Thoracic manipulation versus mobilization in patients with mechanical neck pain: a systematic review

Spinal displacement during thoracic manipulative therapy in mechanical neck pain patients: an observational study

INTRODUCTION

Thoracic manipulative therapy (TMT) is recommended for treating patients with mechanical neck pain (MNP). However, there are multiple proposed recommendations for the mechanism for neck pain reduction.

OBJECTIVE

To investigate displacement of the cervicothoracic spine during the application of TMT in patients with MNP.

METHODS

Thirty-five male patients with MNP were recruited. Displacements of C3, C5, C7, T2, T4 and T6 were measured using a motion capture system while a therapist applied a grade III central posteroanterior TMT (cpa-TMT) to T6.

RESULTS

Mean (SD) displacement ranged from 2.2 (0.62) to 5.5 (1.1) mm. A significant decrease in neck pain intensity at rest was found after the application of the cpa-TMT (mean difference 17 mm, p < 0.001). A downward trend in spinal displacement was noted, with the largest and smallest displacement occurring at T6 and C3, respectively. Correlations between the displacement of T6 and adjacent spinal levels were moderate to high (Pearson's r range 0.70-0.90, p < 0.001). It was showed that cpa-TMT applied to T6 produced the PA displacement toward the upper cervical spine.

CONCLUSION

TMT produces spinal segmental displacements toward the upper cervical spine in MNP patients. These segmental displacements would activate the alleviation effect at both the spinal and supraspinal levels resulting in neck pain reduction. These findings would provide supporting evidence for the use of TMT in neck pain reduction.

Effectiveness and safety of thoracic manipulation in the treatment of neck pain: An updated systematic review and meta-analysis

BACKGROUND

The purpose of this meta-analysis was to evaluate the effectiveness and safety of thoracic manipulation (TM) in patients with neck pain (NP).

OBJECTIVE

The purpose of this meta-analysis was to evaluate the effectiveness and safety of thoracic manipulation (TM) in patients with neck pain (NP).

METHODS

Seven electronic databases were searched from their inception through October 2023 by two authors. The methodological quality assessments were performed with the Physiotherapy Evidence Database (PEDro) scale. Pain, cervical range of motion (ROM), disability, and quality of life (QOL) were estimated for TM treatment in patients with NP.

RESULTS

Eighteen randomized controlled trials (RCTs) with 914 patients were included with a PEDro score of 6.923 ± 3.120. Pooled effect sizes of pain (SMD =-0.481, 95% CI -0.653 to -0.309, P= 0.000), disability (SMD =-1.435, 95% CI -2.480 to -0.390, P= 0.007), QOL-physical component score (PCS) (SMD = 0.658, 95% CI 0.290 to 1.025, P= 0.000), ROM of flexion (SMD = 0.921, 95% CI 0.287 to 1.555, P= 0.000), ROM of extension (SMD = 0.572, 95% CI 0.321 to 0.822, P= 0.000), ROM of left lateral flexion (SMD = 0.593, 95% CI 0.075 to 1.112, P= 0.025) and ROM of left rotation (SMD = 0.230, 95% CI 0.010 to 0.450, P= 0.04) were favored by the TM group.

CONCLUSIONS

TM provides short-term effect on relieving neck pain, increasing cervical ROM, and disability in patients with NP without serious side effects. Continuous therapy and distraction therapy are recommended as optimal choice on reducing pain and improving cervical ROM, especially in patients with chronic NP (> 3 months). The TM-induced improvements in the QOL of patients with NP should be verified by more further high-quality RCTs.

Spinal manipulation and adverse event reporting in the pregnant patient limits estimation of relative risk: a narrative review

OBJECTIVE

To describe variability in spinal manipulation technique details and adverse event (AE) documentation of spinal manipulation during pregnancy.

METHODS

Five databases were searched for peer-reviewed investigations of spinal manipulation during pregnancy. Criteria for inclusion was as follows: high velocity, low amplitude thrust manipulation performed, subjects pregnant during manipulation, and English language. Studies were excluded when participants were not currently pregnant, and when the manipulation performed was not high-velocity, low-amplitude thrust. Data extraction included study design, number of participants, gestational age, spinal region, number of manipulations, manipulation technique details, profession of manipulator, AE reporting (Yes vs. No), type, and number of AE.

RESULTS

Out of 18 studies included in the review, only three provide details of the spinal manipulation technique. The reported variables include patient position, practitioner position, and direction of thrust. Fourteen studies documented AE; however, only seven provide AE details.

DISCUSSION

Reporting of spinal manipulation techniques and AE during pregnancy were inconsistent. Replication of methods in future investigations is limited without more detailed documentation of manipulation techniques performed. Furthermore, determining the relative risk and safety of spinal manipulation during pregnancy is not possible without more detailed reporting of AE. Due to these inconsistencies, a checklist is proposed for standardized reporting of spinal manipulation techniques and AE. With more consistent reporting of these parameters, results of future investigations may allow for more definitive and generalizable safety recommendations on spinal manipulation during pregnancy.

