Authors Names: Jennalyn Lew, Jennifer Kim, Preeti Nair
Reviewer Name: Maggie Wentz, SPT
Reviewer Affiliation: Duke University School of Medicine, Department of Physical Therapy
Paper Abstract:
Background: Patients with myofascial pain syndrome of the neck and upper back have active trigger points and may present with pain and decreased function. Dry needling (DN) and trigger point manual therapy (TMPT) techniques are often used to manage MPS.
Objective: To compare DN and TPMT for reducing pain on the Visual Analog Scale (VAS) and Pressure Pain Threshold (PPT) scores and improving function on the Neck Disability Index (NDI) in patients with neck and upper back MPS.
Methods: PubMed, PEDro, and CINAHL were searched for randomized controlled trials within the last 10 years comparing a group receiving DN and the other receiving TPMT. Studies were assessed using PEDro scale and Cochrane risk-of-bias tool to assess methodological quality. Meta-analyses were performed using random-effect model. Standardized mean differences (Cohen’s d) and confidence intervals were calculated to compare DN to TPMT for effects on VAS, PPT, and NDI.
Results: Six randomized controlled trials with 241 participants total were included in this systematic review. The effect size of difference between DN and TPMT was non-significant for VAS [d = 0.41 (-0.18, 0.99)], for PPT [d = 0.64 (-0.19, 1.47)], and for NDI [d = -0.66 (-1.33, 0.02)].
Conclusions: Both DN and TPMT improve pain and function in the short to medium term. Neither is more superior than the other.
Meta-analysis
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?
Yes
Were the included studies listed along with important characterics and results of each study?
Yes
Was publication bias assessed?
Yes
Was heterogeneity assessed? (This question only applied to meta-analyses.)
Yes
Key Finding:
Based on the meta analysis, there are clear benefits to both trigger point manual therapy and dry needling in the treatment of myofascial pain syndrome in the upper back and neck. Both show significant improvements in pain based on Visual Analog Scale and the Pressure Pain Threshold, meaning that the level of discomfort the patient is experiencing declines with the use of either option. These findings not only demonstrate statistical significance, but also clinical significance.
Key Finding:
Both trigger point manual therapy and dry needling were shown to decrease the amount of disability for patients with myofascial pain syndrome in the upper back or neck. This was measured with the Neck Disability Index and showed both clinical and statistical significance. Therefore, this meta-analysis helped establish the finding that both trigger point manual therapy and dry needling can improve the score of the Neck Disability Index for patients with myofascial pain syndrome.
Key Finding:
Finally, the last key finding of the article is the fact that very few research articles with minimal bias are present on dry needling versus trigger point release manual therapy when treating myofascial pain syndrome affecting the upper back and neck regions. While these are two commonly used methods in treating this population, there is very little research behind the benefits between one over the other. This deficit was clear in the ability to only establish 6 studies that fit the parameters of this meta analysis. This led to the evaluation of only 241 participants in total, which is a relatively small subject pool.
Summary
In this meta-analysis the benefits of dry needling and trigger point manual therapy for patients with myofascial pain syndrome were found in randomized control trials found on PubMed, PEDro, and CINAHL within the last ten years. These studies were picked when they measured pain using the Visual Analog Scale or the Pressure Pain Threshold or they measured disability level with the Neck Disability Index. Originally, 56 studies were found to fit the parameters of the study, but after analyzing bias and duplications, only 6 studies were used for the meta analysis. These 6 studies consisted of 241 participants and significance of results were determined using Cohen’s d. With these measures in place, there was no statistically significant data to demonstrate that one treatment was better than the other. While this meant there was no difference between the outcomes of dry needling versus trigger point manual therapy, both were found to have positive impacts for patients with myofascial pain syndrome. In conclusion, this means patients have options when it comes to the management of myofascial pain syndrome treatments to improve their quality of life.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Through this meta analysis, clinicians are able to see that neither option is necessarily better than the other. This means patients who are experiencing difficulties from myofascial pain syndrome have more autonomy when choosing which method they would prefer. Personally, this means patients will have the ability to choose which treatment they find more tolerable, whether that involves needles or requires a more direct pressure to the bothersome area. Because both of these options offer the same benefits, I will feel more confident in presenting both options to the patient and based on their personal experiences or beliefs, they will be able to make the decision that best suits them. While I may prefer one over the other, knowing this research, I will make sure to show little to no bias in one over the other as they are both good treatments for those suffering from myofascial pain syndrome.
