Author Names
Hidalgo, B, Hall, T, Bossert, J, Dugeny, A, Cagnie, B, Pitance, L
Reviewer Name
Natalia Engel, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Objective: To review and update the evidence for different forms of manual therapy (MT) and exercise for patients with different stages of non-specific neck pain (NP). Method: A qualitative systematic review covering a period from January 2000 to December 2015 was conducted according to updated-guidelines. Specific inclusion criteria only on RCTs were used; including differentiation according to stages of NP (acute – subacute [ASNP] or chronic [CNP]), as well as sub-classification based on type of MT interventions: MT1 (HVLA manipulation); MT2 (mobilization and/or soft-tissue-techniques); MT3 (MT1 + MT2); and MT4 (Mobilization-with-Movement). In each sub-category, MT could be combined or not with exercise and/or usual medical care. Results: Initially 121 studies were identified for potential inclusion. Based on qualitative and quantitative evaluation criteria, 23 RCTs were identified for review. Evidence for ASNP: MODERATE-evidence: In favour of (i) MT1 to the cervical spine (Cx) combined with exercises when compared to MT1 to the thoracic spine (Tx) combined with exercises; (ii) MT3 to the Cx and Tx combined with exercise compared to MT2 to the Cx with exercise or compared to usual medical care for pain and satisfaction with care from short to long-term. Evidence for CNP: STRONG-evidence: Of no difference of efficacy between MT2 at the symptomatic Cx level(s) in comparison to MT2 on asymptomatic Cx level(s) for pain and function. MODERATE to STRONG evidence: In favour of MT1 and MT3 on Cx and Tx with exercise in comparison to exercise or MT alone for pain, function, satisfaction with care and general-health from short to moderate-terms. MODERATE-evidence: In favour (i) of MT1 as compared to MT2 and MT4, all applied to the Cx, for neck mobility, and pain in the very short term; (ii) of MT2 using sof-tissue-techniques to the Cx and Tx or MT3 to the Cx and Tx in comparison to no-treatment in the short-term for pain and disability. Conclusion: This systematic review updates the evidence for MT combined or not with exercise and/or usual medical care for different stages of NP and provides recommendations for future studies. Two majors points could be highlighted, the first one is that combining different forms of MT with exercise is better than MT or exercise alone, and the second one is that mobilization need not be applied at the symptomatic level(s) for improvements of NP patients. These both points may have clinical implications for reducing the risk involved with some MT techniques applied to the cervical spine.
NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described?
- Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
- Yes
- Did the literature search strategy use a comprehensive, systematic approach?
- Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
- Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
- Were the included studies listed along with important characteristics and results of each study?
- Yes
- Was publication bias assessed?
- Yes
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
- Cannot Determine, Not Reported, Not Applicable
Key Finding #1
Combining different forms of manual therapy with exercise is more efficacious than manual therapy or exercise alone.
Key Finding #2
There is moderate to strong evidence for high velocity, low amplitude (HVLA) manual therapy or a combination of HVLA and mobilization/soft tissue techniques combined with exercise for improvement in pain, function, and patient satisfaction.
Key Finding #3
There is strong evidence that for chronic neck pain, mobilization does not need to be applied at the symptomatic level for improvements in pain and function.
Key Finding #4
There is moderate evidence that HVLA, mobilization/soft tissue techniques, and mobilization with movement have similar effects on neck pain.
Please provide your summary of the paper
The results of this systematic review demonstrate that combining manual therapy with exercise leads to improved results in patients with neck pain. Along with this, patient satisfaction and subjective pain levels were improved when high velocity, low amplitude manual therapy or soft tissue mobilization techniques were employed in combination with exercise. These results highlight the importance of employing manual therapy along with exercise, and that the efficacy of manual therapy decreases when it is employed as a stand-alone intervention. For patients with chronic neck pain, the systematic review demonstrates that manual therapy does not need to be applied directly to the symptomatic spinal levels in order to get improvements in pain and function. This implies that physical therapists can use their judgement in choosing which technique to use, in order to reduce the risk of applying various techniques to the cervical level, as well as allowing them to choose the level of treatment in accordance with the patient’s level of irritability. Overall, the systematic review demonstrates that high velocity, low amplitude manual therapy, soft tissue mobilization techniques, and mobilization with movement techniques offer similar results and effects on neck pain. Because of this, therapists have the ability to employ any or all of these techniques at the cervical or thoracic levels along with exercise using their clinical judgement in order to treat patients with neck pain.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This systematic review highlights the importance of employing manual therapy with exercise, versus as a stand-alone intervention, in order for the patient to improve pain levels, function, and satisfaction with treatment. As a physical therapist, this is important not only from a treatment standpoint, but a patient education standpoint as well. Patients may subjectively report improvements with manual therapy, but can benefit even more when it is combined with exercise. It was also useful to learn that physical therapists can employ manual therapy at the thoracic levels instead of the cervical levels for patients with chronic neck pain and still get the intended results; for patients who are highly irritable, this will be an important finding, so that manual therapy can still be employed without increasing the risk of using certain manual therapy techniques in the cervical spine, and increasing the risk of making patients more irritable. In clinic, it is important when employing manual therapy to use clinical judgement based on the patient’s presentation whether or not to perform manual therapy at the symptomatic level or at lower levels, and to use exercise intervention alongside manual therapy for patients with neck pain.