Effectiveness of Thoracic Spine Manipulation on the Management of Neck Pain: A Systematic Review and Meta-Analysis of Randomized Control Trials

There are contradicting findings regarding the effect of thoracic spine manipulation in decreasing pain and disability in patients with chronic mechanical neck pain. Hence, the purpose of this review was to evaluate the current evidence on the effectiveness of thoracic spine thrust manipulation in decreasing pain intensity, and neck disability among subjects with chronic mechanical neck pain. We made a comprehensive search of literature published between 2010 and 2020 from the electronic databases of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, and Physiotherapy Evidence Database (PEDro). We adhered to Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA). The methodological quality was assessed by the PEDro scale, and the level of evidence rated by Grading of Recommendations Assessment, Development, and Evaluation (GRADE) software. Finally, a meta-analysis was done using RevMan 5.3 with a random-effects model to calculate the mean difference (MD) and 95% confidence intervals for pain and disability. Eight eligible randomized controlled trials were identified with a total of 457 participants. The quality assessment of the included studies was found to be fair in quality (mean PEDro score of 6.63/10). The overall GRADE of the review showed low to moderate level of evidence. Effect size estimates of the studies showed modest differences in pain reduction, as it revealed a significant effect in Visual Analog Scale ((VAS) 0-100mm) (MD -12.46; 95% CI: -17.29, -7.64), and Pain Numeric Rating Scale ((PNRS) 0-10 pts) (MD -0.8; 95% CI: -1.60, -0.10). The thoracic manipulation also resulted in a significant effect in decreasing neck disability, in which the mean difference in Neck disability index (NDI) showed (MD -6.46; 95% CI: -10.43 -2.50). This review suggested that thoracic spine manipulation was effective in reducing pain and neck disability in all adults with chronic mechanical neck pain compared to other interventions.

Evidence (-based medicine) in manual medicine/manual therapy—a summary review

Objective

The aim of this summary review is to analyse the current state of evidence in manual medicine or manual therapy.

Methods

The literature search focussed on systematic reviews listed in PubMed referring to manual medicine treatment until the beginning of 2022, limited to publications in English or German. The search concentrates on (1) manipulation, (2) mobilization, (3) functional/musculoskeletal and (4) fascia. The CASP Checklist for Systematic Reviews was used to present the included reviews in a clear way.

Results

A total of 67 publications were included and herewith five categories: low back pain, neck pain, extremities, temporomandibular disorders and additional effects. The results were grouped in accordance with study questions.

Conclusion

Based on the current systematic reviews, a general evidence-based medicine level III is available, with individual studies reaching level II or Ib. This allows manual medicine treatment or manual therapy to be used in a valid manner.

Lessons From Special Forces Operators for Elite Team Sports Training: How to Make the Whole Greater Than the Sum of the Parts

This methodology paper describes the design of a holistic and multidisciplinary human performance program within the Belgian Special Forces Group, the Tier 1 Special Operations unit of the Belgian Defense. Performance management approaches in the military draw heavily on sports science. The key component of the program design described here is its integrative nature, which team sports training might benefit from. The basic rationale behind the program was to bridge several gaps: the gap between physical and mental training; the gap between the curative or preventive medical approach and the performance enhancement approach; and the gap between individual and team training. To achieve this goal, the methodology of Intervention Mapping was applied, and a multidisciplinary team of training and care professionals was constituted with operational stakeholders. This was the first step in the program design. The second step took a year, and consisted of formal and informal consultations, participant observations and task analyses. These two first stages and their conclusions are described in the Method section. The Results section covers the next two stages (three and four) of the process, which aimed at defining the content of the program; and to test a pilot project implementation. The third stage encompassed the choice of the most relevant assessment and intervention tools for the target population, within each area of expertise. This is described extensively, to allow for replication. The fourth and last stage was to "test drive" the real-life integration and implementation of the whole program at the scale of a single team (8 individuals). For obvious confidentiality reasons, the content data will not be reported extensively here. Implications for wider-scale implementation and tie-back to sports team training are presented.

Cervical disc degeneration: important considerations for the manual therapist

Cervical disc degeneration (CDD) is a progressive, age-related occurrence that is frequently associated with neck pain and radiculopathy. Consistent with the majority of published clinical practice guidelines (CPG) for neck pain, the 2017 American Physical Therapy Association Neck Pain CPG recommends cervical manipulation as an intervention to address acute, subacute, and chronic symptoms in the 'Neck Pain With Mobility Deficits' category as well for individuals with 'Chronic Neck Pain With Radiating Pain'. While CPGs are evidence-informed statements intended to help optimize care while considering the relative risks and benefits, these guidelines generally do not discuss the mechanical consequences of underlying cervical pathology nor do they recommend specific manipulation techniques, with selection left to the practitioner's discretion. From a biomechanical perspective, disc degeneration represents the loss of structural integrity/failure of the intervertebral disc. The sequelae of CDD include posterior neck pain, segmental hypermobility/instability, radicular symptoms, myelopathic disturbance, and potential vascular compromise. In this narrative review, we consider the mechanical, neurological, and vascular consequences of CDD, including information on the anatomy of the cervical disc and the mechanics of discogenic instability, the anatomic and mechanical basis of radiculitis, radiculopathy, changes to the intervertebral foramen, the importance of Modic changes, and the effect of spondylotic hypertrophy on the central spinal canal, spinal cord, and vertebral artery. The pathoanatomical and biomechanical consequences of CDD are discussed, along with suggestions which may enhance patient safety.

Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain

Spine pain is a highly prevalent condition affecting over 11% of the world's population. It is the single leading cause of activity limitation and ranks fourth in years lost to disability globally, representing a significant personal, social, and economic burden. For the vast majority of patients with back and neck pain, a specific pathology cannot be identified as the cause for their pain, which is then labeled as non-specific. In a growing proportion of these cases, pain persists beyond 3 months and is referred to as chronic primary back or neck pain. To decrease the global burden of spine pain, current data suggest that a conservative approach may be preferable. One of the conservative management options available is spinal manipulative therapy (SMT), the main intervention used by chiropractors and other manual therapists. The aim of this narrative review is to highlight the most relevant and up-to-date evidence on the effectiveness (as it compares to other interventions in more pragmatic settings) and efficacy (as it compares to inactive controls under highly controlled conditions) of SMT for the management of neck pain and low back pain. Additionally, a perspective on the current recommendations on SMT for spine pain and the needs for future research will be provided. In summary, SMT may be as effective as other recommended therapies for the management of non-specific and chronic primary spine pain, including standard medical care or physical therapy. Currently, SMT is recommended in combination with exercise for neck pain as part of a multimodal approach. It may also be recommended as a frontline intervention for low back pain. Despite some remaining discrepancies, current clinical practice guidelines almost universally recommend the use of SMT for spine pain. Due to the low quality of evidence, the efficacy of SMT compared with a placebo or no treatment remains uncertain. Therefore, future research is needed to clarify the specific effects of SMT to further validate this intervention. In addition, factors that predict these effects remain to be determined to target patients who are more likely to obtain positive outcomes from SMT.

Immediate effects of thoracic manipulation on cervical joint position sense in individuals with mechanical neck pain: A randomized controlled trial

BACKGROUND

Performing thoracic manipulations for neck pain can result in immediate improvements in neck function.

OBJECTIVE

The aim of this study was to investigate the immediate effects of thoracic manipulation on cervical joint position sense and cervical range of motion in individuals with chronic mechanical neck pain.

METHODS

Eighty male volunteers between 18-25 years and having chronic or recurrent neck or shoulder pain of at least 3 months duration with or without arm pain were randomized into two groups: Thoracic Manipulation Group (TMG:50) and Control Group (CG:30), with a pretest-posttest experimental design. The TMG was treated with thoracic extension manipulation while the CG received no intervention. Cervical joint position error and cervical range of motion of the individuals were assessed at baseline and 5 minutes later.

RESULTS

There was no difference in demographic variables such as age (p= 0.764), Body Mass Index (p= 0.917) and Neck Pain Disability Scale (NPDS) scores (p= 0.436) at baseline outcomes between TMG and CGs. Joint position error outcomes between the two groups following intervention were similar in all directions at 30 and 50 degrees. Differences in range of motion following intervention in neck flexion (p< 0.001) and right rotation (p= 0.004) were higher in TMG compared to CG.

CONCLUSIONS

A single session of thoracic manipulation seems to be inefficient on joint position sense in individuals with mild mechanical neck pain. However, thoracic manipulation might be an effective option to increase flexion and rotation of the cervical region as an adjunctive to treatment.

Effects of sling-based manual therapy on cervicothoracic junction in patients with neck pain and forward head posture: A randomized clinical trial

OBJECTIVE

The purpose of this study was to investigate the effect of 4 weeks of sling-based manual therapy on the cervicothoracic junction (CTJ) area in patients with neck pain and forward head posture.

DESIGN

Single-blind randomized controlled trial.

SETTING

Outpatient, Chonbuk National University hospital, Republic of Korea.

SUBJECTS

A total of 22 participants with neck pain (Numeric Pain Rating Scale >3) and forward head posture (craniovertebral angle <51) were randomly assigned to a CTJ group or a control group (n = 11 each).

INTERVENTION

In the control group, joint mobilization and motor control training was applied for the upper cervical spine (C0-C1). The CTJ group applied the same intervention to the upper cervical spine and cervicothoracic junction (C7-T3).

MAIN MEASURES

Numeric pain rating scale and neck disability index, craniovertebral angle, active range of motion, and muscle activity were evaluated before and after 4 weeks of intervention.

RESULT

The CTJ group participants showed significant improvement in the craniovertebral angle and cervical extension range after the intervention than the control group (P = 0.025, P = 0.001). While both groups presented significant differences after the intervention regarding Numeric pain rating scale, neck disability index, and muscle activity (sternocleidomastoid and anterior scalene muscle), there were no statistically significant differences between the groups (P > 0.05).

CONCLUSION

Our results suggest that the CTJ and the upper cervical region in patients with neck pain and forward head posture represent an area which if approached by manual therapy, improves cervical mobility and posture.

Immediate effects of cervicothoracic junction mobilization versus thoracic manipulation on the range of motion and pain in mechanical neck pain with cervicothoracic junction dysfunction: a pilot randomized controlled trial

Background

Cervicothoracic (CT) junction hypomobility has been proposed as a contributing factor for neck pain. However, there are limited studies that compared the effect of CT junction mobilization against an effective intervention in neck pain. Thoracic spine manipulation is a nonspecific intervention for neck pain where remote spinal segments are treated based on the concept of regional interdependence. The effectiveness of segment-specific spinal mobilization in the cervical spine has been researched in the last few years, and no definite conclusions could be made from the previous studies. The above reasons warrant the investigation of the effects of a specific CT junction mobilization against a nonspecific thoracic manipulation intervention in neck pain. The present study aims to compare the immediate effects of C7-T1 Maitland mobilization with thoracic manipulation in individuals with mechanical neck pain presenting with CT junction dysfunction specifically.

