Cervicothoracic

Spinal Manipulative Therapy for Adolescent Idiopathic Scoliosis: A Systematic Review

Author Names

Theroux, J; Stomski, N; Dominique Losco, C; Khadra, C; Labelle, H; Le May, S

Reviewer Name

Timothy Dow, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: The purpose of this study was to perform a systematic review of clinical trials of spinal manipulative therapy for adolescent idiopathic scoliosis. Methods: Search strategies were developed for PubMed, CINHAL, and CENTRAL databases. Studies were included through June 2016 if they were prospective trials that evaluated spinal manipulative therapy (eg, chiropractic, osteopathic, physical therapy) for adolescent idiopathic scoliosis. Data were extracted and assessed by 2 independent reviewers. Cochrane risk of bias tools were used to assess the quality of the included studies. Data were reported qualitatively because heterogeneity prevented statistical pooling. Results: Four studies satisfied the inclusion criteria and were critically appraised. The findings of the included studies indicated that spinal manipulative therapy might be effective for preventing curve progression or reducing Cobb angle. However, the lack of controls and small sample sizes precluded robust estimation of the interventions’ effect sizes. Conclusion: There is currently insufficient evidence to establish whether spinal manipulative therapy may be beneficial for adolescent idiopathic scoliosis. The results of the included studies suggest that spinal manipulative therapy may be a promising treatment, but these studies were all at substantial risk of bias. Further high-quality studies are warranted to conclusively determine if spinal manipulative therapy may be effective in the management of adolescent idiopathic scoliosis. (J Manipulative Physiol Ther 2017;40:452-458) Key Indexing Terms: Spinal Manipulation; Scoliosis; Adolescent; Cobb Angle; Systematic Review

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?

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?

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.)

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Due to limited studies meeting inclusion criteria (4), small samples (5, 6, 42, 156), high risk of bias, studies assessing multiple interventions at once, and lack of control groups, the author concludes that the strength of evidence for spinal manipulative therapy as an effective treatment for adolescent idiopathic scoliosis is low and further high-quality research is required to assess this topic.

Key Finding #2

3 of the 4 studies utilized spinal manipulative therapy in conjunction with other interventions to measure Cobb angle outcomes. Thus, spinal manipulative therapy was not isolated in these studies to understand its effect on adolescent idiopathic scoliosis.

Key Finding #3

Cobb angle was the only outcome measure assessed in each of the studies. Future studies should include additional measures such as pain, disability, quality of life, aesthetic concern, and curve progression.

Please provide your summary of the paper

This study was a systematic review conducted to determine the effect of spinal manipulative therapy on adolescent idiopathic scoliosis. The study searched PubMed, CINHAL, and CENTRAL databases for relevant research studies on this topic that were reported in either English or French. 143 articles were identified in the search. After further screening of these studies, only 4 articles met the inclusion criteria. Of the four studies, one was a randomized controlled pilot study while the remaining three were nonrandomized trials. In each of the studies, the Cobb angle was the outcome measure that was assessed to determine the effectiveness of the spinal manipulative interventions. The author suggests that additional outcomes such as pain, disability, quality of life, aesthetic concern, and curve progression are other measures that are relevant to capture in addition to just Cobb angle. The sample sizes for studies included in this analysis were: 5, 6, 42, and 156. Therefore, the small sample sizes across three of these studies resulted in unreliable estimates of effect size. Two of the studies included a control group while two of the studies did not. Additionally, three of the four studies utilized other interventions in addition to spinal manipulative therapy, making causal relationships between treatments and outcomes difficult to assess. The author also reports substantial risk of bias among the studies included in the systematic analysis. Of the studies, two of them found that Cobb angle was significantly reduced and the other two studies found that there was no significant reduction in Cobb angle. The author concludes that the overall strength of evidence for spinal manipulative therapy as an effective treatment for adolescent idiopathic scoliosis is low. The author states that there may be a benefit of spinal manipulative therapy for adolescent idiopathic scoliosis but additional high-quality studies are needed to validate this claim.

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 highlights the lack of high-quality research on the topic of spinal manipulative therapy and its effect on patients with adolescent idiopathic scoliosis. The search that these authors conducted yielded only 4 studies to be included in the systematic review and there were significant limitations to each of the studies. Small sample sizes, lack of isolating a single independent variable to study, high risk of bias, lack of control groups, a lack of diversity in patient outcome measures, and variable study results all combine to demonstrate that evidence for spinal manipulative therapy as an effective intervention for adolescent idiopathic scoliosis is currently unsupported. Two of the studies demonstrated significant results, however, due to the limitations listed above, it cannot be assumed that spinal manipulative therapy is an effective intervention for adolescent idiopathic scoliosis. This study ultimately demonstrates that further research is required to determine whether or not spinal manipulative therapy is an effective treatment strategy for adolescent idiopathic scoliosis. Therefore, spinal manipulative therapy cannot be recommended as an evidence-based treatment strategy for adolescent idiopathic scoliosis at this time.

The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review.

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?

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?

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.)

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.

Manual therapy interventions in the management of adults with prior cervical spine surgery for degenerative conditions: a scoping review

Author Names

Gliedt, J., Dawson, A., Daniels, C., Spector A., Cupler, Z., King, J., Egede, L.

Reviewer Name

Anastasia Engelsman

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Cervical spine surgeries for degenerative conditions are rapidly increasing. Cervical post-surgery syndrome consisting of chronic pain, adjacent segment disease, recurrent disc herniation, facet joint pain, and/or epidural scarring is common. Repeat surgery is regularly recommended, though patients are often unable to undergo or decline further surgery. Manual therapy is included in clinical practice guidelines for neck pain and related disorders, however clinical guidance for utilization of manual therapy in adults with prior cervical spine surgery is lacking. This study aimed to synthesize available literature and characterize outcomes and adverse events for manual therapy interventions in adults with prior cervical spine surgery due to degenerative conditions.

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?

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?

Cannot Determine, Not Reported, Not Applicable

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?

Was publication bias assessed?

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

There is very limited research available regarding the use of manual therapy following spine surgery for degenerative conditions. Only 2 RCT’s have been published on the matter with the remaining research limited to case studies.

Key Finding #2

Manual therapy following cervical spinal surgery for degenerative conditions may result in advantageous clinical outcomes. Positive results were found in 10 out of the 12 articles reviewed in this study. These include: return to work, pain reduction, increased cervical ranges of motion, decreased disability index, increased sensation, increased grip strength, improvement in fear reduction, and reduction of opioid therapy.

Please provide your summary of the paper

The use of surgery for cervical spine degenerative conditions has been increasing, however, there is very little clinical guidance regarding manual therapy in this population. This paper performed a systematic review of all studies analyzing the effects of manual therapy intervention on adults with prior cervical spine surgery due to degenerative conditions. Following systematic review, only 12 articles were identified, consisting of 10 case reports and 2 RTC’s. All studies included the usage of manual joint mobilization and/or table/instrument assisted manipulation. Out of the 12 studies, 10 reported improved clinical outcomes as a result of manual therapy. 2 studies reported serious adverse events. Given that manual therapy is being practiced on individuals following spinal surgery, further research is imperative to examine the safety of this modality on 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.

This study demonstrated that manual therapy may elicit positive outcomes for patients who received cervical spinal surgery for degenerative diseases. These positive outcomes may include return to work, pain reduction, increased cervical ranges of motion, decreased disability index, increased sensation, increased grip strength, improvement in fear reduction, and reduction of opioid therapy. This study also found a very high proportion of adverse events when compared to the original sample of the review.

Effect of Manual Therapy and Therapeutic Exercise Applied to the Cervical Region on Pain and Pressure Pain Sensitivity in Patients with Temporomandibular Disorders: A Systematic Review

Author Names

La Touche, R., Garcia, S., Garcia, B., Acosta, A., Juarez, D., Perez, J., Angualo-Diaz-Parreno, S., Cuenca-Martinez, F., Paris-Alemany, A., Suso-Marti, L.

Reviewer Name

Anastasia Engelsman

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective. To assess the effectiveness of cervical manual therapy (MT) on patients with temporomandibular disorders (TMDs) and to compare cervico-craniomandibular MT vs cervical MT. Design. Systematic review and meta-analysis (MA). Methods. A search in PubMed, EMBASE, PEDro, and Google Scholar was conducted with an end date of February 2019. Two independent reviewers performed the data analysis, assessing the relevance of the randomized clinical trials regarding the studies’ objectives. The qualitative analysis was based on classifying the results into lev- els of evidence according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Results. Regarding cervical MT, MA included three studies and showed statistically significant differences in pain in- tensity reduction and an increase in masseter pressure pain thresholds (PPTs), with a large clinical effect. In addition, the results showed an increase in temporalis PPT, with a moderate clinical effect. MA included two studies on cervi- cal MT vs cervico-craniomandibular MT interventions and showed statistically significant differences in pain inten- sity reduction and pain-free maximal mouth opening, with a large clinical effect. Conclusions. Cervical MT treatment is more effective in decreasing pain intensity than placebo MT or minimal intervention, with moderate evidence. Cervico-craniomandibular interventions achieved greater short-term reductions in pain intensity and increased pain- free MMO over cervical intervention alone in TMD and headache, with low evidence.

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?

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?

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

Tempo mandibular joint disorder can be treated with cervical or craniomandibular manual therapy interventions and may be even more effective than cervical interventions alone.

Key Finding #2

In comparison to no intervention or cervical intervention alone, manual therapy significantly decreased pain intensity and pressure pain thresholds.

Please provide your summary of the paper

It has been well known that manual therapy is an effective treatment for tempo mandibular joint disorder (TMD), however, it is unknown which area or type of intervention may produce the most effective outcomes. The purpose of this study was to analyze current research for the effectiveness of cervical manual therapy (MT) in patient with TMD and to compare the usefulness of cervico-craniomandibular MT treatment vs cervical treatment. Two researchers conducted a PRISMA-based search for relevant literature to complete the systematic review and meta-analysis. Articles were chosen based on their relevance to the studies objectives, inclusion criteria, and publication before 2019. 6 articles were found to fit all criteria, and it was discovered that cervical MT treatment is more effective at reducing pain than no MT intervention. Furthermore, cervico-craniomandibular MT interventions achieved greater short-term reductions in pain intensity than cervical intervention alone in individuals with TMD.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This review demonstrated that TMD may be treated successfully with cervical or craniomandibular MT interventions and may be even more effective than cervical interventions alone. In comparison to no intervention or cervical intervention, MT significantly decreased pain intensity and pressure pain thresholds. Due to the nature of the review, however, the forms of MT intervention were not uniform in terms of type of manipulation, amplitude, and frequency. More research is needed to determine the most advantageous type and frequency of manipulations for tempo mandibular disorders. In the present, clinicians should utilize MT in the treatment of TMD in addition to other cervical or cervico-craniomandibular interventions.

Thoracic spine thrust manipulation versus cervical spine thrust manipulation in patients with acute neck pain: a randomized clinical trial

Author Names

Puentedura, E. et al.