Author Names: Huisman A. P., Speksnijder M. C., Wijer D. A.
Reviewer Name: Mackenzie Whittaker
Reviewer Affiliation(s): SPT at Duke University
Paper Abstract:
Purpose: The aim of this systematic review was to determine the efficacy of thoracic spine manipulation (TSM) in reducing pain and disability in patients diagnosed with non-specific neck pain.
Methods: An extensive literature search of PubMed, The Cochrane Library, CINAHL, and EMBASE was conducted in February 2012. Randomized controlled trials (RCTs) or controlled clinical trials evaluating the effect of TSM in patients aged 18 to 65 years with non-specific neck pain were eligible. Methodological quality of the studies was assessed according to the Physiotherapy Evidence Database scale (PEDro). Qualitative analyses were conducted by means of the best evidence synthesis of van Peppen et al.
Results: The methodological quality of the 10 included RCTs (677 patients) varied between four and eight points. Eight studies reported significant reduction in pain and/or disability by TSM. Overall, according to the best evidence synthesis, there is insufficient evidence that TSM is more effective than control interventions in reducing pain and disability in patients with non-specific neck pain.
Conclusions: TSM has a therapeutic benefit to some patients with neck pain, when compared to the effect of interventions such as electrotherapy/thermal programme, infrared radiation therapy, spinal mobilization and exercises. However, in comparison to cervical spine manipulation, no evidence is found that TSM is more effective in reducing pain and disability.
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?
Inclusion Criteria: age 18-65 years, diagnosis of non-specific back pain, study interventions consisted of TSM alone or in combo with another intervention, interventions consisted of treatment of current neck pain (not prevention), RT or CCT.
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?
Physiotherapy Evidence Database (PEDro) scale was used to assess the quality of the studies. Two independent reviewers assessed methodological quality. Cohen’s kappa was calculated to be 0.92, almost perfect.
Were the included studies listed along with important characteristics and results of each study?
Yes
Was publication bias assessed?
No
Was heterogeneity assessed? (This question applies only to meta-analyses.)
Qualitative analysis conducted by means of best evidence synthesis.
Key Finding #1:
There is insufficient evidence that in patients with non-specific neck pain, TSM is more effective than control interventions at reducing pain and disability.
Key Finding #2:
There is no evidence that TSM-plus exercises are more effective than CSM-plus exercises in reducing pain and disability.
Key Finding #3:
Certain studies indicated that TSM combined with other treatments led to short-term improvements in pain and disability. These were not consistently superior to alternative treatments.
Please provide your summary of the paper:
This systematic review investigates the effectiveness of thoracic spine manipulation (TSM) in reducing pain and disability in patients with non-specific neck pain. It analyzes randomized control trials (RCTs) to assess whether TSM provides better outcomes compared to other interventions.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented:
This systemic review suggests TSM may provide some therapeutic benefit, particularly when combined with other interventions such as exercise therapy or electrotherapy. Given the insufficient evidence supporting TSM, clinicians should consider it as one possible intervention rather than a primary or stand-alone treatment. A multimodal approach should be used, including patient education, exercise therapy, and manual therapy techniques tailored to the patient’s condition. Patients should be screened individually, and clinicians should rely on patient response and preference when choosing treatment.
Author Names: Emilio J Puentedura, Jessica March, Joe Anders, Amber Perez, Merrill R Landers, Harvey W Wallmann, Joshua A Cleland
Reviewer Name: Julie Wilkerson
Reviewer Affiliation(s): Duke Doctor of Physical Therapy
Paper Abstract:
Background
Cervical spine manipulation (CSM) is a commonly utilized intervention, but its use remains controversial.
Purpose
To retrospectively analyze all available documented case reports in the literature describing patients who had experienced severe adverse events (AEs) after receiving CSM to determine if the CSM was used appropriately, and if these types of AEs could have been prevented using sound clinical reasoning on the part of the clinician.