Methods

A randomized clinical trial is conducted where participants with complaints of mechanical neck pain and CT junction dysfunction randomly assigned to either C7-T1 level Maitland mobilization group or mid-thoracic (T3-T6) manipulation group (active control group). In both the groups, the post graduate student (SJ) pursuing Master’s in orthopedic physiotherapy delivered the intervention. The outcomes of cervical flexion, extension, side flexion & rotation range of motion (ROM) were measured before & after the intervention with a cervical range of motion (CROM) device. Self-reported pain intensity was measured with the numerical pain rating scale (NPRS). The post-intervention between-group comparison was performed using a one-way ANCOVA test.

Results

Forty-two participants with mean age CT junction group: 35.14 ± 10.13 and Thoracic manipulation group: 38.47 ± 11.47 were recruited for the study. No significant differences in the post-intervention baseline adjusted outcomes of cervical ROM & self-reported pain intensity were identified between the groups after the treatment (p = 0.08, 0.95, 0.01, 0.39, 0.29, 0.27for flexion, extension, bilateral lateral flexion & rotations respectively) & neck pain intensity (p = 0.68). However, within-group, pre, and post comparison showed significant improvements in cervical ROM and pain in both groups.

Conclusion

This preliminary study identified that CT junction mobilization is not superior to thoracic manipulation on the outcomes of cervical ROM and neck pain when level-specific CT junction mobilization was compared with remote mid-thoracic manipulation in individuals with mechanical neck pain and CT junction dysfunction.

Trial registration

CTRI: 2018/04/013088, Registered 6 April 2018, http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=24418

Effects of joint mobilisation on clinical manifestations of sympathetic nervous system activity: a systematic review and meta-analysis

BACKGROUND

A potential mechanism of action of manual therapy is the activation of a sympathetic-excitatory response.

OBJECTIVE

To evaluate the effects of joint mobilisation on changes in clinical manifestations of sympathetic nervous system activity.

DATA SOURCES

MEDLINE, EMBASE, AMED, CINAHL, EBSCO, PubMed, PEDro, Cochrane Collaboration Trials Register, Cochrane Database of Systematic Reviews and SCOPUS databases.

STUDY SELECTION

Randomised controlled trials that compared a mobilisation technique applied to the spine or the extremities with a control or placebo.

DATA EXTRACTION AND DATA SYNTHESIS

Human studies collecting data on skin conductance or skin temperature were used. Data were extracted by two reviewers. Risk of bias was assessed using the Cochrane guidelines, and quality of evidence was assessed using the GRADE approach. Standardised mean differences (SMD) and random effects were calculated.

RESULTS

Eighteen studies were included in the review and 17 were included in the meta-analysis. The meta-analysis found a significant increase in skin conductance [SMD 1.21, 95% confidence interval (CI) 0.88 to 1.53, n=269] and a decrease in temperature (SMD 0.92, 95% CI -1.47 to -0.37, n=128) after mobilisation compared with the control group. An increase in skin conductance (SMD 0.73, 95% CI 0.51 to 0.96, n=293) and a decrease in temperature (SMD -0.50, 95% CI -0.82 to -0.18, n=134) were seen after mobilisation compared with placebo. The risk of bias was generally low, but the heterogenicity of the results downgraded the level of evidence.

LIMITATIONS

Most trials (14/18) were conducted on asymptomatic healthy subjects.

CONCLUSION

There is moderate evidence suggesting a sympatho-excitatory effect of joint mobilisation. Systematic Review Registration Number PROSPERO CRD42018089991.

Thoracic Posture and Mobility in Mechanical Neck Pain Population: A Review of the Literature

Neck pain is a common condition with several proposed biomechanical contributing factors. Thoracic spine dysfunction is hypothesized as one of the predisposing factors, which necessitates the need to explore the contribution of thoracic posture and mobility toward neck pain. Accordingly, the present work aimed to review the existing literature investigating the presence of thoracic spine dysfunction in individuals with neck pain. A literature search was conducted in the three electronic databases of PubMed, CINAHL, and Web of Science. Studies published between 1990 and 2017 were considered. After reviewing the abstracts, two authors independently scrutinized the full-text documents for their relevance. The initial search yielded 2,167 articles, of which nine studies involving comparisons of neck pain patients and healthy controls were identified for the review. Increased thoracic kyphosis was positively correlated with the presence of forward head posture but not uniformly associated with neck pain intensity and disability. Thoracic mobility was reduced in the neck pain population, and the role of thoracic kyphosis as a risk factor for pain development could not be confirmed. Thus, an association exists between thoracic kyphosis and postural alteration in the cervical spine. The review favors the inclusion of thoracic spine assessment and treatment in mechanical neck pain patients. Further studies are needed to investigate the cause-effect relationship between thoracic posture and cervical dysfunction.

Immediate and Short-term Effects of Thoracic Spine Manipulation in Patients With Cervical Radiculopathy: A Randomized Controlled Trial

BACKGROUND

Thoracic spine thrust manipulation has been shown to improve patient-rated outcomes for individuals with neck pain. However, there is limited evidence of its effectiveness in patients with cervical radiculopathy.

OBJECTIVES

To compare the immediate and short-term effects of thoracic manipulation to those of a sham thoracic manipulation in patients with cervical radiculopathy.

