A Comparison of the Effects of Stabilization Exercises Plus Manual Therapy to Those of Stabilization Exercises Alone in Patients With Nonspecific Mechanical Neck Pain: A Randomized Clinical Trial – Duke Center of Excellence in Manual and Manipulative Therapy

Author Names

Celenay, S., Akbayrak, T., Kaya, D.

Reviewer Name

Alyssa Bush, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Little is known about the efficacy of providing manual therapy in addition to cervical and scapulothoracic stabilization exercises in people with mechanical neck pain (MNP). The purpose of this study was to compare the effects of stabilization exercises plus manual therapy to those of stabilization exercises alone on disability, pain, range of motion (ROM), and quality of life in patients with mechanical neck pain (MNP). 102 patients with MNP (18-65 years of age) were recruited and randomly placed into 2 groups: stabilization exercise without (n=51) and with (n=51) manual therapy. The program was carried out 3 days per week for 4 weeks. The Neck Disability Index (NDI), visual analog pain scale, digital algometry of pressure pain threshold, goniometric measurements, and Medical Outcomes Study 36-Item Short-Form Health Survey were used to assess participants at baseline and after 4 weeks. Following the 4 week program, improvements in NDI score, night pain, rotation ROM, and the Medical Outcomes Study 36-Item Short-Form Health Survey score were greater in the group that received stabilization exercise with manual therapy compared to the group that only received stabilization exercise. Between-group differences (95% confidence interval) were 2.2 (0.1, 4.3) points for the NDI, 1.1 (0.0, 2.3) cm for pain at night measured on the visual analog scale, -4.3 (-8.1, -0.5) and -5.0 (-8.2, -1.7) for right and left rotation ROM, respectively, and -2.9 (-5.4, -0.5) points and -3.1 (-6.2, 0.0) points for the Medical Outcomes Study 36-Item Short-Form Health Survey physical and mental components, respectively. Changes in resting and activity pain, pain pressure threshold, and cervical extension or lateral flexion ROM did not differ significantly between the groups. Pressure pain threshold increased only in those who received stabilization exercise with manual therapy (P<0.5). The results of this study suggest that stabilization exercises with manual therapy may be superior to stabilization exercises alone for improving disability, pain intensity at night, cervical rotation motion, and quality of life in patients with MNP.

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

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?

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?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

The group that completed a treatment course of stabilization exercise plus manual therapy for 4 weeks experienced significantly greater improvements in disability than the stabilization exercise only group.

Key Finding #2

Patients in the stabilization exercise plus manual therapy group experienced greater improvements in night neck pain than patients in the stabilization exercise only group.

Key Finding #3

Patients in the stabilization exercise plus manual therapy group showed significantly greater improvements in quality of life than the stabilization exercise only group as evident by improved physical component summary (PCS) and mental component summary (MCS) MCS scores on the SF-36.

Please provide your summary of the paper

This study was a randomized clinical trial comparing stabilization exercise to stabilization exercise plus manual therapy in patients with mechanical neck pain (MNP). Patients underwent interventions 3 times a week for 4 weeks. At the end of the 4 week study period, outcome measures were given including the SF-36, the visual analog scale for neck pain at rest, at night and during activity, the Neck Disability Index, and cervical range of motion measurements. The study found that stabilization exercises combined with manual therapy, when compared to stabilization exercises alone lead to greater improvements in disability, neck pain intensity at night, cervical rotation range of motion and quality of life for patients with MNP. This evidence suggests that use of stabilization exercises in combination with manual therapy may be an effective treatment for patients with mechanical neck pain. Although the stabilization exercise plus manual therapy group experienced statistically significant improvements in disability, neck pain at night, cervical rotation range of motion and quality of life, the 95% confidence interval for the Neck Disability Index score and the VAS included the respective MCIDs. Therefore, the authors questioned whether the effects seen in the stabilization exercise plus manual therapy group were clinically significant. A limitation of this study was the 4 week time frame, which limited the ability to assess longer-term effects of treatment. Although this study showed significant benefits to use of manual therapy plus stabilization exercises, the authors noted that it cannot be interpreted that use of stabilization exercise alone is ineffective for treating MNP.

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 suggests that use of stabilization exercises plus manual therapy may be effective for patients with MNP. Additionally, the study suggests that this course of treatment may lead to improvements in disability, quality of life, neck pain at night and cervical rotation range of motion in as little as 4 weeks of treatment. Integrating manual therapy with stabilization exercise when managing patients with MNP could lead to improvements in efficiency and outcomes for management of patients with mechanical neck pain according to the evidence presented in this study. Although the study was limited by duration and not all improvements seen in the stabilization plus manual therapy group were clinically significant, this paper highlights possible benefits of combining manual therapy with stabilization exercises for treatment of MNP and sets the foundation for further research on long term effects of combining manual therapy with stabilization exercise for treatment of MNP.