Data sources
PubMed and the Cumulative Index to Nursing and Allied Health were systematically searched for case reports between 1950 and 2010 of AEs following CSM.
Study selection
Case reports were included if they were peer-reviewed; published between 1950 and 2010; case reports or case series; and had CSM as an intervention. Articles were excluded if the AE occurred without CSM (e.g. spontaneous); they were systematic or literature reviews. Data extracted from each case report included: gender; age; who performed the CSM and why; presence of contraindications; the number of manipulation interventions performed; initial symptoms experienced after the CSM; and type of resultant AE.
Data synthesis
Based on the information gathered, CSMs were categorized as appropriate or inappropriate, and AEs were categorized as preventable, unpreventable, or unknown. Chi-square analysis with an alpha level of 0.05 was used to determine if there was a difference in proportion between six categories: appropriate/preventable, appropriate/unpreventable, appropriate/unknown, inappropriate/preventable, inappropriate/unpreventable, and inappropriate/unknown.
Results
One hundred thirty four cases, reported in 93 case reports, were reviewed. There was no significant difference in proportions between appropriateness and preventability, P = .46. Of the 134 cases, 60 (44.8%) were categorized as preventable, 14 (10.4%) were unpreventable and 60 (44.8%) were categorized as ‘unknown’. CSM was performed appropriately in 80.6% of cases. Death resulted in 5.2% (n = 7) of the cases, mostly caused by arterial dissection.
Limitations
There may have been discrepancies between what was reported in the cases and what actually occurred, since physicians dealing with the effects of the AE, rather than the clinician performing the CSM, published many of the cases.
Conclusions
This review showed that, if all contraindications and red flags were ruled out, there was potential for a clinician to prevent 44.8% of AEs associated with CSM. Additionally, 10.4% of the events were unpreventable, suggesting some inherent risk associated with CSM even after a thorough exam and proper clinical reasoning.
Keywords: Adverse events, Case reports, Cervical spine, Manipulation, Risk of harm, Safety
Quality Assessment Tool for Case Series Studies
Was the study question or objective clearly stated?
Clearly stated.
Was the study population clearly and fully described, including a case definition?
Yes.
Were the cases consecutive?
No.
Were the subjects comparable?
Yes.
Was the intervention clearly described?
Yes.
Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?
Yes.
Was the length of follow-up adequate?
Yes.
Were the statistical methods well-described?
Yes.
Were the results well-described?
Yes.
Key Finding #1
Cervical spine manipulation adverse events can be classified as preventable, unpreventable, or unknown. However, since some could be unpreventable, even with a thorough screen and ruling out of red flags, there is still potential risk.
Key Finding #2
Of 134 cases reviewed where cervical spine manipulation was used as an intervention, death was a result in 5.2% of cases, primarily by arterial dissection. 44.8% of adverse events were preventable, 10.4% unpreventable, and 44.8% unknown.
Key Finding #3
Of the 134 cases reviewed where CSM was used as an intervention, it was found that the maneuver was performed appropriately 80.6% of the time.
Key Finding #4
By doing a thorough screen and ruling out red flags before performing cervical spine manipulation, clinicians can potentially prevent the risk of adverse events.
Please provide your summary of the paper
This paper was a retrospective analysis of 134 case reports on adverse events occurring after cervical spine manipulation. The goal was to see if the CSM was performed appropriately with correct screening and reasoning to gauge if events were preventable, unpreventable, or unknown. Case reports were selected if they were peer reviewed, published between 1950-2010, and had CSM as intervention. This paper considered factors like age, gender, who performed the manipulation/why, contraindications, how many manipulations, initial symptoms, and the type of adverse event. The case reports were then sorted by the type of adverse event: preventable, unpreventable, or unknown. Results showed 44.8% of adverse events were preventable, 10.4% unpreventable, and 44.8% unknown. However, there was no significant difference in proportions between appropriateness and preventability. Limitations and discrepancies may have been due to the fact that many of the cases were published by physicians facing the repercussions of adverse events rather than who performed the CSM. In conclusion, there may be evidence that when adverse events occur they could have been prevented, but there is also potential that some adverse events will occur despite proper evaluations and ruling out red flags.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
As a clinician, this paper serves as a reminder that with all interventions provided there is some level of risk involved and as always, proper screening and ruling out of red flags before performing a cervical spine manipulation is crucial to preventing adverse events. While results may not be conclusive, what is important is noting that sometimes adverse events occur that were unpreventable or due to unknown causes. However, 80% of the time in 134 cases CSM was performed “appropriately” and 44% of the adverse events were “preventable.” This should drive clinicians to perform cervical spine manipulations with sound clinical reasoning and thorough screening. It also should promote the use of literature and research when one has questions about when CSM is appropriate and what the contraindications are. These results could impact clinical practice as clinicians might need to be regulated or do continued education when their skills are deemed not appropriate or their clinical reasoning not sound for CSM.
