A patient who has given consent and an osteopathic physician who has had formal training in OMT during medical school or post-graduate training is necessary for this procedure.

The physician must obtain informed consent from the patient before proceeding with intervention. A clear discussion with the patient of the risks, benefits, and alternative treatment options should be documented prior to starting treatment. Additionally, a complete osteopathic structural exam of the thoracic spine should take place in advance of beginning the procedure.

Two main thoracic HVLA techniques are performable on a patient with a thoracic somatic dysfunction. There is the seated method and the supine method (also called Kirksville Crunch). Descriptions of both techniques will follow, but it is ultimately provider preference and overall comfort level, which will ultimately dictate the choice of the technique [8].

After diagnosing somatic dysfunction, the physician will position the dysfunctional segment in a way such that all restrictive barriers are engaged. This process occurs by reversing all three planes of motion of the dysfunctional segment. For example, if the thoracic segment T7 has demonstrated the somatic dysfunction ERSr (extended, rotated, and side-bent right), then the segment would be placed in flexion, rotated, and side-bent to the left until motion is felt; this is called the restrictive barrier. A short quick thrust is then applied, and the patient then undergoes reassessment.

There are two different variations to performing thoracic HVLA: seated and supine. The steps for performing these various maneuvers appear below.

Seated Position Technique:

1. The clinician stands behind the patient with their hands clasped behind their head.
2. The clinician places their epigastric area behind the posterior transverse process of the dysfunctional segment.
3. The clinician reaches under the patient's arms and holds the forearms. The patient is then instructed to take a deep breath, and during exhalation, the clinician pulls the elbows together and extends the trunk.
4. The clinician should then push their abdomen into the posterior transverse process.
5. At maximal exhalation, a short quick thrust is applied by the clinician's abdomen into the patient's posterior transverse process. The patient should then be rechecked after the manipulation.

Supine Position Technique (Kirksville Crunch):

1. The clinician stands opposite the side of the thoracic rotation.
2. The patient crosses his/her arms with elbows together. From the clinician's perspective, the patient's arm opposite where they are standing should be on top; this is referred to as opposite over adjacent. From the patient's perspective, the arm on the side of the thoracic rotation should be on top. For example, if the patient has a somatic dysfunction at T5 that is flexed, rotated, and side-bent to the right, the patient's right arm would be on top of the left arm.
3. The clinician reaches their caudad arm across the patient and places their thenar eminence behind the posterior transverse process.
4. The clinician leans their epigastric area into the patient's crossed elbows. The clinician's other hand then lifts the patient's head and trunk until pressure from leaning on the elbows is felt by the hand on the posterior transverse process.
5. The patient is asked to take a deep breath as the clinician leans into the elbows during exhalation.
6. At maximum exhalation, the clinician applies a short quick thrust from their abdomen onto the patient's elbows to mobilize the joint. The patient should then be rechecked after the manipulation.

Aside from some muscular soreness or possible symptom exacerbation, there are relatively few side effects of HVLA in the thoracic region. There are more serious side effects if performing HVLA in the cervical or lumbar region, but these are outside of the scope of this article.[9]

Back pain is a very common problem seen in many primary care offices and ERs. Usually, back pain is musculoskeletal, caused by turning, twisting, pulling, or lifting something incorrectly. Many times these patients are amenable to some hands-on treatment as opposed to taking medication. Osteopathic physicians have received training in these special hands-on procedures, many of which can help with back pain. These include counter strain, kneading, and stretching techniques, muscle energy, and HVLA.

Many factors account for which procedure the practitioner chooses, but it is most often based on provider comfort and preference, as well as if the patient is willing and able to receive treatment. Thoracic HVLA is an important method of OMT in the osteopathic physician's toolkit as it can serve to treat musculoskeletal ailments while concurrently allowing for a reduction in the number of NSAIDs or other pain medication that a patient may be taking.[1][10]

Osteopathic manipulative treatment is a form of hands-on therapy that, in the appropriate setting, can help to enhance patient-centered care and improve outcomes. HVLA is a specific treatment modality that is more suited for the younger population. Some of the contraindications mentioned previously occur more in the elderly population, thus not allowing them to receive HVLA treatment. In these patients, it is crucial to weigh the risks and benefits of HVLA treatment before attempting this type of maneuver. Other, less forceful, techniques such as counter strain, kneading and stretching, muscle energy, or articulatory techniques should merit consideration before HVLA.[11] 

Regardless of treatment modality, osteopathic manipulative treatment serves as a manner in which to reduce the number of pain medications a patient is taking.[1][10] Overall, this can help improve patient outcomes by effectively reducing the number of pills a patient takes per day. Ideally, however, this helps patients stop an NSAID or an opioid medication completely.