(844) GO-CHIRO info@chiroup.com

Approximately 34-43% of the population suffers from neck pain in any given year. (1) This complaint comprises almost half of the office visits seen in primary practice.  There is little question that manual therapy and cervical spine manipulation alleviate neck pain symptoms.  However, there is also a growing body of literature that suggests thoracic spine manipulation may have a positive additive effect.  How would an evidence-based chiropractor predict if thoracic spine manipulation will help a patient suffering from neck symptoms? Here’s one test that applies what we already know about coupled spinal motion.


Use this quick maneuver to help predict if thoracic manipulation will help neck pain patients.

Applying research today

Thoracic spine manipulation has made its way into clinical guidelines for neck pain (1). Now, the Cervico-Thoracic Differentiation Test (CTDT) helps identify which patients will respond best to thoracic manipulation. Here’s the CTDT as described by Swanson et al. (5):

Patients begin in a neutral* seated position and are asked to move through full cervical ROM in each direction (flexion, extension, right rotation, left rotation) to identify their most painful movement (comparable sign).

The investigator noted the most painful motion and asked the participant to record their pain on the VAS (3). If rotation was the painful movement, after bringing their head back to midline, the participant was asked to turn their body so that their chest was facing the opposite direction of cervical rotation (counter rotation of thoracic spine). The examiner maintained this body position by stabilizing the participants’ trunk as the participant again turned their neck into the provocative direction until the limit of their ROM was reached, or pain was felt. This position of cervical rotation was again noted by the investigator.

The participant was then asked: “Are your symptoms ‘better,’ ‘worse,’ or ‘the same’”? A positive test was indicated by a response of ‘better’, as well as ‘the same’ if significant improvement in cervical rotation was obtained.

A negative test was indicated by a response of ‘worse’, as well as ‘the same’ when significant improvement in cervical rotation was not obtained. Significant improvement in cervical motion was operationally defined as 10 degrees (4).

If the most painful direction was flexion, the participant was asked to “arch” backwards into extension of the thoracic spine. This position was maintained by the investigator, and the participant then repeated the cervical flexion. If the most painful direction was extension, the participant was asked to “slump” forward into flexion of the thoracic spine. This position was maintained by the investigator, and the participant then repeated the cervical extension — the same follow-up question of “better, worse.”(5)

* All participants were cued to the Frankfurt-horizontal position, defined as the position where a line passing through the inferior margin of the left orbit and the upper margin of each external auditory meatus is most nearly parallel to the floor. This posture was selected for its high levels of reliability and reproducibility between examiners, while not significantly altering the mechanical axis of the spine relative to the self-balanced posture (5,6).

Are we merely exploiting coupled motion?

The upper thoracic spine is designed to move and share load during active cervical ROM.  Thoracic spine positioning can prevent anticipated thoracic spine coupled motion. By isolating cervical ROM, the examiner can identify specific spinal dysfunction as related to the patient’s pain. If painful cervical ROM improves with thoracic positioning, it can be inferred that the thoracic spine is the site of dysfunction – and will improve with manipulation.

This test may accomplish two essential aspects of care and recovery.

  1. Selecting the right care for the right patient at the right time. Consider adding thoracic spine manipulation when indicated, even if the diagnosis seems isolated to the cervical region.
  2. The patient should be made aware of the importance of the posture on their neck pain. They will “feel” first hand the differences in pain and ROM in the neck simply by changing their thoracic posture.  Postural education must be incorporated into your patient education and also integrated into your rehabilitation.  Be sure to educate your patient on proper neutral positioning of their head before initiation of any rehab program.

Now tell us what you think!

ChiroUp provides the resources you need to put this research into action TODAY with customizable patient treatment reports. If you’ve been on the fence about ChiroUp or have been putting off getting started, send me an email at Brandon@ChiroUp.com and let me know WHY. It’s our priority to make sure that ChiroUp contains the information that you need so that we can continue to make chiropractic the undeniable best choice for patients & payors alike. I’ll look forward to reading your thoughts!

ChiroUp Empowers

  1. Blanpied, P.R., Gross, A.R., Elliott, J.M., et al., 2017. Neck pain: revision 2017: clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the American physical therapy association. J. Orthop. Sport Phys. 47 (7), A1–A83.
  2. Evjenth, O., Gloeck, C., 2002. Symptom Localization in the Spine and the Extremity Joints.
  3. Cook, C., Learman, K., Showalter, C., et al., 2015. The relationship between chief complaint and comparable sign in patients with spinal pain: an exploratory study. Man. Ther. 20, 451–455.
  4. Krauss, J., Creighton, D., Ely, J.D., et al., 2008 2008/04/01. The immediate effects of upper thoracic translatoric spinal manipulation on cervical pain and range of motion: a randomized clinical trial. J. Man. Manip. Ther. 16 (2), 93–99.
  5. Brian T. Swanson, Michael B. Gans, Ashten Cullenberg, E. Kelton Cullenbergb Ryan Cyr, Larry Risigo. Reliability and diagnostic accuracy of cervicothoracic differentiation testing and regional unloading for identifying improvement after thoracic manipulation in individuals with neck pain. Musculoskeletal Science and Practice 39 (2019) 80–90
  6. Lundstrom, A., Lundstrom, F., Lebret, L.M., et al., 1995 Apr. Natural head position and natural head orientation: basic considerations in cephalometric analysis and research. Eur. J. Orthod. 17 (2), 111–120.
  7. Armijo-Olivo, S., Jara, X., Castillo, N., et al., 2006 Mar. A comparison of the head and cervical posture between the self-balanced position and the Frankfurt method. J. Oral Rehabil. 33 (3), 194–201.


About the Author

Dr. Brandon Steele

Dr. Brandon Steele


Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.

Rate the Blog

5 / 5. Vote count: 1

No votes so far! Be the first to rate this post.

We are sorry that this post was not useful for you!

Let us improve this post!

Tell us how we can improve this post?