Author Names: Nicola R. Heneghan, Ciprian Pup, Konstantinos Koulidis, Alison Rushton
Reviewer Name: Julie Wilkerson
Reviewer Affiliation(s): Duke Doctor of Physical Therapy
Paper Abstract:
ABSTRACT
Objectives: Spinal manipulative therapy (SMT) is widely used by manual therapists to manage spinal complaints. Notwithstanding the perceived relative safety of SMT, instances of severe thoracic adverse events (AE) have been documented. An evidence synthesis is required to understand the nature, severity and characteristics of thoracic AE following all SMT. The primary objective of this study was to report thoracic AE following SMT and secondly to report patient characteristics to inform further research for safe practice.
Methods: A systematic review and data synthesis were conducted according to a registered protocol (PROSPERO CRD42019123140). A sensitive topic-based search strategy for key databases, gray literature and registers used study population terms and keywords, to search to 12/6/19. Two reviewers were involved at each stage. Using the Oxford Center for Evidence-based Medicine (CEBM) the level evidence was evaluated with grade presented for each AE. Resultswere reported in the context of overall quality.
Results: From 1013 studies identified from searches, 19 studies (15 single case studies and 4 case series) reporting 21 unique thoracic AE involving the spinal cord tissues [nonvascular(n = 7), vascular (n = 6)], pneumothorax or hemothorax (n = 3), fracture (n = 3), esophageal rupture (n = 1), rupture of thoracic aorta (n = 1), partial pancreatic transection (n = 1). Reported outcomes included fully recovery (n = 8), permanent neurological deficit (n = 5), and death
(n = 4).
Conclusion: Although causality cannot be confirmed, serious thoracic AE to include permanent neurological deficit and death have been reported following SMT. Findings highlight the importance of clinical reasoning, including pre-thrust examination, as part of best and safe practice for SMT.
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?
Yes.
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.)
N/A.
Key Finding #1
While the direct cause of the adverse event was not confirmed to be spine manipulation, there have been reported death and serious neurological deficits reported after the intervention.
Key Finding #2
Adverse events recorded included most commonly spinal cord and cauda equina injury. Less common injuries included fracture, internal organ injury, or soft tissue trauma.
Key Finding #3
Findings such as adverse events in the event of undiagnosed pathologies in several cases support the importance of clinical reasoning and a thorough pre-thrust examination.
Key Finding #4
Causality of AE due to spine manipulation cannot be determined from this review. While it appears there are few reported cases of AE, research has limitations based on who published it (surgeons, physicians, etc) and who performed the manipulation (chiropractors, etc). This is why best practice guidelines are critical to ensure safe intervention.
Please provide your summary of the paper
The purpose of this paper was to understand the current evidence of thoracic adverse events after spinal manipulation and what patient characteristics were noted to support best clinical practice. A systematic review and data synthesis was performed and of 1013 studies identified from search, 19 studies selected demonstrated various adverse events including spinal cord injury, vascular compromise, pneumothorax/hemothorax, fracture, etc. Outcomes showed full recovery, severe neurologic compromise, and death. However, results showed that causality between spinal manipulation and thoracic adverse events cannot be confirmed due to limitations in the studies analyzed, including lack of patient characteristics documented, who performed the manipulation, who performed the study, etc. There is a gap in research, but in conclusion it is safest for clinicians to refer to practice guidelines and perform thorough pre-thrust examinations to rule out any contraindication beforehand.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Based on this paper, it is important to note that adverse events have been reported, particularly thoracic adverse events after spinal manipulation, but there is a significant gap in research and characteristics during research. Incorporating this risk into clinical practice is crucial, as clinicians should be performing proper screenings to ensure patients are fit for spinal manipulation and contraindications are ruled out. Also, due to the limitations in research and patient characteristics, clinicians should incorporate these conclusions into their practice by documenting efficiently.