METHODS

In this multicenter randomized controlled trial, participants with cervical radiculopathy were randomized to receive either manipulation (n = 22) or sham manipulation (n = 21) of the thoracic spine. Outcomes were measured at baseline, immediately after treatment, and at a follow-up 48 to 72 hours after manipulation. A repeated-measures analysis of variance was used to analyze neck and upper extremity pain (numeric pain-rating scale), disability (Neck Disability Index), cervical range of motion (ROM), and endurance (deep neck flexor endurance test). The chi-square test was used to analyze changes in neck and upper extremity pain, centralization of symptoms, and beliefs about receiving the active manipulation treatment using a global rating of change scale.

RESULTS

Neck and upper extremity pain, cervical ROM, disability, and deep neck flexor endurance all showed significant interactions between group and time (P<.01). Immediately after treatment and at the 48-to-72-hour follow-up, the manipulation group had lower neck pain (P<.01), better cervical ROM (P<.01), lower disability (P<.01), and better deep neck flexor endurance (P = .02) compared to the sham manipulation group. The manipulation group had moderate to large effect-size changes over time. No between-group differences for upper extremity pain were found immediately following the intervention (P = .34) and at 48 to 72 hours after the intervention (P = .18). At 48 to 72 hours after treatment, a greater proportion of participants in the manipulation group reported improvement (global rating of change scale score of 4 or greater) in neck and upper extremity symptoms (P<.01), centralization of symptoms (P<.01), and beliefs about receiving an active manipulation (P = .01) compared to the sham manipulation group.

CONCLUSION

One session of thoracic manipulation resulted in improvements in pain, disability, cervical ROM, and deep neck flexor endurance in patients with cervical radiculopathy. Patients treated with manipulation were more likely to report at least moderate change in their neck and upper extremity symptoms up to 48 to 72 hours following treatment.

LEVEL OF EVIDENCE

Therapy, level 2. J Orthop Sports Phys Ther 2019;49(5):299-309. doi:10.2519/jospt.2019.8150.

Thoracic spine manipulation for the management of mechanical neck pain: A systematic review and meta-analysis

Objective

To investigate the role of thoracic spine manipulation (TSM) on pain and disability in the management of mechanical neck pain (MNP).

Data sources

Electronic databases PubMed, CINAHL, Pedro, Embase, AMED, the Cochrane Library, and clinicaltrials.gov were searched in January 2018.

Study selection

Eligible studies were completed RCTs, written in English, had at least 2 groups with one group receiving TSM, had at least one measure of pain or disability, and included patients with MNP of any duration. The search identified 1717 potential articles, with 14 studies meeting inclusion criteria.

Study appraisal and synthesis methods

Methodological quality was evaluated independently by two authors using the guidelines published by the Cochrane Collaboration. Pooled analyses were analyzed using a random-effects model with inverse variance methods to calculate mean differences (MD) and 95% confidence intervals for pain (VAS 0-100mm, NPRS 0-10pts; 0 = no pain) and disability (NDI and NPQ 0–100%; 0 = no disability).

Results

Across the included studies, there was increased risk of bias for inadequate provider and participant blinding. The GRADE approach demonstrated an overall level of evidence ranging from very low to moderate. Meta-analysis that compared TSM to thoracic or cervical mobilization revealed a significant effect favoring the TSM group for pain (MD -13.63; 95% CI: -21.79, -5.46) and disability (MD -9.93; 95% CI: -14.38, -5.48). Meta-analysis that compared TSM to standard care revealed a significant effect favoring the TSM group for pain (MD -13.21; 95% CI: -21.87, -4.55) and disability (MD -11.36; 95% CI: -18.93, -3.78) at short-term follow-up, and a significant effect for disability (MD -4.75; 95% CI: -6.54, -2.95) at long-term follow-up. Meta-analysis that compared TSM to cervical spine manipulation revealed a non-significant effect (MD 3.43; 95% CI: -7.26, 14.11) for pain without a distinction between immediate and short-term follow-up.

Limitations

The greatest limitation in this systematic review was the heterogeneity among the studies making it difficult to assess the true clinical benefit, as well as the overall level of quality of evidence.

Conclusions

TSM has been shown to be more beneficial than thoracic mobilization, cervical mobilization, and standard care in the short-term, but no better than cervical manipulation or placebo thoracic spine manipulation to improve pain and disability.

Trial registration

PROSPERO CRD42017068287

Management of thoracic spine pain and dysfunction: A survey of clinical practice in the UK

BACKGROUND

The thoracic spine (TS) is relatively under-researched compared to the neck and low back. As the challenge of managing spinal pain persists, understanding current physiotherapy clinical practice for TS pain and dysfunction is necessary to inform future research in this area.

OBJECTIVE

To investigate physiotherapy practice for managing thoracic spine pain and dysfunction (TSPD) in the UK, with a secondary focus on examining differences across settings and expertise.

DESIGN AND METHOD

A cross sectional e-survey informed by existing evidence was designed. Comprising closed and open questions, the survey is reported in line with Checklist for Reporting Results of Internet E-Surveys. Eligible participants were UK-trained physiotherapists managing patients with TSPD, recruited for 9 weeks up to 8/2/16. Data analysis included descriptive analyses (closed questions) and thematic analysis (open questions).

RESULTS

From the 485 respondents, fulfilling the required sample size, key findings included.

EXAMINATION

Active motion testing, palpation and postural assessment was 'always' undertaken by >89% of respondents.

MANAGEMENT

Active (exercises) and passive (e.g. mobilisations) techniques were used by >85% of respondents, with ∼50% using manipulation, taping and acupuncture. Practice settings: Although broadly similar passive techniques were used more in private practice and sport. Expertise: Broadly similar patterns were seen for use of exercise across levels of expertise, although differences observed for electrotherapy and manipulation.