Reviewer Name

Miranda Frohlich, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: A CPR had been proposed to identify patients with neck pain who would likely respond favorably to thoracic spine TJM. Research on validation of that CPR had not been completed when this trial was initiated. In our clinical experience, though many patients with neck pain responded favorably to thoracic spine TJM, they often reported that their symptomatic cervical spine area had not been adequately addressed.

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)?

Cannot Determine, Not Reported, or Not Applicable

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)?

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?

Cannot Determine, Not Reported, or Not Applicable

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

Patients who were treated with a combination of cervical spine TJM (thrust joint manipulation) and exercises showed significant improvements in pain and disability compared to patients who were treated with thoracic spine TJM and exercises.

Key Finding #2

Findings showed fewer and shorter post-treatment side effects for patients who were treated with a combination of cervical spine TJM and exercise versus thoracic spine TJM and exercise.

Key Finding #3

The clinical prediction rule (CPR) criteria for the success of thoracic spine TJM combined with exercise for the treatment of patients with neck pain, may actually be a more useful tool in identifying patients who would benefit from cervical spine TJM and exercise.

Please provide your summary of the paper

This study was performed to assess if patients who met the CPR criteria for the success of thoracic spine thrust joint manipulation (TJM) for the treatment of neck pain would have a different/improved outcome if they were treated with a cervical spine TJM. This study consisted of 2 treatment groups for which all patients were randomly assigned, with a primary complaint of neck pain, and meeting 4 out of 6 CPR criteria for thoracic TJM . The thoracic spine group was treated with thoracic TJM and cervical range-of-motion (ROM) exercise. The cervical spine group was treated with cervical TJM and the same cervical range-of-motion (ROM) exercises. A standardized exercise program was given to both groups after the first 2 sessions for the following 3 sessions. There were several methods used to compare changes in pain and function, including the Neck Disability Index (NDI), numeric pain rating scale (NPRS), and Fear-Avoidance Beliefs Questionnaire – physical activity and work (FABQ-PA and FABQ-W). These outcome measures are reliable and were collected at week 1, week 4, and 6 months. It can be strongly suggested from the results of this study that patients with neck pain of less than 30 days, who meet 4 out of 6 CPR criteria for thoracic spine TJM, may demonstrate better outcomes and benefit more from cervical than thoracic TJM. Furthermore, patients receiving cervical TJM presented with fewer transient post treatment side-effects (neck pain, headache, fatigue). There are important limitations concerning the results of this study including: small sample size (24 participants), generalization of acute neck pain (neck pain for less than 30 days), recruitment from 1 of 2 clinics in Las Vegas, use of Bonferroni correction, and all interventions provided by 1 physical therapist. Future testing with appropriate sample sizes, more diversity, and an increased number of practitioners will be needed to better apply these findings to the neck pain population as a whole.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

I believe the study was conducted diligently and with good intention to better a clinical prediction rule (CPR) that’s validity has recently been questioned. I find the results of this study to be very enlightening and hope future studies are conducted for better application in clinical practice.

Acute effects of manual therapy on respiratory parameters in thoracic outlet syndrome

Author Names

Tüzün Fırat, Melda Sağlam, Naciye Vardar Yağlı, Yasin Tunç, Ebru Çalık Kütükçü, Kıvanç Delioğlu, Deniz İnal İnce, Hülya Arıkan, and Bülent Mustafa Yenigün

Reviewer Name

Erik Furseth SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy

Paper Abstract

Background This study aims to investigate the acute effects of manual therapy on pain perception and respiratory parameters in patients with thoracic outlet syndrome. Methods The study included 10 patients with thoracic outlet syndrome (1 male, 9 females; mean age 31.3±9.0 years; range, 20 to 43 years). Patients were accepted in a single session of manual therapy involving the cervical spine and thorax. Stretching of scalene, upper trapezius, sternocleidomastoid, rectus abdominis, hip flexor muscles; and mobilization of first rib, cervical and thoracic spine, sacroiliac joints and thorax were applied as manual therapy program. Pain perceptions of upper arm and neck were assessed with visual analog scale. Measurements were performed before and immediately after of a 30-minute session of manual therapy. Pulmonary function testing was performed with a spirometer. Respiratory muscle strength (inspiratory and expiratory muscle strength, maximal inspiratory pressure and maximal expiratory pressure, respectively) was measured. Respiratory muscle endurance was recorded using sustained threshold loading of 35% maximal inspiratory pressure. Results There were no significant changes in any pulmonary function parameters or maximal expiratory pressure following manual therapy intervention (p>0.05). However, maximal inspiratory pressure and respiratory muscle endurance improved (p<0.05). Pain perceptions of upper arm and neck reduced after treatment (p<0.05). Conclusion A 30-minute single manual therapy session improved inspiratory muscle strength and respiratory muscle endurance but not pulmonary function and expiratory muscle strength in patients with thoracic outlet syndrome. Manual therapy may facilitate functional breathing and support use of primary respiratory muscles more effectively together with rapid pain reduction. The long-term effects of regular manual therapy on respiratory parameters should be investigated after surgical procedures.

NIH Risk of Bias Tool

Was the study question or objective clearly stated?

Were eligibility/selection criteria for the study population prespecified and clearly described?

Were the participants in the study representative of those who would be eligible for the test/service/intervention in the general or clinical population of interest?

Were all eligible participants that met the prespecified entry criteria enrolled?

Was the sample size sufficiently large to provide confidence in the findings?

Was the test/service/intervention clearly described and delivered consistently across the study population?

Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed consistently across all study participants?

Were the people assessing the outcomes blinded to the participants’ exposures/interventions?

Cannot Determine, Not Reported, Not Applicable

Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?

Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that provided p values for the pre-to-post changes?

Were outcome measures of interest taken multiple times before the intervention and multiple times after the intervention (i.e., did they use an interrupted time-series design)?

If the intervention was conducted at a group level (e.g., a whole hospital, a community, etc.) did the statistical analysis take into account the use of individual-level data to determine effects at the group level?

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

A 30-minute single manual therapy session improved inspiratory muscle strength and respiratory muscle endurance in patients with thoracic outlet syndrome.

Key Finding #2

A 30-minute single manual therapy session did not improve pulmonary function and expiratory muscle strength in patients with thoracic outlet syndrome.

Key Finding #3

Manual therapy may facilitate functional breathing and support use of primary respiratory muscles more effectively together with rapid pain reduction.

Key Finding #4

The use of manual therapy techniques can help reduce pain with breathing in patients with thoracic outlet syndrome.

Please provide your summary of the paper

The purpose of this study was to investigate the acute effects of manual therapy on pain perception and respiratory parameters in patients with thoracic outlet syndrome (TOS). 10 patients with neurogenic thoracic outlet syndrome (TOS) (1 male, 9 females; mean age 31.9 +/- 9.0 years; range, 20-41) were included in this study. To start, patients had their age, gender, height, and weight taken and BMI calculated. Each patient was asked for their VAS pain rating score. Respiratory muscle strength was measured for each patient (both maximal inspiratory pressure and maximal expiratory pressure) using a rigid flanged mouthpiece. Respiratory muscle endurance tests were measured with a threshold loading inspiratory muscle trainer device. Tests were repeated until there were no improvements and there was less than a 10% difference between the two best tests. For the manipulations, patients were positioned in supine, given 5 minutes to rest, and had soft tissue mobilizations to various inspiratory and expiratory muscle groups, mobs to the costovertebral, costotransverse and SI joints, manipulations to the T5 to T9 using thrust techniques, and finally, mobs of the upper cervical spine using the Mulligan technique while patients were sitting. Then the patients were reassessed for their inspiratory and expiratory volume. In conclusion of the study, the researchers found no significant differences were found in the patients’ pulmonary function and expiratory muscle strength. They did find significant change in the patients’ inspiratory muscle strength and their muscular endurance. Lastly, they found a meaningful change in the patients functional breathing and rapid reduction in pain.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Although the use of these multiple manipulations did not work on patients pulmonary functions and expiratory muscle strength, they did find some benefits in inspiratory muscle strength and muscular endurance. This could prove beneficial before getting patients up and moving. There was also a significant change in patient pain rating, which could help get patient buy-in, allowing for more rehabilitation exercises to be done and a greater adherence to therapy.

Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review

Author Names

Peter Hoogvliet,1 Manon S Randsdorp,1,2 Rudi Dingemanse,1,2 Bart W Koes,2 Bionka M A Huisstede1,2

Reviewer Name

Kayla (Sloane) Grace, Duke SPT, B.S Exercise Physiology

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Owing to the change in paradigm of the histological nature of epicondylitis, therapeutic modalities as exercises such as stretching and eccentric loading and mobilisation are considered for its treatment.

Objective: To assess the evidence for effectiveness of exercise therapy and mobilisation techniques for both medial and lateral epicondylitis.

Methods: Searches in PubMed, Embase, Cinahl and Pedro were performed to identify relevant randomised clinical trials (RCTs) and systematic reviews. Two reviewers independently extracted data and assessed the methodological quality.

Results: One review and 12 RCTs, all studying lateral epicondylitis, were included. Different therapeutic regimes were evaluated: stretching, strengthening, concentric/eccentric exercises and manipulation of the cervical or thoracic spine, elbow or wrist. No statistical pooling of the results could be performed owing to heterogeneity of the included studies. Therefore, a best-evidence synthesis was used to summarise the results. Moderate evidence for the short-term effectiveness was found in favour of stretching plus strengthening exercises versus ultrasound plus friction massage. Moderate evidence for short-term and midterm effectiveness was found for the manipulation of the cervical and thoracic spine as add-on therapy to concentric and eccentric stretching plus mobilisation of wrist and forearm. For all other interventions only limited, conflicting or no evidence was found.

Conclusions: Although not yet conclusive, these results support the belief that strength training decreases symptoms in tendinosis. The short-term analgesic effect of manipulation techniques may allow more vigorous stretching and strengthening exercises resulting in a better and faster recovery process of the affected tendon in lateral epicondylitis.

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?

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?

Were the included studies listed along with important characteristics and results of each study?

Was publication bias assessed?

Key Finding #1

“The short-term analgesic effect of manipulation techniques may allow the patient to do more vigorous stretching and strengthening exercises and, therefore, allow better and faster recovery of the affected tendon in LE resulting in decreased pain and improved function on the midterm” (Hoogvliet et. al).

Key Finding #2

Several works implemented a follow-up period that was relatively short (as short as immediately after treatment), and the question remains as to what the long-term effects (which are clinically more relevant) of these treatments might be.

Key Finding #3

“Moderate evidence for short-term and midterm effectiveness was found for the manipulation of the cervical and thoracic spine as add-on therapy to concentric and eccentric stretching plus mobilization of wrist and forearm” (Hoogvliet et. al).