Author Names
Jessica García-González, Raúl Romero-del Rey, Virginia Martínez-Martín, Mar Requena-Mullor and Raquel Alarcón-Rodríguez
Reviewer Name
Madison Zaun, SPT
Reviewer Affiliation(s)
Duke University Doctor of Physical Therapy Program – Class of 2026
Paper Abstract
Spinal manipulations for chronic non-specific neck pain (CNNP) include cervical, cervicothoracic junction, and thoracic spine (CCT) manipulations as well as upper cervical spine (UCS) manipulations. This study aimed to compare the short-term effects of UCS manipulation versus a combination of CCT spine manipulations on pain intensity, disability, and cervical range of motion (CROM) in CNNP patients. In a private physiotherapy clinic, 186 participants with CNNP were randomly assigned to either the UCS (n = 93) or CCT (n = 93) manipulation groups. Neck pain, disability, and CROM were measured before and one week after the intervention. No significant differences were found between the groups regarding pain intensity and CROM. However, there was a statistically significant difference in neck disability, with the CCT group showing a slightly greater decrease (CCT: 16.9 ± 3.8 vs. UCS: 19.5 ± 6.8; p = 0.01). The findings suggest that a combination of manipulations in the CCT spine results in a slightly more pronounced decrease in self-perceived disability compared to UCS manipulation in patients with CNNP after one week. However, no statistically significant differences were observed between the groups in terms of pain intensity or CROM.
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)?
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?
Yes
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
Key Finding #1
There was a significant difference between treatment groups in neck disability, with the cervical, cervicothoracic junction, and thoracic manipulation treatment group compared to the upper cervical spine manipulation treatment group after 1 week post intervention.
Key Finding #2
Both treatment groups showed a significant reduction in pain intensity 1 week post intervention, but there was no significant difference between the two treatment groups.
Please provide your summary of the paper
The article sought to compare short term effects of spinal manipulations at the upper cervical spine (USC) compared to a combination of manipulations at the cervical, cervicothoracic junction, and thoracic spine (CCT) on pain intensity, self-reported neck disability, and cervical range of motion. 210 patients with chronic non-specific neck pain were initially recruited to participate in the study and 186 remained after exclusions. The patients were randomly assigned to either the USC or the CCT treatment groups. A pre-treatment measure of neck pain intensity, neck disability, and cervical range of motion was taken. The patients then received their respective treatment at their initial evaluation. The USC group received an atlantoaxial joint manipulation and the CCT group received a thoracic spine manipulation as well as a mid-cervical manipulation, and a cervicothoracic junction manipulation. One week after the intervention, patients’ neck pain intensity, neck disability, and cervical range of motion were again measured. Analyses showed that there was no significant difference between the two groups for pain intensity and cervical range of motion, but there was a significant difference between the two groups for neck disability self-reports. Both groups did show a statistically significant decrease in the mean score of pain intensity one week after intervention. The researchers suggest that the manual treatment effects may be more attributed to neurophysiological aspects rather than mechanical. The nature of the study necessitates that the participants know their condition group and with that, participants in the CCT group were exposed to a broader set of spinal manipulations techniques than the UCS group. The researchers posit that this could have led participants in the CCT group to have higher perceptions and expectations of treatment. The researchers note their limitations such as having no placebo group and being unable to blind participants. They also mention that natural remission may have occurred and could have been an alternative explanation to results. The researchers also suggest that future research be done with a focus on longer term outcomes beyond one week and potentially assessing the impact of therapeutic exercise either in combination or in comparison to manual therapy of the spine for chronic non-specific 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 research has findings that may guide clinicians in their treatment of patients with chronic non-specific neck pain in the context of including techniques that target the cervical spine, cervicothoracic junction, and thoracic spine to reduce disability. Patients’ self-reported disability measure is a good indication of not only how well the patient is able to function amidst pain, but also how the patient feels regarding their injury. The research showed significant findings related to this measurement and thus, I can be helpful for clinicians looking to help patients improve their function and self-perception of their function. However, it is important to take this result with caution as these results may have been skewed by contextual factors such as that the CCT treatment group received a broader range of treatment when compared to the UCS group, which may have led to increased perception and expectation of treatment outcomes from the CCT group and could explain the results. The research did not find a significant change in cervical range of motion in either group but did find significant change in pain intensity ratings for both groups suggesting that the effects of the manual therapy treatment in this study may be linked to neurophysiological aspects rather than mechanical and thus, this treatment may be best for pain management rather than for gaining further range of motion. Further research is needed to gain a better appreciation of the effect and comparison of these interventions on this population.