CONCLUSION

Despite limited research exercise is widely used in all areas of practice and across all level of expertise. Further research is required to investigate exercise prescription for TSPD and implementation of evidence-based practice.

Functional Magnetic Resonance Imaging of Cerebral Hemodynamic Responses to Pain Following Thoracic Thrust Manipulation in Individuals With Neck Pain: A Randomized Trial

OBJECTIVE

The purpose of this study was to examine whether cerebral activation in response to noxious mechanical stimuli varies with thrust manipulation (TM) when compared with sham manipulation (SM) as measured by blood oxygenation level-dependent functional magnetic resonance imaging.

METHODS

Twenty-four volunteers (67% female) with complaints of acute or subacute mechanical (nontraumatic) neck pain satisfied eligibility requirements and agreed to participate. Participants were randomized to receive TM to the thoracic spine or SM, and then underwent functional magnetic resonance scanning while receiving noxious stimuli before and after TM or SM. An 11-point numeric pain rating scale was administered pre- and postmanipulation for neck pain and to determine perceptions of pain intensity with respect to neck pain and mechanical stimuli. Blood oxygenation level-dependent functional magnetic resonance imaging recorded the cerebral hemodynamic response to the mechanical stimuli.

RESULTS

Imaging revealed significant group differences, with those individuals in the manipulation group exhibiting increased areas of activation (postmanipulation) in the insular and somatosensory cortices and individuals in the sham group exhibiting greater areas of activation in the precentral gyrus, supplementary motor area, and cingulate cortices (P < .05). However, between-group differences on the numeric pain rating scale for mechanical stimuli and for self-reported neck pain were not statistically significant.

CONCLUSIONS

This study provides preliminary level 2b evidence suggesting cortical responses in patients with nontraumatic neck pain may vary between thoracic TM and a sham comparator.

3-Dimensional Cervical Movement Characteristics and the Influence of Thoracic Treatment on a Subgroup of Acute Neck Pain Patients

OBJECTIVE

The purpose of this study was to investigate the influence of thoracic high-velocity low-amplitude thrust (HVLAT) manipulation on quantitative and qualitative 3-dimensional cervical spine kinematic patterns in a subgroup of patients with acute neck pain.

METHODS

Thirty patients with acute neck pain, aged 20 to 59, received a thoracic HVLAT manipulation. Three-dimensional kinematics of the cervical spine were registered pretreatment and posttreatment using an electromagnetic tracking system. Quantitative and qualitative parameters were calculated for axial rotation, lateral bending, and flexion-extension movement. Subjective pain ratings were measured with the visual analogue scale and the Neck Disability Index and were collected pretreatment and posttreatment.

RESULTS

After treatment, the range of motion of the main motion improved significantly for axial rotation (P = .034), lateral bending (P < .001), and flexion-extension (P = .031). Although for axial rotation as the main motion, the smoothness of the flexion-extension movement improved significantly after treatment (P = .036), the reverse was true for flexion-extension as the main motion. Visual analogue scale scores exhibited a statistically (P < .001) and clinically significant reduction of pain sensation. The mean change in Neck Disability Index scores only exhibited a statistically significant improvement 1 week after treatment.

CONCLUSION

Thoracic HVLAT manipulation led to positive changes in quantitative and qualitative aspects of 3-dimensional cervical spine kinematics. Because of the 1-intervention group design, external factors influencing the healing process could not be eliminated.

Pragmatically Applied Cervical and Thoracic Nonthrust Manipulation Versus Thrust Manipulation for Patients With Mechanical Neck Pain: A Multicenter Randomized Clinical Trial

Study Design Randomized clinical trial. Background The comparative effectiveness between nonthrust manipulation (NTM) and thrust manipulation (TM) for mechanical neck pain has been investigated, with inconsistent results. Objective To compare the clinical effectiveness of concordant cervical and thoracic NTM and TM for patients with mechanical neck pain. Methods The Neck Disability Index (NDI) was the primary outcome. Secondary outcomes included the Patient-Specific Functional Scale (PSFS), numeric pain-rating scale (NPRS), deep cervical flexion endurance (DCF), global rating of change (GROC), number of visits, and duration of care. The covariate was clinical equipoise for intervention. Outcomes were collected at baseline, visit 2, and discharge. Patients were randomly assigned to receive either NTM or TM directed at the cervical and thoracic spines. Techniques and dosages were selected pragmatically and applied to the most symptomatic level. Two-way mixed-model analyses of covariance were used to assess clinical outcomes at 3 time points. Analyses of covariance were used to assess between-group differences for the GROC, number of visits, and duration of care at discharge. Results One hundred three patients were included in the analyses (NTM, n = 55 and TM, n = 48). The between-group analyses revealed no differences in outcomes on the NDI (P = .67), PSFS (P = .26), NPRS (P = .25), DCF (P = .98), GROC (P = .77), number of visits (P = .21), and duration of care (P = .61) for patients with mechanical neck pain who received either NTM or TM. Conclusion NTM and TM produce equivalent outcomes for patients with mechanical neck pain. The trial was registered with ClinicalTrials.gov (NCT02619500). Level of Evidence Therapy, level 1b. J Orthop Sports Phys Ther 2018;48(3):137-145. Epub 6 Feb 2018. doi:10.2519/jospt.2018.7738.