Please provide your summary of the paper

The aim of this systematic review was to examine the effectiveness of exercise and mobilization techniques in treating medial and lateral epicondylitis. 232 reviews/RCTs were assessed based on five inclusion criteria and one review and 12 RCTs were selected for further investigation. From there, the selected works were divided into three groups (Exercise Therapy, Mobilization Techniques, and Exercise Plus Mobilization Therapy) for thorough review. Four works in the Exercise Therapy category were evaluated and results were as follows: (1) Moderate evidence for effectiveness of stretching and strengthening exercises combined vs ultrasound and stretching relative to short-term follow-up, (2) Limited evidence for (a) long-term results on effectiveness of strengthening and stretching exercises vs. ultrasound therapy, (b) effectiveness of eccentric exercise vs. stretching to decrease symptoms of LE on the midterm; for the short and long term, no evidence was found, (3) No evidence in the short-term for effectiveness of conservative vs. concentric strengthening or a combined stretching and concentric exercise program as add-on therapy to stretching. Eight works in the Mobilization category were evaluation and the results were as follows: (1) Conflicting evidence for effectiveness of C-spine manipulation vs placebo following treatment, (2) Moderate evidence in the short and mid-term for effectiveness of cervical and thoracic manipulation as add-on therapies to concentric and eccentric stretching with mobilization of the wrist and forearm, (3) Limited evidence (a) in the short-term for effectiveness of mobilization of the radial head and nerve vs ultrasound therapy and friction massage, as well as stretching and strengthening exercises for the extensors of the wrist, (b) in the short-term for effectiveness of the Mulligan mobilization accompanying ultrasound and exercise therapy, (c) on utilizing a lateral glide mobilization with movement (MWM) intervention vs a placebo/control, (d) for the effectiveness of MWM at the elbow vs a placebo/control immediately following treatment, (e) for effectiveness in favor of MWM with a force of 2.5 N versus a force of 1.2 or 1.9 N immediately following treatment, (f) the short-term effectiveness of oscillating energy manual therapy of the elbow vs a placebo (g) for the short-term effectiveness of manipulation of the wrist vs ultrasound, friction massage combined with muscle stretching and strengthening exercises. One piece was addressed to evaluate exercise plus mobilization therapy and the results consisted of limited evidence for the short-term effectiveness of ultrasound vs chiropractic therapy used in conjunction with strengthening exercises.

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 the findings above, it is clear that utilizing mobilizations in treating Lateral Epicondylitis would benefit from further investigation to extrapolate the long-term effectiveness. It is evident that mobilizations are best used in conjunction with additional therapeutic interventions (i.e stretching and strengthening exercises). The short-term analgesic effects of mobilization/manipulation will benefit additional physical therapy interventions by minimizing patient symptoms and improving time to treat. Although tendinosis may still be ambiguous in nature, minimizing symptoms and capitalizing on efforts to increase analgesic effects will therefore work towards improving patient buy-in and strengthening therapeutic alliance.

Effectiveness of cervicothoracic and thoracic manual physical therapy in managing upper quarter disorders – a systematic review

Author Names

Ronald Schenk, Megan Donaldson , Jennifer Parent-Nichols, Mark Wilhelm , Alexis Wright and Joshua A. Cleland

Reviewer Name

Kayla (Sloane) Grace, Duke SPT, B.S Exercise Physiology

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study Design: Systematic review. Background: Physical therapists often use cervicothoracic and thoracic manual techniques to treat musculoskeletal disorders of the upper quarter ,however, the overall effectiveness of this approach remains to be elucidated. Objective: This systematic review explored studies that examined the short- and long-term effectiveness of manual physical therapy directed at the cervicothoracic and thoracic region in the management of upper quarter musculoskeletal conditions. Methods: The electronic databases MEDLINE, AMED, CINAHL, and Embase were searched from their inception through 30 October 2020. Eligible clinical trials included those where human subjects treated with cervicothoracic and/or thoracic manual procedures were compared with a control group or other interventions. The methodological quality of individual studies was assessed using the PEDro scale. Results: The initial search returned 950 individual articles. After the screening of titles and abstracts, full texts were reviewed by two authors, with 14 articles determined to be eligible for inclusion. PEDro scores ranged from 66 to 10 (out of a maximum score of 10). In the immediate to 52-week follow-up period, studies provided limited evidence that cervicothoracic and thoracic manual physical therapy may reduce pain and improve function when compared to control/sham or other treatments. Conclusions: Evidence provides some support for the short-term effectiveness of cervicothoracic and thoracic manual physical therapy in reducing pain and improving function in people experiencing upper quarter musculoskeletal disorders. Evidence is lacking for long-term effectiveness as only two studies explored outcomes beyond 26 weeks and this was for patient-perceived improvement. Prospero ID: CRD42020219456

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?

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?

Were the included studies listed along with important characteristics and results of each study?

Was publication bias assessed?

Key Finding #1

“Evidence provides some support for the short-term effectiveness of cervicothoracic and thoracic manual physical therapy in reducing pain and improving function in people experiencing upper quarter musculoskeletal disorders. Evidence is lacking for long-term effectiveness as only two studies explored outcomes beyond 26 weeks and this was for patient-perceived improvement” (Schenk et al.).

Key Finding #2

“Results of this systematic review suggest that treatments including cervicothoracic or thoracic manual physical therapy procedures (non-thrust and thrust manipulation) have limited effectiveness in reducing pain and disability for people with upper-quarter MSDs” (Schenk et al.).

Key Finding #3

“Favorable outcomes related to cervicothoracic or thoracic manipulation were found when comparing the intervention to an active control, when comparing thoracic manipulation intervention to other interventions, and when assessing patient perception of long-term recovery” (Schenk et al.).

Please provide your summary of the paper

This systematic review screened 950 individual articles for necessary consideration criteria to which 14 were met and selected for inclusion. These studies examined the short- and long-term effectiveness of cervicothoracic manual therapy techniques in managing upper quarter musculoskeletal conditions. The included studies consisted of randomized clinical or controlled trials with individuals between the ages of 18 and 80 with musculoskeletal condition-related pain and/or disability related to the upper quarter not pertaining to post-surgical care. The studies included were separated by three categories (thoracic manual procedures versus control/sham, cervicothoracic and thoracic manual procedures versus other interventions, and long-term effects of thoracic manipulation). Of the five studies examining thoracic manual procedures versus control/sham, only one reported a significant improvement in pain and function in the treatment group compared to an active control. Of the eight studies examining cervicothoracic and thoracic manual procedures versus other interventions, three studies reported findings of significant improvements in pain and function. Of the two studies examining the long-term effects of thoracic manipulation, significant improvement in perceived recovery were found in each but did not find a significant improvement in pain or function. As a result of the systematic and comprehensive review of each of the 14 studies, three key conclusions were drawn: “Evidence from studies of upper quarter MSDs suggests that manipulation of the cervicothoracic and thoracic spine performed by physical therapists has questionable effectiveness when compared to no treatment, sham, or other interventions for improving pain and function. Further, the limited evidence found in this review for the effectiveness of manipulation directed to the cervicothoracic or thoracic spine for upper quarter MSDs is in relation to short-term outcomes. Further high-quality studies involving other upper quarter MSDs are needed to determine the short-and long-term effectiveness of cervicothoracic and thoracic manipulation in managing these conditions” (Schenk et al.).

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 the above findings, it is clear that the effects of cervicothoracic manual therapy could benefit from further investigation. Although there were a few instances of favorable outcomes here, additional research conducted should aim to strengthen and expand upon these findings. This SR utilized only 14 articles based on the inclusion/exclusion criteria and cannot be applied directly beyond the constructs of each unless specifically examined beyond the stated parameters. These articles applied investigations exclusively to the scope of Physical Therapy. It would therefore be necessary to examine findings within an interdisciplinary framework to navigate the depth and breadth necessary to substantiate the effectiveness of this intervention. Moving forward in practice I will utilize these techniques not as a catch-all, but in conjunction with additional therapeutic interventions if necessary to increase patient buy-in and improve therapeutic alliance and perceived degree of function.

Manual joint mobilisation techniques, supervised physical activity, psychological treatment, acupuncture and patient education for patients with tension-type headache. A systematic review and meta-analysis

Author Names

Kroll, L et al

Reviewer Name

Laurel Hale, SPT ’24

Reviewer Affiliation(s)

Duke Doctor of Physical Therapy

Paper Abstract

Background: Tension-type headache (TTH) has been ranked the second most prevalent health condition worldwide. Non-pharmacological treatments for TTH are widely used as a supplement or an alternative to medical treatment. However, the evidence for their effects are limited. Therefore, the aim of this study was to review the evidence for manual joint mobilisation techniques, supervised physical activity, psychological treatment, acupuncture and patient education as treatments for TTH on the effect of headache frequency and quality of life. Methods: A systematic literature search was conducted from February to July 2020 for clinical guidelines, systematic reviews, and individual randomised controlled trials (RCT). The primary outcomes measured were days with headache and quality of life at the end of treatment along with a number of secondary outcomes. Meta-analyses were performed on eligible RCTs and pooled estimates of effects were calculated using the random-effect model. The overall certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach (GRADE). In addition, patient preferences were included in the evaluation. Results: In all, 13 RCTs were included. Acupuncture might have positive effects on both primary outcomes. Supervised physical activity might have a positive effect on pain intensity at the end of treatment and headache frequency at follow-up. Manual joint mobilisation techniques might have a positive effect on headache frequency and quality of life at follow-up. Psychological treatment might have a positive effect on stress symptoms at the end of treatment. No relevant RCTs were identified for patient education. The overall certainty of evidence was downgraded to low and very low. No serious adverse events were reported. A consensus recommendation was made for patient education and weak recommendations for the other interventions. Conclusion: Based on identified benefits, certainty of evidence, and patient preferences, manual joint mobilisation techniques, supervised physical activity, psychological treatment, acupuncture, and patient education can be considered as non-pharmacological treatment approaches for TTH. Some positive effects were shown on headache frequency, quality of life, pain intensity and stress symptoms. Few studies and low sample sizes posed a challenge in drawing solid conclusions. Therefore, high-quality RCTs are warranted. Keywords: Dry needling; Exercise; Headache; Manual therapy; Mindfulness; Non-pharmacological treatment.

NIH Risk of Bias Tool

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?

Cannot Determine, Not Reported, Not Applicable

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?

Were the included studies listed along with important characteristics and results of each study?

Was publication bias assessed?

Cannot Determine, Not Reported, Not Applicable

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Key Finding #1

A weak recommendation is made for both manual therapy and supervised physical activity may lead to decreased headache frequency and increased quality of life.

Key Finding #2

Some studies lead to improvements in headache frequency, quality of life, pain intensity, and stress symptoms.

Key Finding #3

Patient education is recommended for patients with Tension Type Headaches (TTH).

Please provide your summary of the paper

While this study gave weak recommendations for manual therapy and supervised physical activity to treat TTH, further research could be beneficial on this topic due to the interferences of bias, inconsistency, and imprecision on the studies reviewed in this systemic review.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

With the high prevalence that TTH have in society, more research needs to be done on non-pharmacological interventions that can be done to give patients short- and long-term relief of symptoms. Further research comparing mobilization vs supervised physical activity with both groups receiving patient education could provide valuable information on the best treatment protocol for patients with TTH.

Can the sleep quality of patients with chronic neck pain be improved by muscle energy techniques combined with Swedish massage?

