending.
Thoracic Spine traction: Sitting opening distraction / manipulation; this
technique can be applied to T3 – T9 segments
Patient position: seated with arms crossed over the chest maintaining the lumbar/TS in neutral
position.
Therapist position: the therapist stands behind the
patient. The transverse processes of the lower
segment of the desired level are blocked by a towel
roll. The towel is placed over the transverse process
and blocked by the sternum of the therapist (the
therapist must not place any pressure over his/her
xiphoid process). The therapist stands in squat
position, wraps both arms around the patient and
grabs the patient’s inferior elbow.
Procedure (distraction): the patient is asked to
relax. The therapist pulls up on the patient’s elbow
(by straightening his/her knees) as though attempting
to drag the patient up and off the bed. This position is maintained for few seconds. Patient’s
symptoms should be monitored during this technique.
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Procedure (manipulation): the patient is asked to relax and slightly extend the neck which is
supported by the therapist’s head/shoulder. The therapist applies compression with his/her arms
and pulls up on the patient’s elbow by straightening his/her knees. The patient is asked to inhale
and exhale. Upon the completion of exhalation, the therapist applies a high velocity, low
amplitude thrust diagonally in a caudal to cranial direction.
Indication: a treatment technique used to apply vertical distraction and/or gapping manipulation
References—lumbo-pelvic manipulation:
Assendelft, W. J., Morton, S. C., Yu, E. I., Suttorp, M. J., & Shekelle, P. G. (2003). Spinal
manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other
therapies. Ann Intern Med, 138(11), 871-881.
Bronfort, G., Haas, M., Evans, R. L., & Bouter, L. M. (2004). Efficacy of spinal manipulation
and mobilization for low back pain and neck pain: A systematic review and best evidence
synthesis. Spine J, 4(3), 335-356.
Childs, J. D., Fritz, J. M., Flynn, T. W., Irrgang, J. J., Johnson, K. K., Majkowski, G. R., et al.
(2004). A clinical prediction rule to identify patients with low back pain most likely to
benefit from spinal manipulation: A validation study. Ann Intern Med, 141(12), 920-928.
Flynn, T., Fritz, J., Whitman, J., Wainner, R., Magel, J., Rendeiro, D., et al. (2002). A clinical
prediction rule for classifying patients with low back pain who demonstrate short-term
improvement with spinal manipulation. Spine, 27(24), 2835-2843.
Flynn, T. W., Fritz, J. M., Wainner, R. S., & Whitman, J. M. (2003). The audible pop is not
necessary for successful spinal high-velocity thrust manipulation in individuals with low
back pain. Arch Phys Med Rehabil, 84(7), 1057-1060.
Fritz, J. M., Delitto, A., & Erhard, R. E. (2003). Comparison of classification-based physical
therapy with therapy based on clinical practice guidelines for patients with acute low
back pain: A randomized clinical trial. Spine, 28(13), 1363-1371; discussion 1372.
Fritz, J. M., Whitman, J. M., Flynn, T. W., Wainner, R. S., & Childs, J. D. (2004). Factors
related to the inability of individuals with low back pain to improve with a spinal
manipulation. Phys Ther, 84(2), 173-190.
Philadelphia panel evidence-based clinical practice guidelines on selected rehabilitation
interventions for low back pain. (2001). Phys Ther, 81(10), 1641-1674.
Scientific approach to the assessment and management of activity-related spinal disorders. A
monograph for clinicians. Report of the quebec task force on spinal disorders. (1987).
Spine, 12(7 Suppl), S1-59.
Senstad, O., Leboeuf-Yde, C., & Borchgrevink, C. (1997). Frequency and characteristics of side
effects of spinal manipulative therapy. Spine, 22(4), 435-440; discussion 440-431.
Shekelle, P. G., Adams, A. H., Chassin, M. R., Hurwitz, E. L., & Brook, R. H. (1992). Spinal
manipulation for low-back pain. Ann Intern Med, 117(7), 590-598.
van Tulder, M. W., Tuut, M., Pennick, V., Bombardier, C., & Assendelft, W. J. (2004). Quality
of primary care guidelines for acute low back pain. Spine, 29(17), E357-362.
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http://www.ptjournal.org/March2002/Mar02_Letters.cfm
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3. Agency for Health Care Policy and Research; Low Back Pain Guideline; United States, 1994
www.ahcpr.gov
Bigos S, Bowyer O, Braen G. Acute low back problems in adults. Clinical Practice
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www.rcgp.org.uk
Hutchinson A, Waddell G, Feder G, et al. Clinical Guidelines for the Management
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9. New Zealand Guidelines (www.nzgg.org.nz/library)
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Diagnosis, and Treatment. Philadelphia: Lippincott Williams & Wilkins; 2000. Back and
Neck Pain. 2000. Nachemson, Jonnson et. al.
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Bloomington, MN; 2001. http://www.gacguidelines.ca/article.pl?sid=02/07/03/2022215
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15. Arthritis Advisory Panel- FDA, Feb 08, 2001
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