Author Names
Joshi, S, Balthillaya, G, Neelapala, R
Reviewer Name
Jaime Pardee
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
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.
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?
- Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
- No
- 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)?
- Cannot Determine, Not Reported, or Not Applicable
- 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?
- Cannot Determine, Not Reported, or Not Applicable
- 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?
- Yes
- Is the review based on a focused question that is adequately formulated and described?
- Were eligibility criteria for included and excluded studies predefined and specified?
- Did the literature search strategy use a comprehensive, systematic approach?
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
- Yes
- Were the included studies listed along with important characteristics and results of each study?
- Was publication bias assessed?
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
Key Finding #1
In the cervicothoracic junction mobilization group, there was a statistically significant change in cervical flexion, extension, left side flexion and bilateral rotation ROM post-treatment (p-value < 0.05).
Key Finding #2
In the thoracic manipulation group, there was a statistically significant change identified in cervical ROM (p-value < 0.05) and in pain scores (p-value = < 0.01; mean difference 1.28).
Key Finding #3
For both groups, mean differences did not exceed the MDC values for cervical ROM.
Key Finding #4
Significant improvements were shown within-group, pre and post-comparison in cervical ROM and pain for both groups.
Please provide your summary of the paper
In this paper, the authors sought to compare the immediate effects of C7-T1 mobilization with thoracic manipulations in individuals with mechanical neck pain that presented with CT junction dysfunction. A randomized clinical trial was conducted where 42 patients with primary complaints of mechanical neck pain and CT junction dysfunction were randomly assigned to either the C7-T1 mobilization group or the mid-thoracic (T3-T6) manipulation group. Before and after the intervention, cervical flexion, extension, side flexion, and rotation range of motion (ROM) were measured with a cervical range of motion device (CROM). The numerical pain rating scale (NPRS) was also measured for each patient. Both groups had no significant differences in the post-intervention baseline outcomes of cervical ROM and pain. However, both groups within-group, pre, and post-comparison showed significant improvements in cervical ROM with no pain. This study concluded that CT junction mobilization is not superior to thoracic manipulation on the outcomes of cervical range of motion and neck pain specific to the CT junction.
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 concluded that thoracic spinal manipulations have no greater advantage than level-specific mobilization over the manipulation of an interdependent area. The authors suggest that mobilization of a regionally interdependent segment may be beneficial when mobilization of a specific hypomobile segment is not possible due to tenderness in those with severe neck pain. The long-term effects were not explored in this study. Although, this study had many limitations including a small sample size, it does provide positive reinforcement that cervical and thoracic mobilizations can improve range of motion in pain. This study did not include other interventions such as exercise in this study. The combination of exercise with manipulations in these two regions could potentially provide great benefit to the patient long term. Although the results of this study were not great due to its limitations, it supports that CT and thoracic manipulations are safe for patients with severe neck pain.