Author Names

Hadamus, A

Reviewer Name

Laurel Hale, SPT ’24

Reviewer Affiliation(s)

Duke University, Doctor of Physical Therapy

Paper Abstract

Background and purpose: Muscle energy techniques (METs) are used to reduce tension in neck muscles and therefore, can be used together with Swedish massage to enhance its effect. The aim of this study was to assess if using METs combined with massage could improve sleep quality. Materials and methods: In this prospective, randomised controlled trial forty patients with chronic cervical spine pain were divided into two equal groups. Both groups attended 10 sessions of Swedish massage, and the study group additionally attended MET-sessions. Sleep disturbances were assessed with the Pittsburgh Sleep Quality Index (PSQI). Results: A significant improvement in terms of sleep disturbances was seen in both groups. The MET group demonstrated improvement in all PSQI components. In the control group, the improvement included only 4 components of the index. Conclusion: Massage therapy combined with relaxing METs may be more effective than massage therapy alone in this group of patients. Keywords: massage therapy; muscle energy technique; sleep disorder; neck pain

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)?

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)?

Cannot Determine, Not Reported, or Not Applicable

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

Both groups experienced significant improvements by reducing sleep disturbances as seen in pre and post treatment scores on Pittsburg Sleep Quality Index Score (PSQI).

Key Finding #2

After the treatment, the experimental group (MET group) achieved better results in all 7 sleep components of PSQI while the control group only showed improvement in 4 components. Massage therapy combined with relaxing muscle energy techniques is more effective at reducing neck pain causing sleep disturbances than massage alone.

Please provide your summary of the paper

The findings of this study showed that massage in conjunction with muscle energy techniques is an effective tool to reduce neck pain causing sleep disturbances.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

I feel that given the high prevalence of chronic neck pain, that this study could be repeated with a larger sample size to get more data on effective treatment options for patients struggling with sleep who are experiencing chronic neck pain. I also think that in future studies introducing a second experimental group that has massage, muscle energy techniques, and exercise could be valuable to see if adding in a treatment component that could be continued at home after the trial ends could help in long term reduction of sleep disturbances in those experiencing chronic neck pain.

Changes in Shoulder Pain and Disability After Thrust Manipulation in Subjects Presenting with Second and Third Rib Syndrome

Author Names

Dunning, J; Mourad, F; Giovannico, G; Maselli, F; Perreault, T; Fernandez-de-las-Penas, C

Reviewer Name

Brenna Hammer, SPT, LAT, ATC

Reviewer Affiliation(s)

Duke University School of Medicine – Doctor of Physical Therapy

Paper Abstract

Objective: The purpose of this preliminary study was to investigate changes in shoulder pain, disability, and perceived level of recovery after 2 sessions of upper thoracic and upper rib high-velocity low-amplitude (HVLA) thrust manipulation in patients with shoulder pain secondary to second and third rib syndrome. Methods: This exploratory study evaluated 10 consecutive individuals with shoulder pain, with or without brachial pain, and a negative Neer impingement test, who completed the Shoulder Pain and Disability Index (SPADI), the numeric pain rating scale (NPRS), and the global rating of change. Patients received 2 sessions of HVLA thrust manipulation targeting the upper thoracic spine bilaterally and the second and third ribs on the symptomatic side. Outcome measures were completed after the first treatment session, at 48 hours, 1 month, and 3 months. Results: Patients showed a significant decrease in SPADI (F = 59.997; P = .001) and significant decrease in resting shoulder NPRS (F = 63.439; P = .001). For both NPRS and SPADI, there were significant differences between the pretreatment scores and each of the postintervention scores through 3-month follow-up (P b .05). Large within-group effect sizes (Cohen’s d ≥ 0.8) were found between preintervention data and all postintervention assessments in both outcomes. Mean global rating of change scores (+6.8 at 3 months) indicated “a very great deal better” outcome at long-term follow-up. Conclusion: This group of patients with shoulder pain secondary to second and third rib syndrome who received upper thoracic and upper rib HVLA thrust manipulations showed significant reductions in pain and disability and improvement in perceived level of recovery. (J Manipulative Physiol Ther 2015;38:382-394)

NIH Risk of Bias Tool

Was the study question or objective clearly stated?

Was the study population clearly and fully described, including a case definition?

Were the cases consecutive?

Were the subjects comparable?

Was the intervention clearly described?

Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?

Was the length of follow-up adequate?

Were the statistical methods well-described?

Were the results well-described?

Key Finding #1

Patients with shoulder pain secondary to second and third rib syndrome responded positively to thrust manipulation of the upper thoracic zygapophyseal joints.

Key Finding #2

Pain and disability index scores decreased 48 hours, 1 month, and 3 months after thrust manipulation in patients with shoulder pain secondary to second and third rib syndrome.

Please provide your summary of the paper

10 patients with shoulder pain secondary to first or second rib syndrome were treated with HVLA thrust manipulation to the upper thoracic zygapophyseal joints bilaterally and the costotransverse joints of the second and third rib on the symptomatic side. They returned 48 hours later and completed questionnaires and received the treatment again. SPADI, NPRS, and GROC were all used to measure the effect of the intervention. On average, there pain and disability decreased after intervention at 48 hours, 4 days, 1 month, and 3 months post intervention.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This paper indicates that thrust manipulation of the thoracic spine and costotransverse joints may be effective in treating pain and disability related to second or third rib syndrome. However, this study did have some limitations that are worth noting in clinical practice. First, the sample size was too small to make any causative conclusions. A randomized control trial would be effective in determining the true effect of this intervention. Second, follow up only lasted 3 months. A longer follow up time, such as 1 year, would be beneficial in determining long term benefits of this intervention, as well as giving appropriate time for any adverse effect. Third, this study does not take into effect any other treatments that are given in standard physical therapy practice and only examined HVLA thrust manipulation as a stand alone treatment, which decreases the external validity of the study as this is not how one would expect standard physical therapy to occur. However, despite various limitations, this study does show promise for thrust manipulation in treating shoulder pain secondary to second or third rib syndrome.

Thoracic spinal manipulation for musculoskeletal shoulder pain: Can an instructional set change patient expectation and outcome?

Author Names

Riley, S. P, Bialosky, J., Cote, M. P., Swanson, B. T., Tafuto, V., Sizer, P. S., & Brisme, J. M.

Reviewer Name

Jada Holmes, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study design: Planned secondary analysis of a randomized clinical trial. Objectives: To examine: 1) patients’ baseline expectations for treatment outcome of thoracic high velocity low amplitude thrust manipulations (HVLATM) to the thoracic spine for shoulder pain; 2) if the message conveyed by the clinician changed the patients’ expectation; 3) any differences in outcome based on expectation independent of messaging.; and 4) any differences in outcome for those patients whose expectations significantly changed as a result of the messaging. Background: Thoracic HVLATM may be an effective intervention for patients suffering from musculoskeletal shoulder pain. The role of expectation in the treatment effectiveness of this intervention has not been established. Methods: Subjects’ expectations regarding the effectiveness of HVLATM on shoulder pain were recorded at baseline. This was reassessed immediately following the provision of positive or neutral instructional set. The subjects then received a thoracic or scapular HVLATM. The Shoulder Pain and Disability Index (SPADI) and the numeric pain rating scale (NPRS) were used as outcomes measures. Results: There was a 10-subject change (23%) in positive expectation that was statistically significant (p = 0.019) following a positive message. There was no statistically significant difference in pain and function when these subjects were compared to all other subjects. Conclusion: Although patients’ expectations of positive outcome significantly changed when providing a positive instructional set, these changes did not translate into clinically significant short-term changes in shoulder pain and function. Level of Evidence: 1b.

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

This study showed that the baseline expectations of success were low as compared to previous studies. By providing positive messaging, we were able to significantly alter patients’ expectations of treatment outcomes following thoracic spinal manipulation for musculoskeletal shoulder conditions.

Key Finding #2

Expectations may not be as important when the communication/interaction and alliance between the patient and clinician are removed.

Key Finding #3

Research should be done to evaluate the effect of both communication/interaction and expectations on outcomes. Additional research with larger sample size is needed to confirm these findings.

Please provide your summary of the paper

In general, studies show that patients reporting to PT have pretty high expectations for efficiency of treatments being done in clinic. This study shows that when treating shoulder pain with thoracic and placebo HVLATM treatment, patient’s expectations of a positive outcome was only at 20% at baseline. In comparison, when treating neck pain and LBP with manual therapy techniques, patient’s expectations of a positive outcome was 75% and 60%, respectively. Therefore, this study was looking to see if messaged conveyed prior to treatment could influence patient expectations of treatment effectiveness. The findings didn’t show any clinical differences in expectation of treatment to influence treatment outcome, however other researchers have found different clinical outcomes.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This idea in theory seems sound that messages conveyed could influence patient expectations of manual therapy outcomes. Perhaps because the message wasn’t from the clinician but via a video, they didn’t have as much confidence in the expectations being conveyed whereas if it came from the treating clinician, they might’ve felt more confident about their outcomes. However, this changing the internal validity of a study and makes things a lot more difficult. Regardless, more research is needed is this area to see how manual therapy done in the thoracic region can effect shoulder pain.

Manual therapy in infantile torticollis: a randomized, controlled pilot study

Author Names

Haugen, E., Benth, J., Nakstad, B.

Reviewer Name

Alexandra Hultstrom, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Aim: Torticollis in infancy is routinely treated by child physiotherapists. The addition of manual therapy to the treatment is a new approach in Norway. As the effect of manual therapy for this condition is poorly documented, we designed a pilot study to evaluate measurement methods and examine the short-time effect of manual therapy in addition to child physiotherapy. Methods: Randomized controlled trial, double blinded. Thirty-two patients aged 3–6 months were randomized to intervention group (manual therapy and child physiotherapy) and control group (child physiotherapy alone). Primary outcome: Change of symptoms because of torticollis evaluated by video recordings. Secondary outcomes: 12 parameters including spontaneous movements, active and passive range of motion and head righting reaction. Results: We found a nonsignificant tendency to greater improvement in lateral flexion (p = 0.092) and head righting reaction (p = 0.116) in the intervention group. Conclusion: In this pilot study, we found that in patients with moderate symptoms related to torticollis, the short-time effect of manual therapy in addition to physiotherapy is not significantly better than physiotherapy alone.

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?

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

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)?

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

There were no significant differences between the two groups for the primary (change of symptoms due to torticollis evaluated by video recordings) or secondary (12 parameters including spontaneous movement, AROM, PROM, and head righting) outcome measures.

Key Finding #2

The intervention group had slightly better outcomes in passive (p=0.116) and active (p=0.092) lateral flexion against gravity than the control group from inclusion to week 8.

Key Finding #3

There was a slight, short-term improvement in children with moderate torticollis with manual therapy in addition to traditional physiotherapy than physiotherapy alone.

Key Finding #4

Overall, manual therapy in infants remains controversial due to the lack of documentation in scientific studies.

