Author Names

Rodríguez-Sanz, J., Malo-Urriés, M.,  Lucha-López, MO., Pérez-Bellmunt, A., Carrasco-Uribarren, A., Fanlo-Mazas, P., Corral-de-Toro, J., Hidalgo-García, C.

Reviewer Name

Casie Coffman SPT, NBC-HWC

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

 

Paper Abstract

BACKGROUND: Flexion-rotation test predominantly measures rotation in C1-2 segment. Restriction in flexion-rotation may be due to direct limitation in C1-2, but also to a premature tightening of the alar ligament as a result of lack of movement in C0-1 or C2-3. The aim of this study was to compare the effect of a 20-min single cervical exercise session, with or without manual therapy of C0-1 and C2-3 segment in flexion-rotation test, in patients with chronic neck pain and positive flexion-rotation test. METHODS: Randomized controlled clinical trial in 48 subjects (24 manual therapy+exercise/24 exercise). Range of motion and pain during flexion-rotation test, neck pain intensity and active cervical range of motion were measured before and after the intervention. RESULTS: Significant differences were found in favour of the manual therapy group in the flexion-rotation test: right (p < 0.001) and left rotation (p < 0.001); pain during the flexion-rotation test: right (p < 0.001) and left rotation (p < 0.001); neck pain intensity: (p < 0.001); cervical flexion (p < 0.038), extension (p < 0.010), right side-bending (p < 0.035), left side-bending (p < 0.002), right rotation (p < 0.001), and left rotation (p < 0.006). CONCLUSIONS: Addition of one C0-C1 and C2-C3 manual therapy session to cervical exercise can immediately improve flexion-rotation test and cervical range of motion and reduce pain intensity.

 

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

  1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
  • Yes
  1. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
  • Yes
  1. Was the treatment allocation concealed (so that assignments could not be predicted)?
  • Yes
  1. Were study participants and providers blinded to treatment group assignment?
  • Cannot Determine, Not Reported, or Not Applicable
  1. Were the people assessing the outcomes blinded to the participants’ group assignments?
  • Yes
  1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
  • Yes
  1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
  • Yes
  1. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
  • Yes
  1. Was there high adherence to the intervention protocols for each treatment group?
  • Yes
  1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
  • Yes
  1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
  • Yes
  1. 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?
  • Cannot Determine, Not Reported, or Not Applicable
  1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
  • Yes
  1. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
  • Yes

 

Key Finding #1

Combined manual therapy and exercise resulted in a statistically significant reduction in pain intensity measured via NPRS.

Key Finding #2

Exercise alone did not result in statistically significant changes in pain intensity measured via NPRS.

Key Finding #3

Combined manual therapy and exercise resulted in a greater increase in ROM assessed during the flexion-rotation test.

 

Please provide your summary of the paper

This RCT compared the effects of cervical exercise with or without the addition of manual therapy in individuals with chronic neck pain and a positive flexion-rotation test. 48 participants who met the inclusion criteria of chronic neck pain (greater than 3 months), a positive flexion-rotation test, and loss of C1-0 and/or C2-3 motion were randomly assigned groups.  The primary outcome was ROM available during the flexion-rotation test. Current pain intensity and pain intensity during the flexion-rotation test were assessed via the numeric pain rating scale (NPRS). Active cervical ROM was measured with a cervical ROM (CROM) device. Each group underwent a 20-minute session. In the exercise (control) group, participants performed 2 sets of 10 reps of a deep neck flexor exercise, held for 10 seconds with 40 seconds of rest between reps and 2 minutes of rest between sets. The combined manual therapy and exercise (experimental) group underwent manipulation and/or mobilization of C0-1 and C2-3 spinal segments prior to exercise. Within 3 minutes and with the participant’s head in a near neutral position, up to 2 trials of thrusts could be performed at each indicated level. Mobilization was performed for 45 seconds with 15 seconds of rest between cycles. Participants then performed the same exercise intervention, with the minor difference of a 30-second rest between reps to keep total session durations consistent.  Within-group and between-group outcomes favored combined manual therapy and exercise across all domains. After intervention, the combined manual therapy and exercise group demonstrated a statistically significant difference in the improvement of ROM (bilateral rotation) and pain intensity during the flexion-rotation test compared to the exercise-only group. There were also significantly better outcomes in current pain intensity. Lastly, while active cervical ROM decreased in some measures of the exercise group, the combined manual therapy and exercise group demonstrated improved left side-bending. Furthermore, between-group differences for cervical AROM showed statistically significant differences in all directions.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

Neck pain is a prevalent condition that people across older and younger ages experience, particularly with desk work. Pain can become disabling and costly, which makes physical therapy a valuable intervention to attempt. This study showed that combining C0-1 and C2-3 manual therapy with exercise can immediately improve pain intensity and ROM in individuals with chronic neck pain and a positive flexion-rotation test. While this can be easily adopted to clinical practice, it should be noted that the long-term efficacy of this treatment is unknown, and requires further research.