Author Names
Jessica García-González, Raúl Romero-del Rey, Virginia Martínez-Martín, Mar Requena-Mullor and Raquel Alarcón-Rodríguez
Reviewer Name
Madison Zaun, SPT
Reviewer Affiliation(s)
Duke University Doctor of Physical Therapy Program – Class of 2026
Paper Abstract
Spinal manipulations for chronic non-specific neck pain (CNNP) include cervical, cervicothoracic junction, and thoracic spine (CCT) manipulations as well as upper cervical spine (UCS) manipulations. This study aimed to compare the short-term effects of UCS manipulation versus a combination of CCT spine manipulations on pain intensity, disability, and cervical range of motion (CROM) in CNNP patients. In a private physiotherapy clinic, 186 participants with CNNP were randomly assigned to either the UCS (n = 93) or CCT (n = 93) manipulation groups. Neck pain, disability, and CROM were measured before and one week after the intervention. No significant differences were found between the groups regarding pain intensity and CROM. However, there was a statistically significant difference in neck disability, with the CCT group showing a slightly greater decrease (CCT: 16.9 ± 3.8 vs. UCS: 19.5 ± 6.8; p = 0.01). The findings suggest that a combination of manipulations in the CCT spine results in a slightly more pronounced decrease in self-perceived disability compared to UCS manipulation in patients with CNNP after one week. However, no statistically significant differences were observed between the groups in terms of pain intensity or CROM.
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)?
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?
Yes
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
Key Finding #1
There was a significant difference between treatment groups in neck disability, with the cervical, cervicothoracic junction, and thoracic manipulation treatment group compared to the upper cervical spine manipulation treatment group after 1 week post intervention.
Key Finding #2
Both treatment groups showed a significant reduction in pain intensity 1 week post intervention, but there was no significant difference between the two treatment groups.
Please provide your summary of the paper
The article sought to compare short term effects of spinal manipulations at the upper cervical spine (USC) compared to a combination of manipulations at the cervical, cervicothoracic junction, and thoracic spine (CCT) on pain intensity, self-reported neck disability, and cervical range of motion. 210 patients with chronic non-specific neck pain were initially recruited to participate in the study and 186 remained after exclusions. The patients were randomly assigned to either the USC or the CCT treatment groups. A pre-treatment measure of neck pain intensity, neck disability, and cervical range of motion was taken. The patients then received their respective treatment at their initial evaluation. The USC group received an atlantoaxial joint manipulation and the CCT group received a thoracic spine manipulation as well as a mid-cervical manipulation, and a cervicothoracic junction manipulation. One week after the intervention, patients’ neck pain intensity, neck disability, and cervical range of motion were again measured. Analyses showed that there was no significant difference between the two groups for pain intensity and cervical range of motion, but there was a significant difference between the two groups for neck disability self-reports. Both groups did show a statistically significant decrease in the mean score of pain intensity one week after intervention. The researchers suggest that the manual treatment effects may be more attributed to neurophysiological aspects rather than mechanical. The nature of the study necessitates that the participants know their condition group and with that, participants in the CCT group were exposed to a broader set of spinal manipulations techniques than the UCS group. The researchers posit that this could have led participants in the CCT group to have higher perceptions and expectations of treatment. The researchers note their limitations such as having no placebo group and being unable to blind participants. They also mention that natural remission may have occurred and could have been an alternative explanation to results. The researchers also suggest that future research be done with a focus on longer term outcomes beyond one week and potentially assessing the impact of therapeutic exercise either in combination or in comparison to manual therapy of the spine for chronic non-specific 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 research has findings that may guide clinicians in their treatment of patients with chronic non-specific neck pain in the context of including techniques that target the cervical spine, cervicothoracic junction, and thoracic spine to reduce disability. Patients’ self-reported disability measure is a good indication of not only how well the patient is able to function amidst pain, but also how the patient feels regarding their injury. The research showed significant findings related to this measurement and thus, I can be helpful for clinicians looking to