Please provide your summary of the paper

Congenital Muscular Torticollis is a common diagnosis in infants and toddlers that has been shown to improve with physiotherapy treatment involving passive and active movement exercise and encouragement of symmetrical motor performance. Germany has been using manual therapy to treat infants with torticollis for years as they believe that the cause is due to functional disturbance of the joints (AA and AO) and describe it as “Kinematic Imbalance due to Suboccipital Strain” (KISS). Manipulation is performed with the child in supine and the head in neutral without any extension and only a moderate force application. 32 children with torticollis ages 3-6 months were recruited for the study and randomly assigned to intervention or control groups. Inclusion criteria were reduced mobility in the neck in at least one axial plane and exclusion criteria were other cause of asymmetry or serious pathology. At inclusion, week 2, and week 8 the patients underwent clinical examination by an experienced pediatric physiotherapist and these sessions were recorded for analysis by 3 blinded, independent assessors. The manual therapist providing intervention was the only one who knew of group assignment as the parents and assessing physiotherapist were both blinded. Overall, there were no significant differences between the intervention and control groups between the primary or secondary outcomes and there was only a slight, short term improvement noted in the intervention group.

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 opens the door to continued research into the safety and efficacy of adding manual therapy to the standard physical therapy treatment for torticollis. However, there were still multiple limitations to the study and the differences noted between the experimental and control groups were small. The sample was not representative of the whole population of children with torticollis and the study size was small with only 32 participants. There were also issues with the reliability of measurements due to the variability of activity level and cooperation of the children during examination. Finally, the children with severe torticollis were excluded from the study as they had already received manual therapy, but they may have demonstrated the greatest improvements.

Medium term effects of including manual therapy in a pulmonary rehabilitation program for chronic obstructive pulmonary disease (COPD): a randomized controlled pilot trial.

Author Names

Engel, R., Gonski, P., Beath, K., Vemulpad, S.

Reviewer Name

Alexandra Hultstrom, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study design Randomized clinical trial. Objective To investigate the effect of including manual therapy (MT) in a pulmonary rehabilitation program for patients with chronic obstructive pulmonary disease (COPD). Background The primary source of exercise limitation in people with COPD is dyspnea. The dyspnea is partly caused by changes in chest wall mechanics, with an increase in chest wall rigidity (CWR) contributing to a decrease in lung function. As MT is known to increase joint mobility, administering MT to people with COPD carries with it the potential to influence CWR and lung function. Methods Thirty-three participants with COPD, aged between 55 and 70 years (mean = 65·5±4 years), were randomly assigned to three groups: pulmonary rehabilitation (PR) only, soft tissue therapy (ST) and PR, and ST, spinal manipulative therapy (SM), and PR. Outcome measures including forced expiratory volume in the 1st second (FEV1), forced vital capacity (FVC), 6-minute walking test (6MWT), St. George’s respiratory questionnaire (SGRQ), and the hospital anxiety and depression (HAD) scale were recorded at 0, 8, 16, and 24 weeks. Results There was a significant difference in FVC between the three groups at 24 weeks (P = 0·04). For the ST+SM+PR group versus PR only the increase was 0·40 l (CI: 0·02, 0·79; P = 0·03). No major or moderate adverse events (AE) were reported following the administration of 131 ST and 272 SM interventions. Discussion The increase in FVC is a unique finding. Although the underlying mechanisms responsible for this outcome are not yet understood, the most likely explanation is the synergistic effect resulting from the combination of interventions. These results support the call for a larger clinical trial in the use of MT for COPD.

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?

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

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)?

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

There was a significant difference between groups for Forced Vital Capacity (FVC) at 24 weeks, which is eight weeks after the end of intervention.

Key Finding #2

There was a significant difference in distance walked in the 6MWT from week 16 to week 24 between the Soft Tissue + Spinal Manipulation + Pulmonary Rehab group and the Soft Tissue + Pulmonary Rehab group.

Key Finding #3

Though increases in lung function (as measured by FVC) were found, there were no improvements in quality of life measures (HAD and SGRQ) in any of the groups.

Please provide your summary of the paper

There appears to be a lasting effect (8 weeks) of Soft Tissue Mobilization (ST) + Spinal Manipulation (SM) + Pulmonary Rehab on lung capacity as measured by FVC. However, it is unclear as to whether these changes are the result of ST or SM. Additionally, there were changes in the 6MWT in the group where SM was added. There were no improvements in quality of life measures (HAD & SGRQ) though lung capacity (FVC) and endurance (6MWT) increased. No major or moderate adverse events were reported. The underlying mechanism that led to these changes is still unknown though the authors speculate that it may be due to synergistic effects of soft tissue mobilization of respiratory muscles combined with spinal manipulation of related thoracic intervertebral and costovertebral joints.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Overall, this study calls for further investigation and research with larger sample sizes before any generalizations and firm conclusions can be drawn. There were many limitations, such as small sample size and unknown outside effects. The participants were encouraged to exercise on their own after the Pulmonary Rehab (PR) sessions had ended (weeks 16-24) and their activity levels outside of PR were not tracked. Additionally, there were no reports of medications used or whether the patients were dependent on O2. Finally, the implications from this study and future research into the intersection of Manual Therapy and Pulmonary Rehab indicates that future COPD rehabilitation may need to be interdisciplinary between orthopedic and cardiopulmonary providers.

Immediate and Short-term Effects of Thoracic Spine Manipulation in Patients With Cervical Radiculopathy: A Randomized Controlled Trial

Author Names

Young, I., Pozzi, F., Dunning, J., Linkonis, R., Michener, L.

Reviewer Name

Jake Isaac, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Thoracic spine thrust manipulation has been shown to improve patient-rated outcomes for individuals with neck pain. However, there is limited evidence of its effectiveness in patients with cervical radiculopathy. Objectives: To compare the immediate and short-term effects of thoracic manipulation to those of a sham thoracic manipulation in patients with cervical radiculopathy. Methods: In this multicenter randomized controlled trial, participants with cervical radiculopathy were randomized to receive either manipulation (n = 22) or sham manipulation (n = 21) of the thoracic spine. Outcomes were measured at baseline, immediately after treatment, and at a follow-up 48 to 72 hours after manipulation. A repeated-measures analysis of variance was used to analyze neck and upper extremity pain (numeric pain-rating scale), disability (Neck Disability Index), cervical range of motion (ROM), and endurance (deep neck flexor endurance test). The chi-square test was used to analyze changes in neck and upper extremity pain, centralization of symptoms, and beliefs about receiving the active manipulation treatment using a global rating of change scale. Results: Neck and upper extremity pain, cervical ROM, disability, and deep neck flexor endurance all showed significant interactions between group and time (P<.01). Immediately after treatment and at the 48-to-72-hour follow-up, the manipulation group had lower neck pain (P<.01), better cervical ROM (P<.01), lower disability (P<.01), and better deep neck flexor endurance (P = .02) compared to the sham manipulation group. The manipulation group had moderate to large effect-size changes over time. No between-group differences for upper extremity pain were found immediately following the intervention (P = .34) and at 48 to 72 hours after the intervention (P = .18). At 48 to 72 hours after treatment, a greater proportion of participants in the manipulation group reported improvement (global rating of change scale score of 4 or greater) in neck and upper extremity symptoms (P<.01), centralization of symptoms (P<.01), and beliefs about receiving an active manipulation (P = .01) compared to the sham manipulation group. Conclusion: One session of thoracic manipulation resulted in improvements in pain, disability, cervical ROM, and deep neck flexor endurance in patients with cervical radiculopathy. Patients treated with manipulation were more likely to report at least moderate change in their neck and upper extremity symptoms up to 48 to 72 hours following treatment.

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)?

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

One treatment of upper and mid-thoracic thrust manipulation resulted in improvements in pain, disability, and perceived recovery in patients with symptoms of cervical radiculopathy.

Key Finding #2

Thoracic manipulation may be beneficial as an early treatment option in patients presenting with cervical radiculopathy.

Please provide your summary of the paper

This randomized controlled trial investigated the short-term effects of thoracic spine manipulation in patients with cervical radiculopathy. Patients with cervical radiculopathy who met the inclusion criteria were randomly assigned to either the manipulation or sham manipulation group. The manipulation group received a supine HVLA thrust manipulation at both upper thoracic and mid thoracic levels. Those in the sham manipulation group were placed in a position identical to the manipulation group, however, no thrust manipulation was performed. Outcomes were administered at baseline, immediately after treatment, and 48-to-72 hours after treatment. The primary outcomes assessed were self-reported pain of the neck and upper extremity (NPRS), and perceived changes in improvement (GROC). Secondary outcomes were disability on the NDI, cervical ROM, deep neck flexor muscle endurance, and numbness, tingling and distribution of symptoms. Significant improvements were seen both immediately and 48-to-72 hours after treatment in neck pain, cervical ROM, disability, and deep neck flexor muscle endurance in the manipulation group compared to the sham manipulation group. Patients in the manipulation group were also more likely to report at least moderate improvement in their neck and upper extremity symptoms on the GROC scale at the 48-to-72 hour follow-up. No significant differences in upper extremity pain were reported between groups.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This randomized controlled trial demonstrates the immediate benefits of thoracic spine manipulation in patients with cervical radiculopathy. Many studies have examined the benefit of thoracic manipulations for individuals with neck pain, however, evidence of the effectiveness in those with cervical radiculopathy is limited. These results indicate that thoracic spine manipulation can be used as an effective early treatment option to improve pain, disability, and ROM in patients with cervical radiculopathy. The acute effects suggest that this intervention may be a useful tool to employ at the beginning of a session to allow for increased tolerance for therapeutic exercise delivered later in the session. Although the results indicate effectiveness in the short-term, more research is warranted to determine the lasting effects of this intervention. Further research is necessary to examine the benefits of this technique over several sessions and in conjunction with other interventions commonly used to treat cervical radiculopathy.

Comparison of 2 Manual Therapy and Exercise Protocols for Cervical Radiculopathy: A Randomized Clinical Trial Evaluating Short-Term Effects

Author Names

Langevin, P., PT, FCAMPT, MClSc; Desmeules, F., PT, PhD; Lamothe, M., PT, MS; Robitaille, S., PT; Roy, J., PT, PhD

Reviewer Name

Jordan Jaklic, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Abstract

Study Design

Participant- and assessor-blinded randomized clinical trial.

Objectives

To compare a rehabilitation program thought to increase the size of the intervertebral foramen (IVF) of the affected nerve root to a rehabilitation program that doesn’t include any specific techniques thought to increase the size of the IVF in patients presenting with cervical radiculopathy (CR).

Background

Clinical approaches for the treatment of CR commonly include exercises and manual therapy techniques thought to increase the size of the IVF, but evidence regarding the effectiveness of these specific manual therapy techniques is scarce.

Methods

Thirty-six participants with CR were randomly assigned either to a group that received a manual therapy and exercise program aimed at increasing the size of the IVF of the affected nerve root (experimental group, n = 18) or to a group that received a manual therapy and exercise program without the specific goal of increasing the size of the IVF of the affected level and side (comparison group, n = 18). Primary (Neck Disability Index) and secondary (shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire [QuickDASH] and numeric pain-rating scale) outcomes were evaluated at baseline, at the end of the 4-week program (week 4), and 4 weeks later (week 8). A mixed-model, 2-way analysis of variance was used to analyze treatment effects.