The effectiveness of combining inspiratory muscle training with manual therapy and a therapeutic exercise program on maximum inspiratory pressure in adults with asthma: a randomized clinical trial

OBJECTIVE

The objective of this study was to evaluate whether the addition of manual therapy and therapeutic exercise protocol to inspiratory muscle training was more effective in improving maximum inspiratory pressure than inspiratory muscle training in isolation.

DESIGN

This is a single-blinded, randomized controlled trial.

SUBJECTS

In total, 43 patients with asthma were included in this study.

INTERVENTIONS

The patients were allocated into one of the two groups: (1) inspiratory muscle training ( n = 21; 20-minute session) or (2) inspiratory muscle training (20-minute session) combined with a program of manual therapy (15-minute session) and therapeutic exercise (15-minute session; n = 22). All participants received 12 sessions, two days/week, for six weeks and performed the domiciliary exercises protocol.

MAIN MEASURES

The main measures such as maximum inspiratory pressure, spirometric measures, forward head posture, and thoracic kyphosis were recorded at baseline and after the treatment.

RESULTS

For the per-protocol analysis, between-group differences at post-intervention were observed in maximum inspiratory pressure (19.77 cmH₂O (11.49-28.04), P < .05; F = 22.436; P < .001; η²_p = 0.371) and forward head posture (-1.25 cm (-2.32 to -0.19), P < .05; F = 5.662; P = .022; η²_p = 0.13). The intention-to-treat analysis showed the same pattern of findings.

CONCLUSION

The inspiratory muscle training combined with a manual therapy and therapeutic exercise program is more effective than its application in isolation for producing short-term maximum inspiratory pressure and forward head posture improvements in patients with asthma.

Clinical outcomes following conservative management of chronic traumatic cervical myelopathy: A case report

BACKGROUND AND PURPOSE

There is limited evidence supporting the conservative management of patients with cervical myelopathy. The purpose of this report is to describe the intervention and outcomes of conservative physical therapy interventions for one patient with chronic cervical myelopathy.

CASE DESCRIPTION

This case was a 50-year-old male who sustained a neck injury following a rear-end collision 4 years prior to this therapeutic episode. The patient presented with decreased range of motion in the cervical spine and right upper extremity, strength deficits, altered sensation, poor posture, and reported chronic cervical region pain and difficulty sleeping.

INTERVENTION

The patient completed 10 weeks of conservative physical therapy. The patient completed the Neck Disability Index (NDI), Medical Outcome Survey Sleep Scale (MSS), short-form McGill Pain Questionnaire (SFMPQ), Patient-Specific Functional Scale (PSFS), and baseline clinical measurements of flexibility and strength were obtained.

OUTCOMES

After the 10-week episode of care, the following changes were noted from baseline: 18% improvement on the NDI, 26% improvement on the MSS, 25% decrease in pain on the SFMPQ, and a 39% improvement on the total score of the PSFS. Cervical range of motion measurements increased between 25% and 100%. Grip strength demonstrated a 465% increase on the right upper extremity and a 25% increase on the left upper extremity.

DISCUSSION

This case report suggests that conservative management of chronic traumatic cervical myelopathy was effective in helping to improve pain, sleep, and function in this patient with a traumatic mechanism of injury.

Neck Pain: Revision 2017

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to neck pain. J Orthop Sports Phys Ther. 2017;47(7):A1-A83. doi:10.2519/jospt.2017.0302.

The risk associated with spinal manipulation: an overview of reviews

BACKGROUND

Spinal manipulative therapy (SMT) is a widely used manual treatment, but many reviews exist with conflicting conclusions about the safety of SMT. We performed an overview of reviews to elucidate and quantify the risk of serious adverse events (SAEs) associated with SMT.

METHODS

We searched five electronic databases from inception to December 8, 2015. We included reviews on any type of studies, patients, and SMT technique. Our primary outcome was SAEs. Quality of the included reviews was assessed using a measurement tool to assess systematic reviews (AMSTAR). Since there were insufficient data for calculating incidence rates of SAEs, we used an alternative approach; the conclusions regarding safety of SMT were extracted for each review, and the communicated opinion were judged by two reviewers independently as safe, harmful, or neutral/unclear. Risk ratios (RRs) of a review communicating that SMT is safe and meeting the requirements for each AMSTAR item, were calculated.

RESULTS

We identified 283 eligible reviews, but only 118 provided data for synthesis. The most frequently described adverse events (AEs) were stroke, headache, and vertebral artery dissection. Fifty-four reviews (46%) expressed that SMT is safe, 15 (13%) expressed that SMT is harmful, and 49 reviews (42%) were neutral or unclear. Thirteen reviews reported incidence estimates for SAEs, roughly ranging from 1 in 20,000 to 1 in 250,000,000 manipulations. Low methodological quality was present, with a median of 4 of 11 AMSTAR items met (interquartile range, 3 to 6). Reviews meeting the requirements for each of the AMSTAR items (i.e. good internal validity) had a higher chance of expressing that SMT is safe.

CONCLUSIONS

It is currently not possible to provide an overall conclusion about the safety of SMT; however, the types of SAEs reported can indeed be significant, sustaining that some risk is present. High quality research and consistent reporting of AEs and SAEs are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015030068 .

