Effects of Thoracic Spine Manipulation With and Without Costovertebral Joint Manipulation in Patients Mid-back Pain

Participants aged 18-45 years with non-specific mid-back pain will be randomly assigned to receive either thoracic spine manipulation alone or in combination with costovertebral joint manipulation. Primary outcomes will include pain intensity measured by the Numeric Pain Rating Scale (NPRS), while secondary outcomes will involve thoracic spine range of motion measured by Bubble Inclinometer, and functional disability assessed by the Oswestry Disability Index (ODI). Statistical analysis will be performed using the statistical software IBM SPSS Statistics SPSS 25.0 for calculations. This study aims to provide evidence-based insights into the relative benefits of these manual therapy techniques, potentially informing clinical practice and enhancing treatment outcomes for patients with non-specific mid-back pain.

• thoracic facet manipulations (Other): Group A will receive thoracic facet manipulations of the restricted segments between T3 to T9, in the prone position and cephalic direction. The duration of the intervention will be followed by 4 weeks 3 sessions each week and pre- and post-intervention observations will be recorded. Bilateral hypothenar Cross bilateral hypothenar manipulation.
• thoracic facet and costovertebral manipulations (Other): Group B will receive thoracic facet and costovertebral manipulations of the restricted segments between T3 to T9 and ribs 3 to 9 (costovertebral joints), in the prone position. The duration of the intervention will be followed by 4 weeks 3 sessions each week and pre and post-intervention observations will be recorded. Hypothenar Costal Manipulative technique Ilial Hypothenar costal manipulation between T3-T9
• Standard Physiotherapy (Other): Hot pack given for 10 minutes. Cervical spine given isometric exercises with 10 repetitions and 6 seconds hold. These flexibility exercises will be targeted for * Rhomboid and middle trapezius stretching (2-3 times daily; 3 sets for 30 seconds)) * Pectoralis muscle stretch in a corner (2-3 times daily; 3 sets for 30 seconds) * Prone on the elbow with upper thoracic extension exercise (2-3 times daily; 3 sets for 30 seconds) . The postural exercises will be the following * Postural strengthening/ stabilization with back to a wall. The participant will press their arms into the wall while retracting scapulae. * Trunk rotation stretching in the sitting position

Primary outcomes

• Numerical Pain Rating Scale (NPRS) [upto 4 weeks]: The Numeric Pain Rating Scale (NPRS) is perhaps the most frequently applied scale used to quantify pain intensity in the clinical setting. It is an 11-point numeric scale, ranging from 0 indicating no pain to 10 indicating worst pain imaginable.
• Oswestry Disability Index [upto 4 weeks]: The Oswestry Disability Index (ODI) is an index derived from the Oswestry Low Back Pain Questionnaire used by clinicians and researchers to quantify disability for low back pain and quality of life. Oswestry Disability Index. Purpose. used to qualify low back pain. Patients manage daily activities well, typically requiring only guidance on posture and exercise.21%-40% (Moderate Disability): Pain affects sitting, standing, lifting, and work, though personal care remains manageable.41%-60% (Severe Disability): Daily activities are heavily disrupted by persistent pain, prompting detailed clinical evaluation.61%-80% (Crippling/Severe Restriction): Back pain broadly limits daily and social functioning, requiring active medical intervention.81%-100%: Individuals are either bed-bound or experiencing extreme symptom exaggeration.
• Bubble Inclinometer [upto 4 weeks]: A bubble inclinometer is a simple, handheld device used to measure the angle of inclination or tilt of a surface. In the context of thoracic spine assessments, it is particularly useful for quantifying the range of motion and curvature of the spine.

Sex: All, ages: 18 Years to 45 Years

Inclusion Criteria:

* Participants will be between 18 - 45 years of age
* For this study, mid-back pain included all the following signs and symptoms:
* Sharp, shooting, or aching mid-back pain
* Mid back pain experienced during deep inspiration, sneezing, and/or coughing

Exclusion Criteria:

* Individuals who did not sign or understand the letter of informed consent
* Individuals with contraindications to manipulation in the thoracic spine (15)
* Weakened bone due to: Osteoporosis, Infection and Neoplasm

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• Samrood Akram, PhD*, Principal investigator, Riphah International University