Author Names
Rodriguez-Sanz, J. et al
Reviewer Name
Megan Benzie, SPT, B.S.
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Chronic neck pain is one of today’s most prevalent pathologies. The International Classification of Diseases categorizes four subgroups based on patients’ associated symptoms. However, this classification does not encompass upper cervical spine dysfunction. The aim is to compare the short- and mid-term effectiveness of adding a manual therapy approach to a cervical exercise protocol in patients with chronic neck pain and upper cervical spine dysfunction. Fifty-eight subjects with chronic neck pain and upper cervical spine dysfunction were recruited (29 = Manual therapy + Exercise; 29 = Exercise). Each group received four 20-min sessions, one per week during four consecutive weeks, and a home exercise regime. Upper flexion and flexion-rotation test range of motion, neck disability index, craniocervical flexion test, visual analogue scale, pressure pain threshold, global rating of change scale, and adherence to self-treatment were assessed at the beginning, end of the intervention and at 3- and 6-month follow-ups. The Manual therapy + Exercise group statistically improved short- and medium-term in all variables compared to the Exercise group. Four 20-min sessions of Manual therapy + Exercise along with a home-exercise program is more effective in the short- to mid-term than an exercise protocol and a home-exercise program for patients with chronic neck pain and upper cervical dysfunction.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
- Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
- Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
- Yes
- Were study participants and providers blinded to treatment group assignment?
- No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
- No
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
- Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
- Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
- Yes
- Was there high adherence to the intervention protocols for each treatment group?
- Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
- Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
- Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
- No
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
- Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
- Cannot Determine, Not Reported, or Not Applicable
Key Finding #1
The participants who received manual therapy and exercise had statically significant better outcomes than the exercise only group.
Key Finding #2
Three participants in the exercise only group had mild neck pain at the six month follow up, which the exercise and manual therapy group had no reported long term symptoms.
Key Finding #3
The sample size was 29 participants total. A small sample size can cause the findings to not be as transferable to similar population groups than if there were a larger sample size.
Key Finding #4
This study did not discuss or look into which manual therapy technique is most effective for this patient population.
Please provide your summary of the paper
This randomized, longitudinal controlled trial looked at the effect of utilizing manual therapy with exercise versus only exercise for the treatment of upper cervical neck pain. This study used four 20-minute sessions, once a week for four weeks. It looked at upper flexion, flexion-rotation test range of motion, neck disability index, craniocervical flexion test, the visual analogue pain threshold, etc. The manual therapy performed was individualized to the specific participant and aimed to improve the range of motion at a specific joint, which was measured by the flexion rotation test. These patients also showed decreased ratings of pain and an increased pressure pain threshold. For both groups, the exercises used were standardized and performed. The group with exercise and manual therapy showed more improvement than the exercise only group at both short and midterm follow ups in neck disability index, patients’ perfection of improvement, range of motion, pain intensity, and pressure pain thresholds. This study shows the potential importance of utilizing manual therapy for upper cervical neck pain, in addition to an individualized exercise program. This study did not look into which exercises result in the greatest ECG activation or which manual therapy technique is most effective. Therefore, individualized care and continued research is needed.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study shows that for upper cervical pain, manual therapy in conjunction with exercise is an effect treatment. These participants were also only treated once a week, for four weeks. This shows that manual therapy may be able to take effect in a short time period. However, the study only had 29 participants total. Further studies would need to be done with much larger sample sizes for this to be applicable to a large population group. In addition, the most effective type of manual therapy for this population was not studied, but would be helpful for clinicians.