Results

No significant group-by-time interaction or group effect was observed for Neck Disability Index, QuickDASH, and numeric pain-rating scale scores (P≥.14) following the intervention. However, both groups showed statistically and clinically significant improvement from baseline to week 4 and to week 8 in Neck Disability Index, QuickDASH, and numeric pain-rating scale scores (P<.05).

Conclusion

Results suggest that manual therapy and exercises are effective in reducing pain and functional limitations related to CR. The addition of techniques thought to increase the size of the IVF of the affected nerve root yielded no significant additional benefits. Given the absence of a “no treatment” group, a spontaneous resolution of symptoms cannot be excluded. However, the magnitude of improvement makes spontaneous resolution unlikely. The trial was registered at ClinicalTrials.gov (NCT01500044).

Level of Evidence

Therapy, level 1b-. J Orthop Sports Phys Ther 2015;45(1):4–17. Epub 24 Nov 2014. doi:10.2519/jospt.2015.5211

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)?

Cannot Determine, Not Reported, or Not Applicable

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?

Cannot Determine, Not Reported, or Not Applicable

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

Although there was no statistical difference between the group that received intervention to increase the size of the IVF on the same side and the group that did not increase the size of the IVF, both groups achieved highly favorable outcomes in terms of pain, disability, and patient-perceived improvement.

Key Finding #2

The findings of this study suggest that there are no limitations to using mobilizations and exercises that are specific to the level of the radiculopathy in acute or subacute patients with cervical radiculopathy.

Please provide your summary of the paper

In this randomized control trial, 36 patients with cervical radiculopathy symptoms were randomly assigned to manual therapy groups that either increased the intervertebral foramen (IVF) at the same level and side or did not increase the IVF at the same level and side. Patients all received 4 weeks of treatment and measured symptoms at baseline, after 4 weeks of treatment, and 4 weeks post the end of treatment. The patients completed the Neck Disability Index, QuickDASH, and numeric pain rating scale at each bench mark. Patients were included in the study if they satisfied the following criteria: 1) between 18 and 65 years of age; (2) pain, paresthesia, or numbness in 1 upper limb, with cervical or periscapular pain of less than 3 months in duration; (3) at least 1 neurological sign of a lower motor neuron lesion in a cervical spine nerve root or spinal nerve; and (4) positive responses to at least 3 of the 4 following clinical tests (positive likelihood ratio for CR of 6): Spurling A test, upper-limb tension test A, cervical distraction test, and less than 60° of cervical rotation to the painful side. Patients were excluded from the study if they had (1) prior surgery to the cervicothoracic spine, (2) bilateral symptoms, (3) signs of upper motor neuron impairments, (4) cervical spine injection in the previous 4 weeks, (5) current use of steroidal anti-inflammatory drugs, or (6) financial compensation for the cervical condition. At the end of the study, the results concluded that both groups experienced significant improvement in patient-reported outcomes. However, there was no statistical difference between the group that received manual therapy to increase the IVF on the same level and side and the group that did not receive manual therapy to increase the IVF on the same level and side. Although there were no differences between groups, it is hypothesized that some form of manual therapy is better than none.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Although this paper had a small sample size, the conclusion can be applied to all settings. Even though increasing the IVF on the same side and level did not show any more improvement than other manual therapy techniques, this paper did show that some amount of manual therapy is helpful for patient outcomes. Patients may not be able to lie in standardized positions to receive manual therapy in the cervical spine, but this paper demonstrates that it may still be beneficial to provide manual therapy in any capacity the patient can tolerate. Therapists can even focus on muscle stiffness if joint mobilizations are not feasible for the patient in order to offer some relief. The conclusions of this paper can be applied in most settings including outpatient and acute care.

Effectiveness of manual therapy in the treatment of cervicogenic headache: A systematic review

Author Names

Núñez-Cabaleiro, P., Leirós-Rodríguez, R.

Reviewer Name

Hannah Koch, SPT

Reviewer Affiliation(s)

Duke University

Paper Abstract

Objective: The aim of this study was to identify the manual therapy (MT) methods and techniques that have been evaluated for the treatment of cervicogenic headache (CH) and their effectiveness. Background: MT seems to be one of the options with the greatest potential for the treatment of CH, but the techniques to be applied are varied and there is no consensus on which are the most indicated. Methods: A systematic search in Scopus, Medline, PubMed, Cinahl, PEDro, and Web of Science with the terms: secondary headache disorders, physical therapy modalities, musculoskeletal manipulations, cervicogenic headache, manual therapy, and physical therapy. We included articles published from 2015 to the present that studied interventions with MT techniques in patients with CH. Two reviewers independently screened 365 articles for demographic information, characteristics of study design, study-specific intervention, and results. The Oxford 2011 Levels of Evidence and the Jadad scale were used. Results: Of a total of 14 articles selected, 11 were randomized control trials and three were quasi-experimental studies. The techniques studied were: spinal manipulative therapy, Mulligan’s Sustained Natural Apophyseal Glides, muscle techniques, and translatory vertebral mobilization. In the short-term, the Jones technique on the trapezius and ischemic compression on the sternocleidomastoid achieved immediate improvements, whereas adding spinal manipulative therapy to the treatment can maintain long-term results. Conclusions: The manual therapy techniques could be effective in the treatment of patients with CH. The combined use of MT techniques improved the results compared with using them separately. This review has methodological limitations, such as the inclusion of quasi-experimental studies and studies with small sample sizes that reduced the generalizability of the results obtained.

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?

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?

Were the included studies listed along with important characteristics and results of each study?

Was publication bias assessed?

Cannot Determine, Not Reported, Not Applicable

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Manual therapy can be beneficial in the treatment of patients with cervicogenic headaches. The techniques that may improve cervicogenic related symptomatology includes spinal manipulation, Mulligan’s SNAGs, ischemic trigger point compression, suboccipital musculature relaxation, Jones technique, and vertebral translatory mobilization.

Key Finding #2

Of manual therapy techniques that may be utilized for the treatment of cervicogenic headaches, spinal manipulation therapy appears to be most beneficial for long term reduction of symptoms.

Key Finding #3

For immediate, but short lasting results, the employment of the Jones technique on the trapezius and ischemic compression on the sternocleidomastoid is applicable.

Please provide your summary of the paper

This paper reviewed the literature regarding manual therapy treatment effectiveness in cervicogenic headache. Key findings of this systematic review indicate that manual therapies are effective treatment options for individuals seeking relief from cervicogenic headaches. Of the available therapies, spinal manipulation therapies are the most effective in long term reduction of symptom intensity. However, for patients desiring a quick relief, the Jones technique of the trapezius and ischemic compression on the sternocleidomastoid may be desirable. Significant improvements were seen after four treatment sessions with these techniques. Overall, there are a variety of effective manual treatment options that physical therapist’s have the ability to choose from based on therapist skill acquisition and patient preference. More research is indicated to further analyze potential differences in manual therapy techniques. This study compiled data from 14 studies; additional research investigating the relationship between cervicogenic headaches and manual therapy is indicated to improve patient outcomes. Additionally, the current research lacks the longevity to fully appreciate the long term effects manual therapy may have on cervicogenic headaches.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Key findings of this systematic review indicate that manual therapies are effective treatment options for individuals seeking relief from cervicogenic headaches. Of the available therapies, spinal manipulation therapies are the most effective in long term reduction of symptoms. However, for patients desiring an immediate relief, the Jones technique of the trapezius and ischemic compression on the sternocleidomastoid may be desirable. The reduction of symptoms is observed in a large variety of manual techniques, allowing the physical therapist the opportunity to utilize a therapy that is within their own personal scope. If a physical therapy does not possess any manual therapy techniques within their own personal scope, it is important for them to seek out opportunities for skill acquisition. With 2.2-4.1% of the population having cervicogenic headaches, it is imperative that physical therapists possess the necessary skills to employ manual therapy techniques to improve patient outcomes. This paper should encourage physical therapists to seek opportunities to become competent in manual therapy techniques. Ultimately, this review demonstrates that cervicogenic headache outcomes are not overly dependent on the specific manual therapy technique utilized. Instead, employment of any manual therapy techniques should yield better outcomes. This encourages physical therapists to integrate these methods to their plan of care.

Thoracic manipulation versus mobilization in patients with mechanical neck pain: a systematic review

Author Names
Young, J. L., Walker, D., Snyder, S., & Daly, K.

Reviewer Name
Emily LaPlante, LAT, ATC, SPT

Reviewer Affiliations
Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract
ABSTRACT
Objectives: Thoracic manipulation is widely used in physical therapy and has been shown to be effective at addressing mechanical neck pain. However, thoracic mobilization may produce
similar effects. The purpose of this systematic review was to evaluate the current literature regarding the effectiveness of thoracic manipulation versus mobilization in patients with
mechanical neck pain.

Methods: ProQuest, NCBI-PubMed, APTA’s Hooked on Evidence, Cochrane Library, CINAHL and SPORTDiscus were searched to identify relevant studies. Fourteen studies meeting the inclusion
criteria were analyzed using the Physiotherapy Evidence Database (PEDro) scale and the GRADE approach.

Results: The literature as assessed by the PEDro scale was fair and the GRADE method showed overall quality ranging from very low to moderate quality. The 14 included studies showed
positive outcomes on cervical pain levels, range of motion, and/or disability with the use of thoracic manipulation or mobilization. There was a paucity of literature directly comparing
thoracic manipulation and mobilization.

Discussion: Current limitations in the body of research, specifically regarding the use of thoracic mobilization, limit the recommendation of its use compared to thoracic manipulation for
patients with mechanical neck pain. There is, however, a significant amount of evidence, although of varied quality, for the short-term benefits of thoracic manipulation in treating
patients with this condition. Further high quality research is necessary to determine which technique is more effective in treating patients with mechanical neck pain.

Keywords: Manipulation, Mechanical neck pain, Mobilization, Systematic review, Thoracic

NIH Risk of Bias Tool:

Quality Assessment of Systematic Reviews and Meta- Analyses

1. Is the review based on a focused question that is adequately formulated and described?
-Yes

2. Were eligibility criteria for included and excluded studies predefined and specified?
-Yes

3. Did the literature search strategy use a comprehensive, systematic approach?
-Yes

4. Were titles, abstracts and full text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
-Yes

5. Were the included studies listed along with important characteristics and results of each study?
-Yes

6. Was publication bias assessed?
-Yes

7. Was heterogeneity assessed?
-Not applicable

Key Finding #1
Research is limited on the comparison of thoracic manipulation and mobilization and its effect on mechanical neck pain.

Key Finding #2
Of the 14 included studies, positive outcomes were demonstrated in neck pain levels and range of motion with the use of thoracic manipulation or mobilization.

Key Finding #3
Neck pain and disability can be decreased in short term with the implementation of thoracic manipulation or mobilization both with and without exercise.