help patients improve their function and self-perception of their function. However, it is important to take this result with caution as these results may have been skewed by contextual factors such as that the CCT treatment group received a broader range of treatment when compared to the UCS group, which may have led to increased perception and expectation of treatment outcomes from the CCT group and could explain the results. The research did not find a significant change in cervical range of motion in either group but did find significant change in pain intensity ratings for both groups suggesting that the effects of the manual therapy treatment in this study may be linked to neurophysiological aspects rather than mechanical and thus, this treatment may be best for pain management rather than for gaining further range of motion. Further research is needed to gain a better appreciation of the effect and comparison of these interventions on this population. In the meantime, clinicians can use the results of this study to help guide potential treatment to those with a rotator cuff lesion and/or shoulder impingement syndrome by providing mobilizations with movement with kinesiotaping in the time between manual treatments, particularly to reduce the patient’s perception of pain.
Author Names
Borusiak, P., Biedermann, H., Bosserhoff, S., & Opp, J. (2010).
Reviewer Name
Yushan Zhang
Reviewer Affiliation(s)
Duke University Doctor of Physical Therapy Program
Paper Abstract
Objective: Clinical trials concerning cervical spine manipulation and mobilization in children and adolescents with cervicogenic headache are lacking. Methods: We performed a multicenter, prospective, randomized, placebo-controlled, and blinded trial in 52 children and adolescents (21 boys, 31 girls) aged 7-15. After prospective baseline documentation for 2 months patients were either assigned to placebo or true manipulation with another 2-month follow-up. Main outcome measures were defined as: percentage of days with headache, total duration of headache, days with school absence due to headache, consume of analgesics, intensity of headache.Results: We did not find a significant difference comparing the groups with placebo and true manipulation with respect to the defined main outcome measures.
NIH Risk of Bias Tool: Answer Only the Questions Specific to Tool Used, Delete All Other Tool Items, THEN DELETE THIS HIGHLIGHTED INSTRUCTIONS.
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)?
Cannot Determine, Not Reported
Were study participants and providers blinded to treatment group assignment?
no
Were the people assessing the outcomes blinded to the participants’ group assignments?
Cannot Determine, Not Reported
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?
Cannot Determine, Not Reported
Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Cannot Determine, Not Reported
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
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?
yes
Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
no
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
Key Finding #1
There was no statistically significant reduction in the percentage of days with headaches in the manual therapy group compared to the placebo group after the intervention period.
Key Finding #2
Both groups reported similar total headache duration and headache intensity over the follow-up period. Manual therapy did not lead to a meaningful reduction in how long the headaches lasted or how severe they were.
Key Finding #3
There was no significant difference between the manual therapy and placebo groups in the amount of pain medication used or the number of school days missed, indicating that the intervention did not improve these functional outcomes either.
Summary of the Paper:
The study by Borusiak et al. aimed to evaluate the effectiveness of cervical spine manipulation in treating cervicogenic headaches among children and adolescents. The included 52 participants aged 7 to 15 years. Following a 2 month baseline documentation period, participants were randomized to receive either true cervical spine manipulation or a placebo intervention, with outcomes assessed over a subsequent 2-month follow-up. The primary outcome measures were the percentage of days with headache, total duration of headaches, days absent from school due to headaches, analgesic consumption, and headache intensity. The study found no significant differences between the treatment and placebo groups across these measures, indicating that cervical spine manipulation did not demonstrate efficacy in this population
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
The results of this study indicate that cervical spine manipulation does not provide significant benefits for children and adolescents with suspected cervicogenic headaches. Clinicians should exercise caution when considering manual therapy for this demographic and explore alternative evidence-based treatments. Implementing these findings into clinical practice involves prioritizing interventions with demonstrated efficacy and safety for managing pediatric cervicogenic headaches.