Effect of maitland mobilization in cervical and thoracic spine and therapeutic exercise on functional impairment in individuals with chronic neck pain

[Purpose] This study evaluated joint mobilization and therapeutic exercise applied to the cervical spine and upper thoracic spine for functional impairment caused by chronic neck pain. [Subjects and Methods] Eighteen study subjects were randomly assigned to two groups of nine people each. Therapeutic exercise only was applied to the cervical and upper thoracic spine for Group I, while both therapeutic exercise and joint mobilization were applied to Group II. The visual analog scale, neck disability index, active cervical range of motion, static balance capacity, and muscle tone were assessed with a pre-test. The intervention was carried out for 60 minutes a day, three times a week, for two weeks for each group, followed by a post-test using the same protocol as the pre-test. [Results] The visual analog scale, neck disability index, and active cervical range of motion improved significantly in both groups. Group II improved significantly more on right lateral flexion and rightward rotation. Muscle tone improved significantly in the upper trapezius in both groups. [Conclusion] The joint mobilization and therapeutic exercise for functional impairments caused by chronic neck pain had a significant effect on several types of functional impairment.

A Knowledge Translation Programme to Increase the Utilization of Thoracic Spine Mobilization and Manipulation for Patients with Neck Pain

BACKGROUND

There is extensive evidence that mobilization and manipulation of the thoracic spine is associated with improved outcomes in patients with neck pain. However, these evidence-based techniques are not always utilized. Successful knowledge translation programmes are needed to move the best available evidence to clinical practice. The purpose of the present research was to evaluate the effects of a structured knowledge translation programme on the frequency of manual therapy techniques performed by physical therapists on patients with neck pain.

METHODS

Prior to our intervention, we assessed physical therapists' use of thoracic spine intervention for the treatment of neck pain and their knowledge of the evidence. We delivered a multimodal knowledge translation programme and then reassessed their use and knowledge of the interventions.

RESULTS

The majority of our physical therapists increased the use of thoracic spine techniques for their patients with neck pain. The increase was greater in those who used the techniques infrequently. Overall knowledge of the evidence appeared unchanged.

DISCUSSION

Knowledge translation programmes are essential in ensuring clinical use of evidence-based practice. Our programme results, although on a small scale and not statistically significant, showed a positive trend toward increased thoracic spine manual therapy use for neck pain. Copyright © 2015 John Wiley & Sons, Ltd.

Regional interdependence and manual therapy directed at the thoracic spine

Thoracic spine manipulation is commonly used by physical therapists for the management of patients with upper quarter pain syndromes. The theoretical construct for using thoracic manipulation for upper quarter conditions is a mainstay of a regional interdependence (RI) approach. The RI concept is likely much more complex and is perhaps driven by a neurophysiological response including those related to peripheral, spinal cord and supraspinal mechanisms. Recent evidence suggests that thoracic spine manipulation results in neurophysiological changes, which may lead to improved pain and outcomes in individuals with musculoskeletal disorders. The intent of this narrative review is to describe the research supporting the RI concept and its application to the treatment of individuals with neck and/or shoulder pain. Treatment utilizing both thrust and non-thrust thoracic manipulation has been shown to result in improvements in pain, range of motion and disability in patients with upper quarter conditions. Research has yet to determine optimal dosage, techniques or patient populations to which the RI approach should be applied; however, emerging evidence supporting a neurophysiological effect for thoracic spine manipulation may negate the need to fully answer this question. Certainly, there is a need for further research examining both the clinical efficacy and effectiveness of manual therapy interventions utilized in the RI model as well as the neurophysiological effects resulting from this intervention.

Effect of manual versus mechanically assisted manipulations of the thoracic spine in neck pain patients: study protocol of a randomized controlled trial

BACKGROUND

Neck pain is a common musculoskeletal condition with a point prevalence of around 15% in males and 23% in females that often presents in physiotherapy practice. Physical therapy and/or manipulation therapy is generally the first management option for patients with mechanical neck pain. Physical therapists treat mechanical neck pain with a number of interventions including joint mobilization and/or manipulation, therapeutic exercises or education. However, manipulation of the cervical spine carries some risks. Treating the thoracic spine for neck pain is an alternative approach. Emerging evidence suggests that it may be effective for treating neck pain without the risks associated with cervical spine manipulation. A new electromechanical device has recently been developed and tested for delivering multiple high velocity, low amplitude thrust manipulations to the spine. This device incorporates both auditory and visual systems that provide real time feedback on the applied treatment. The objective of this study is to compare the short- and long-term effects of manual versus mechanically assisted manipulations of the thoracic spine for neck pain patients.

METHODS/DESIGN

A 6-month, randomized controlled trial consisting of 54 patients with acute or chronic neck pain patients will be conducted. Patients with no signs of major pathology and with little or no interference with daily activities will be recruited. Three treatment sessions with 4-day intervals will be carried out. The patients will be randomly assigned to receive either manually performed manipulations or electromechanical manipulations at the thoracic spine. The primary outcome is pain intensity as measured by the Visual Analogue Pain Rating Scale. The secondary outcome measures are neck physical disability using the Neck Disability Index, quality of life measured by the European Quality of Life 5 Dimensions 5 Levels and patients' improvement using the Patient's Global Impression of Change Scale.

DISCUSSION

It is expected that both interventions will improve neck pain. This would be a significant finding, as thoracic spine manipulation for neck pain does not carry the same risk of injury as cervical spine manipulation. In addition, the results may provide useful information about therapeutic options for health care providers and patients for the problem of neck pain.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN88585962, registered January 2013.