Please provide your summary of the paper
Research is limited on the comparison of thoracic manipulation and mobilization and its effect on mechanical neck pain. Fourteen studies were included in the systematic review that all included mechanical neck pain with an intervention on the thoracic spine, 10 studies being randomized controlled trials with the other four studies including one quasi experimental study, one cohort study, one case series and one secondary analysis of a randomized controlled trial. Only one study compared thoracic manipulation to thoracic mobilization with each group having 30 subjects. The results of the one study demonstrated clinically and statistically significant reductions in disability and pain as well as in perceived recovery. No significant differences were observed between the manipulation and mobilization groups. The studies that used isolated manipulation techniques showed statistically significant improvements in disability at follow ups immediately post intervention, 1 week and up to 6 months duration. While one of the lowest quality studies included in the systematic review, Ko et al., compared thoracic spine mobilization with exercises to exercises alone and found the mobilization and exercise group demonstrated a clinically and statistically significant reduction in neck disability
and pain.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Mechanical neck pain can commonly be treated with conservative measures, such as physical therapy. The use of mobilization and manipulation techniques are commonly implemented as a
course of treatment to increase range of motion and decrease pain. However, the studies only included short term effects of thoracic techniques and could further benefit from research that
includes long term follow up. The results of the systematic review can be applied to treatment if it is understood that statistically significant differences have been found with decreasing neck
pain regardless of thoracic mobilization versus manipulation. Future research is still needed to further compare thoracic manipulation to mobilization and the effects on mechanical neck pain.

Manual Therapy as a Management of Cervical Radiculopathy: A Systematic Review

Author Names
Borrella-Andrés, S., Marqués-García, I., Orosia Lucha-López, M., Fanlo-Mazas, P., Hernández-Secorún, M., Pérez-Bellmunt, A., Miguel Tricás-Moreno, J., and Hidalgo-García, C.

Reviewer Name
Giulia Marsella, SPT at Duke

Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract
Background. Cervical radiculopathy is defined as a disorder involving dysfunction of the cervical nerve roots characterized by pain radiating and/or loss of motor and sensory function towards the root affected. There is no consensus on a good definition of the term. In addition, the evidence regarding the effectiveness of manual therapy in radiculopathy is contradictory.

Objective. To assess the effectiveness of manual therapy in improving pain, functional capacity, and range of motion in treating cervical radiculopathy with and without confirmation of altered
nerve conduction. Methods. Systematic review of randomized clinical trials on cervical radiculopathy and manual therapy, in PubMed, Web of Science, Scopus, PEDro, and Cochrane
Library Plus databases. The PRISMA checklist was followed. Methodological quality was evaluated using the PEDro scale and RoB 2.0. tool. Results. 17 clinical trials published in the past 10 years were selected. Manual therapy was effective in the treatment of symptoms related to cervical radiculopathy in all studies, regardless of the type of technique and dose applied.

Conclusion. This systematic review did not establish which manual therapy techniques are the most effective for cervical radiculopathy with electrophysiological confirmation of altered nerve
conduction. Without this confirmation, the application of manual therapy, regardless of the protocol applied and the manual therapy technique selected, appears to be effective in
reducing chronic cervical pain and decreasing the index of cervical disability in cervical radiculopathy in the short term. However, it would be necessary to agree on a definition and
diagnostic criteria of radiculopathy, as well as the definition and standardization of manual techniques, to analyze the effectiveness of manual therapy in cervical radiculopathy in depth.

NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses

1. Is the review based on a focused question that is adequately formulated and
  described?
  -Yes
2. Were eligibility criteria for included and excluded studies predefined and specified?
  -Yes
3. Did the literature search strategy use a comprehensive, systematic approach?
  -Yes
4. Were titles, abstracts, and full-text articles dually and independently reviewed for
  inclusion and exclusion to minimize bias?
  -Yes
5. Was the quality of each included study rated independently by two or more reviewers
  using a standard method to appraise its internal validity?
6. Were the included studies listed along with important characteristics and results of
  each study?
  -Yes
7. Was publication bias assessed?
  -Yes
8. Was heterogeneity assessed? (This question applies only to meta-analyses.)
  -Yes

Key Finding #1
All studies displayed a statistically significant improvement in pain and cervical disability in the manual therapy group, irrespective of the protocol and technique, which contributes to the
uncertainty of which manual therapy technique(s) are most effective for treating cervical radiculopathy.

Key Finding #2
Short-term benefits of manual therapy for cervical radiculopathy have been shown to be beneficial, yet its long-term effectiveness has not been established.

Key Finding #3
Cervical and thoracic manipulations appeared to have the most satisfactory results, whereas manual traction and neural mobilization were the least satisfactory for cervical radiculopathy.

Please provide your summary of the paper

This systemic review aims to address the effectiveness of manual therapy in the treatment of cervical radiculopathy (including or not including the confirmation of altered nerve conduction).
The outcomes observed were pain, functional capacity, and range of motion of the neck. Across all 17 studies included in this systematic review, manual therapy techniques appear beneficial
for reducing chronic cervical pain and disability in the short-term. Of the 17 studies, 9 were deemed high quality, 3 were deemed moderate quality, and 5 were deemed low quality.
Limitations to this study were the lack of blinding and variability of inclusion criteria. All studies lacked blinding, yet 3 of them had assessors blinded to assign participants to groups. The
precise manual therapy techniques varied across studies and the inclusion criteria of this systematic review was heterogeneous, making comparison across studies challenging. Future
studies must employ more precise comparison of interventions and stricter inclusion parameters to analyze results more accurately.

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 may impact clinical practice in how manual therapy techniques, especially cervical and thoracic manipulations are an appropriate treatment approach for the short-term
improvement of pain and disability related to cervical radiculopathy. It is important to note that the benefits gleaned from these 17 studies were concluded without an EMG and ENG
confirmation. Implementing manual therapy techniques to treat cervical radiculopathy are supported by this literature, yet the lack of technique standardization, methodological
limitations, and lack of follow-up to determine longer-term outcomes should be acknowledged an individual patient bases.

Effectiveness of manual therapy for chronic tension-type headache: A pragmatic, randomised, clinical trial

Author Names

Castien, R., van der Windt, D., Grooten, A., Dekker, J.

Reviewer Name

Mallory Martlock, SPT

Reviewer Affiliation(s)

Duke Doctor of Physical Therapy Duke School of Medicine

Paper Abstract

Objective: To evaluate the effectiveness of manual therapy (MT) in participants with chronic tension-type headache (CTTH). Subjects and Methods: We conducted a multicentre, pragmatic, randomised, clinical trial with partly blinded outcome assessment. Eighty-two participants with CTTH were randomly assigned to MT or to usual care by the general practitioner (GP). Primary outcome measures were frequency of headache and use of medication. Secondary outcome measures were severity of headache, disability and cervical function. Results: After 8 weeks (n _ 80) and 26 weeks (n _ 75), a significantly larger reduction of headache frequency was found for the MT group (mean difference at 8 weeks, 6.4 days; 95% CI 8.3 to 4.5; effect size, 1.6). Disability and cervical function showed significant differences in favour of the MT group at 8 weeks but were not significantly different at 26 weeks. Conclusions: Manual therapy is more effective than usual GP care in the short- and longer term in reducing symptoms of CTTH. Dutch Trial Registration no. TR 1074.

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)?

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?

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Key Finding #1

Manual therapy treatment was effective for chronic tension-type headache in reducing frequency, intensity and impact of headache on daily life.

Key Finding #2

The use of medication did not show a significant difference in pain between the patients receiving manual therapy and the patients receiving usual care for headache.

Please provide your summary of the paper

This paper investigated the effects of manual therapy on patients with chronic tension type headache. The manual therapy treatment consisted of mobilization at the cervical and thoracic spine, exercises and postural correction for the treatment of cervicogenic headache. The control group received “usual care” which consisted of information, reassurance and advice and education on lifestyle changes. If necessary, the doctor also prescribed analgesics to the control group. Over the course of 26 weeks, the manual therapy group showed better outcomes compared to the control group. There was a significant difference in headache frequency and pain intensity in favor of the manual therapy group. The manual therapy group also reported a decreased impact of headache on disability and took less sick days from work compared to the control group. Finally, a larger percentage of the control group required additional care for their headache symptoms compared to the manual therapy group. The data shows that manual therapy is an effective intervention for chronic tension-type headache and should be a relevant referral from primary care physicians

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

The data found in this article was in favor of manual therapy as treatment for chronic tension-type headache. The type of manual therapy used in this study was relevant, but I think the more important part were the implications of referral from primary care physicians. Since the data was strongly in favor of manual therapy, this paper provides great support for physicians to refer patients to physical therapy instead of going through typical treatment, especially considering typical treatment consists of education, lifestyle changes and a prescription for pain medication.

Effectiveness of manual therapy to the cervical spine with and without manual therapy to the upper thoracic spine in the management of non-specific neck pain; a randomized controlled trial

Author Names

Arsh A, Darain H, Iqbal M, Rahman M, Ullah I, Khalid S

Reviewer Name

Aria Mathew, SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy Division

Paper Abstract

Objective: To compare the effectiveness of manual therapy to the cervical spine with and without manual therapy to the upper thoracic spine in the management of non-specific neck pain. Methods: The randomized controlled trial was conducted at 3 different hospitals in Peshawar, Pakistan, from October 2016 to January 2017, and comprised patients suffering from non-specific neck pain aged 25-60 years. The control group received cervical manual therapy alone while the experimental group received cervical along with thoracic manual therapy for 2 weeks. Data was analyzed using SPSS 20. Results: Of the 37 subjects, 20(54%) were cases and 17(46%) were controls. The overall mean age was 35.9±9.6 years. There was no significant difference between the groups at baseline in terms of the levels of pain (p=0.125) and disability (p=0.392). The experiential group showed greater reduction in pain (p=0.02) and disability (p=0.03) compared to the control group. Conclusion: Cervical along with thoracic manual therapy reduced neck pain and associated neck disability more effectively than cervical manual therapy alone. Keywords: Cervical, Manual therapy, Neck pain, Thoracic (JPMA 70: 399; 2020)

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)?

Cannot Determine, Not Reported, or Not Applicable

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?

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

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

Cervical along with thoracic manual therapy reduced neck pain and associated neck disability more effectively than cervical manual therapy alone

Key Finding #2

Thoracic manual therapy lowers mechanical stresses of cervical spine and improves normal distribution of joint forces, resulting into the restoration of normal biomechanics of cervical spine

Please provide your summary of the paper

After reviewing the results included in the randomized controlled trial, there does seem to be increased benefits to providing both cervical and thoracic manual therapy in comparison to just cervical manual therapy when treating patients with cervical neck pain. This could be due to the close anatomical relationship between the cervical and thoracic spine and the overlapping neural connections. This study measured effects after two weeks, so long term effectiveness is unclear.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Because of its acute effectiveness in reducing neck pain, cervical manual therapy in conjunction with thoracic manual therapy should be used to treat patients with neck pain.

