Article: Masaracchio M, Kirker K, States R, Hanney WJ, Liu X, Kolber M. Thoracic spine manipulation for the management of mechanical neck pain: A systematic review and meta-analysis. PLoS One. 2019;14(2):e0211877. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6373960/  

Study Design: Systematic Review  

Abstract: The study’s objective was to investigate the role of thoracic spine manipulation (TSM) on pain and disability in the management of mechanical neck pain (MNP). The study reviewed the electronic databases of: PubMed, CINAHL, Pedro, Embase, AMED, the Cochrane Library, and clinicaltrials.gov were searched in January 2018. Eligible studies were completed RCTs, written in English, had at least 2 groups with one group receiving TSM, had at least one measure of pain or disability, and included patients with MNP of any duration. The search identified 1717 potential articles, with 14 studies meeting inclusion criteria. Methodological quality was evaluated independently by two authors using the guidelines published by the Cochrane Collaboration. Pooled analyses were analyzed using a random-effects model with inverse variance methods to calculate mean differences (MD) and 95% confidence intervals for pain (VAS 0-100mm, NPRS 0-10pts; 0 = no pain) and disability (NDI and NPQ 0–100%; 0 = no disability). Across the included studies, there was increased risk of bias for inadequate provider and participant blinding. The GRADE approach demonstrated an overall level of evidence ranging from very low to moderate. Meta-analysis that compared TSM to thoracic or cervical mobilization revealed a significant effect favoring the TSM group for pain (MD -13.63; 95% CI: -21.79, -5.46) and disability (MD -9.93; 95% CI: -14.38, -5.48). Meta-analysis that compared TSM to standard care revealed a significant effect favoring the TSM group for pain (MD -13.21; 95% CI: -21.87, -4.55) and disability (MD -11.36; 95% CI: -18.93, -3.78) at short-term follow-up, and a significant effect for disability (MD -4.75; 95% CI: -6.54, -2.95) at long-term follow-up. Meta-analysis that compared TSM to cervical spine manipulation revealed a non-significant effect (MD 3.43; 95% CI: -7.26, 14.11) for pain without a distinction between immediate and short-term follow-up. The greatest limitation in this systematic review was the heterogeneity among the studies making it difficult to assess the true clinical benefit, as well as the overall level of quality of evidence. The authors conclude that TSM has been shown to be more beneficial than thoracic mobilization, cervical mobilization, and standard care in the short-term, but no better than cervical manipulation or placebo thoracic spine manipulation to improve pain and disability. 

NIH Risk of Bias Score: 8/8 (Low Risk of Bias) 

Key Findings of the Study 

  1. Thoracic spine manipulation (TSM) provided short-term pain, disability, and self-perceived rating of change in function in the majority of studies.  
  1. The technique should theoretically reduce the risk of adverse events that are present with spinal manipulation of the neck 
  1. Clinicians should interpret these findings carefully with an overall quality of evidence ranging from very low to moderate 

Reviewer Summary: There does seem to be a short-term effect with thoracic manipulation for neck pain and function. The quality of the many studies is generally low and the effect does not seem to last much longer than 1 week (although some found differences between groups at longer periods. TSM appears to be a useful approach for selected individuals with neck pain in which a clinician may have concerns about applying direct manual therapy at the neck.