Spinal Manipulative Therapy for Acute Neck Pain: A Systematic Review and Meta-Analysis of Randomised Controlled Trials”

Author Names

Chaibi, A., Stevem, K., Russell, M.

Reviewer Name

Miles Moore SPT CSCS

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

(1) Background: Acute neck pain is common and usually managed by medication and/or manual therapy. General practitioners (GPs) hesitate to refer to manual therapy due to uncertainty about the effectiveness and adverse events (AEs); (2) Method: To review original randomized controlled trials (RCTs) assessing the effect of spinal manipulative therapy (SMT) for acute neck pain. Data extraction was done in duplicate and formulated in tables. Quality and evidence were assessed using the Cochrane Back and Neck (CBN) Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria, respectively; (3) Results: Six studies were included. The overall pooled effect size for neck pain was very large −1.37 (95% CI, −2.41, −0.34), favouring treatments with SMT compared with controls. A single study that showed that SMT was statistically significantly better than medicine (30 mg ketorolac im.) one day post-treatment, ((−2.8 (46%) (95% CI, −2.1, −3.4) vs. −1.7 (30%) (95% CI, −1.1, −2.3), respectively; p = 0.02)). Minor transient AEs reported included increased pain and headache, while no serious AEs were reported; (4) Conclusions: SMT alone or in combination with other modalities was effective for patients with acute neck pain. However, limited quantity and quality, pragmatic design, and high heterogeneity limit our findings.

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?

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?

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

The main conclusion is that spinal manipulation alone or in combination with another modality is likely to be effective in the treatment of acute neck pain.

Key Finding #2

Randomized Clinical Trials report few, mild and transient adverse effects of Spinal Manipulations.

Key Finding #3

The literature surrounding spinal manipulations for acute neck pain contains large levels of heterogeneity with RCTs, small sample sizes, lack of blinding, and unaccounted for placebo effects.

Please provide your summary of the paper

Acute neck pain is an experience that warrants comprehensive assessment and adequate intervention when treating. At times, clinicians can display hesitancy when reasoning through whether to deploy spinal manipulation or other treatment intervention for this pathology. This systematic review and meta-analysis revealed spinal manipulation alone or as an adjunct with other interventions can likely be effective in treating patients with acute neck pain. Importantly, the authors note that the included randomized clinical trials reported few, mild and transient adverse effects when patients received spinal manipulations. However, robustness is lacking in the literature on acute neck pain and spinal manipulations as a treatment method. The literature surrounding spinal manipulations for acute neck pain contains large levels of heterogeneity with RCTs, small sample sizes, lack of blinding, and unaccounted-for placebo effects calling into question the true efficacy of spinal manipulations as a treatment intervention.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Spinal manipulative therapy can be an effective treatment for acute neck pain. However, due to the heterogeneity, small sample sizes, and like of blinding within the RCTs supporting the efficacy of this treatment it is difficult to infer direct correlation and causation. Additionally, since the mechanism this treatment follows is still largely debated it is difficult for me to deploy this intervention confidently within my clinical reasoning framework. Though these results do add to the growing body of literature around manual therapy and neck pain and will equip clinicians with ways to better serve patients in the future.

Stretching exercises vs manual therapy in treatment of chronic neck pain: a randomized, controlled cross-over trial

Author Names

Jari Ylinen 1, Hannu Kautiainen, Kaija Wirén, Arja Häkkinen

Reviewer Name

Marc Moreno-Takegami, Doctor of Physical Therapy Student

Reviewer Affiliation(s)

Duke University

Paper Abstract

Objective: To compare the effects of manual therapy and stretching exercise on neck pain and disability. Design: An examiner-blinded randomized cross-over trial. Patients: A total of 125 women with non-specific neck pain. Methods: PATIENTS were randomized into 2 groups. Group 1 received manual therapy twice weekly and Group 2 performed stretching exercises 5 times a week. After 4 weeks the treatments were changed. The follow-up times were after 4 and 12 weeks. Neck pain (visual analogue scale) and disability indices were measured. Results: Mean value (standard deviation) for neck pain was 50 mm (22) and 49 mm (19) at baseline in Group 1 and Group 2, respectively, and decreased during the first 4 weeks by 26 mm (95% Confidence Interval 20-33) and 19 mm (12-27), respectively. There was no significant difference between groups. Neck and shoulder pain and disability index decreased significantly more in Group 1 after manual therapy (p=0.01) as well as neck stiffness (p=0.01). Conclusion: Both stretching exercise and manual therapy considerably decreased neck pain and disability in women with non-specific neck pain. The difference in effectiveness between the 2 treatments was minor. Low-cost stretching exercises can be recommended in the first instance as an appropriate therapy intervention to relieve pain, at least in the short-term.

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)?

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

Although the difference was not statistically different between the groups, there was a significantly greater benefit reported subjectively from the manual therapy group in comparison with the stretching exercise group.

Key Finding #2

The Neck and Shoulder Pain and Disability Index clearly favored manual therapy at the 4-week follow-up, while the Vernon Disability Index did not reach statistical significance.

Key Finding #3

Reduction in the occurrence of chronic neck pain was significantly more effective when stretching exercises were combined with either neck muscle endurance or strength training.

Please provide your summary of the paper

The objective of this randomized controlled trial was to compare the effects of manual therapy and stretching exercise on neck pain and disability. The patient population was 125 women with non-specific neck pain who were randomized into two groups, with one group receiving manual therapy twice a week and the other group stretching five times a week. For the manual therapy group, mobilization was based on an 8 osteopathic-type mobilization technique and no manipulations or high velocity thrusts with low amplitude were performed. For the stretching group, exercises were targeted towards lateral flexion of the upper part of the trapezius, ipsilateral flexion and rotation for the scalene and flexion for the extensor muscles, holding each movement for 30 seconds and repeating three times. After 4 weeks, the manual therapy group had a 52% decrease in neck pain and the stretching group had a 39% decrease in neck pain, with a more significant benefit being subjectively reported by the manual therapy group. The outcome measure of the Neck and Shoulder Pain Disability Index also clearly favored manual therapy at the 4-week follow up. However, in conclusion, both stretching exercises and manual therapy considerably decreased both neck pain and disability, and the difference between the two treatments was minor.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

One limitation of this study was the short-follow up time of 4 weeks. Nevertheless, the article acknowledges that there is not extensive evidence in support of manual therapy as a sole long-term treatment for chronic neck pain. Rather, manual therapy needs to be combined with neck muscle training and stretching exercises in order to have any significant long-term effects. Another interesting finding worth noting in this study was that only half of the patients in the study used medication to ease neck symptoms, and the patients that did you pharmacological treatment did not experience much pain relief from them. As a future physical therapist, I hope to use articles such as these in order to provide evidence-based support for physical therapy and active rehabilitation as opposed to pharmacological as a primary treatment option for my patients. Lastly, the article acknowledged that much of the benefit attributable to manual therapy has been suggested to be a placebo effect in the past. This raises the question of how effective some of these interventions really are. However, as future physical therapists, I think our responsibility is to inform patients of the potential benefits of different treatment options, and to do our best to increase patient confidence in treatments like manual therapy through a strong therapeutic alliance and comprehensive patient education.

The impact of spinal manipulation on migraine pain and disability: A systematic review and meta-analysis

Author Names

Rist, C., Hernandez, A., Bernstein, C., Kowalski, M., Osypiuk, K., Vinning, R., Long, C., Goertz, C., Song, R., Wayne, P.

Reviewer Name

Nikol Papa, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Several small studies have suggested that spinal manipulation may be an effective treatment for reducing migraine pain and disability. We performed a systematic review and meta- analysis of published randomized clinical trials (RCTs) to evaluate the evidence regarding spinal manipulation as an alternative or integrative therapy in reducing migraine pain and disability. Methods: PubMed and the Cochrane Library databases were searched for clinical trials that evaluated spinal manipulation and migraine-related outcomes through April 2017. Search terms included: migraine, spinal manipulation, manual therapy, chiropractic, and osteopathic. Meta- analytic methods were employed to estimate the effect sizes (Hedges’ g) and heterogeneity (I^2) for migraine days, pain, and disability. The methodological quality of retrieved studies was examined following the Cochrane Risk of Bias Tool. Results: Our search identified 6 RCTs (pooled n=677; range of n=42–218) eligible for meta- analysis. Intervention duration ranged from 2–6 months; outcomes included measures of migraine days (primary outcome), migraine pain/intensity and migraine disability. Methodological quality varied across the studies. For example, some studies received high or unclear bias scores for methodological features such as compliance, blinding, and completeness of outcome data. Due to high levels of heterogeneity when all six studies were included in the meta-analysis, the one RCT performed only among chronic migraineurs was excluded. Heterogeneity across the remaining studies was low. We observed that spinal manipulation reduced migraine days with an overall small effect size (Hedges’ g = −0.35, 95% CI: −0.53, −0.16, p<0.001) as well as migraine pain/ intensity. Conclusions: Spinal manipulation may be an effective therapeutic technique to reduce migraine days and pain/intensity. However, given the limitations to studies included in this meta-analysis, we consider these results to be preliminary. Methodologically rigorous, large-scale RCTs are warranted to better inform the evidence base for spinal manipulation as a treatment for migraine.

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?

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?

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

The researchers considered the results of this meta-analysis to be preliminary considering the variation in study quality and specific study design features. With this in mind, the review found that spinal manipulation has the potential to reduce frequency, pain, and levels of disability related to migraines with overall small effect sizes.

Key Finding #2

This review included studies that looked at chronic migraineurs and others that included patients with as few as one migraine per month. Studies assessing individuals which experience chronic migraines noted larger effect estimates than any of the other studies included in this meta-analysis. In other words, there may be potential for increased positive outcomes for chronic migraine populations compared to acute onsets however more research in needed to better establish a difference.

Please provide your summary of the paper

This meta analysis reviewed 6 clinical trials with a total of 677 participants, 670 of which were included in analyses because they had baseline measurements. The average age of participants was 39.3 years and 75% of participants were female. All studies allowed patients to continue current medications. Spinal manipulations were performed by chiropractors in three studies, an osteopathic physician in two studies, and a medical practitioner/physiotherapist/chiropractor in one study. Five of the six studies used migraine diaries to assess outcomes. Results from this preliminary meta-analysis suggest that spinal manipulation reduced migraine days and migraine pain or intensity with an overall small effect size and did not impact migraine disability compared to control 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 meta analysis did not provide detail regarding the type of spinal manipulation nor the spinal level of manipulation. This lack of specificity limits the clinician’s ability to employ clinical reasoning to help triangulate what the appropriate manual therapy intervention (when, how often, which technique, etc.) to employ for migraineurs. Overall, if the clinician has appropriately screened their patients to rule out vascular compromise, cervical fractures, and other contraindications, they may consider employing spinal manipulation to potentially see a modest reduction in migraine frequency and pain.

Immediate effects of cervicothoracic junction mobilization versus thoracic manipulation on the range of motion and pain in mechanical neck pain with cervicothoracic junction dysfunction: a pilot randomized controlled trial

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

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?

Cannot Determine, Not Reported, or Not Applicable

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?

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?

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.

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