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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

Angelo Pata 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. Level of evidence: Therapy, level 2. J Orthop Sports Phys Ther 2019;49(5):299-309. doi:10.2519/jospt.2019.8150. Keywords: clinical trial; neck pain; radiculopathy; thoracic spine; thrust manipulation.

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

After undergoing thoracic manipulation, patients with cervical radiculopathy experienced a reduction in neck pain as compared to those who received sham treatment for the same condition.

Key Finding #2

The study found significant improvements in deep neck flexor endurance, active cervical range of motion (AROM) in all directions, and the Neck Disability Index (NDI) in patients who received thoracic manipulation compared to the sham manipulation group immediately after treatment and at 48 to 72 hours after treatment

Please provide your summary of the paper

This article delves into a randomized controlled trial that aimed to compare the immediate and short-term effects of thoracic manipulation versus sham manipulation in patients diagnosed with cervical radiculopathy. The study observed remarkable improvements in neck and upper extremity pain, cervical range of motion, disability, and deep neck flexor endurance in patients who underwent thoracic manipulation as opposed to the sham manipulation group. Furthermore, patients who received thoracic manipulation reported moderate to significant improvements in their neck and upper extremity symptoms for up to 48 to 72 hours after the treatment. These findings suggest that thoracic manipulation may be a viable treatment option for patients with cervical radiculopathy, and further research is needed to explore its long-term effects.

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 implies that thoracic manipulation may present a promising and effective treatment option for patients with cervical radiculopathy. Thoracic manipulation may be particularly helpful for patients with cervical radiculopathy who are experiencing limited cervical range of motion, neck and upper extremity pain, or poor deep neck flexor endurance While thoracic manipulation should not be considered the sole treatment option for patients with cervical radiculopathy, it should certainly be considered as one of many great options available to clinicians. As with all manual therapies, a holistic approach that considers the patient’s unique circumstances and preferences is crucial for optimal outcomes.

Manual therapy in adults with tension-type headache: A systematic review

Author Names

Cumplido-Trasmonte, C., Fernández-González, P., Alguacil-Diego, I. M., & Molina-Rueda, F.

Reviewer Name

Emilija Peleckas, SPT, B.S

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Introduction: Tension-type headache is the most common primary headache, with a high prevalence and a considerable socioeconomic impact. Manual physical therapy techniques are widely used in the clinical field to treat the symptoms associated with tension-type headache. This systematic review aims to determine the effectiveness of manual and non-invasive therapies in the treatment of patients with tension-type headache. Development: We conducted a systematic review of randomised controlled trials in the following databases: Brain, PubMed, Web of Science, PEDro, Scopus, CINAHL, and Science Direct. Ten randomised controlled trials were included for analysis. According to these studies, manual therapy improves symptoms, increasing patients’ well-being and improving the outcome measures analysed. Conclusions: Manual therapy has positive effects on pain intensity, pain frequency, disability, overall impact, quality of life, and craniocervical range of motion in adults with tension-type headache. None of the techniques was found to be superior to the others; combining different techniques seems to be the most effective approach. Keywords: Cefalea tensional; Fisioterapia; Manual therapy; Physiotherapy; Rehabilitación; Rehabilitation; Tension-type headache; Terapia manual; Tratamiento; Treatment.

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?

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

Manual therapy techniques targeting the cervical region done independently showed improvement in neck mobility, pain ratings, and disability scores after 4-6 weeks of treatment.

Key Finding #2

Combined manual therapy, soft tissue techniques, and exercises showed the greatest improvement in outcomes of neck mobility, pain intensity and frequency, disability, and quality of life in patients with tension-type headaches compared to treatments done individually.

Please provide your summary of the paper

This study utilized a systematic review to explore the effect of various manual therapy techniques and other non-invasive therapies such as exercises, posture re-training and modalities in the treatment of patients with tension-type headaches. The studies consisted of groups receiving just manual therapy techniques, just alternate non-invasive therapies, combined treatments, and control groups. After 4-6 weeks of treatment sessions lasting between 10-30 minutes findings from multiple studies consisted of improved pain intensity and frequency (visual analogue scale and McGill Pain Questionnaire), increased craniocervical ROM, significant overall improvement in headache disability index, and improved quality of life measured by the short form-12. No one specific treatment group or technique yielded better outcomes comparatively, but an overall improvement in patient outcomes was found from performing manual therapy and/or other non-invasive therapies for this patient 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 analyzed 10 studies using variable manual techniques targeted at the cervical region with a selection of different non-invasive techniques. The findings were positive for effects of manual therapy combined with other non-invasive therapies however the quality of the studies reviewed were poor with sample populations being small or the same population being used in two of the studies. There was also limitation in the studies where only 3 studies were double blinded, one blinded only the participants, and other failed to mention any blinding. Therefore, there is a need for higher quality studies not limited by sample size/selection and blinding to better determine the effectiveness of the intervention. However, with the current information, clinicians should continue to participate in studies and clinically use a combination of manual and non-invasive therapies to see what works best for each patient for the most optimal outcomes.

Cervicothoracic Manual Therapy Plus Exercise Therapy Versus Exercise Therapy Alone in the Management of Individuals With Shoulder Pain: A Multicenter Randomized Controlled Trial

Author Names

Mintken, P., McDevitt, A., Cleland, J., Boyles, R., Beardslee, A., Burns, S., Haberl, M., Hinrichs, L., Michener, L.

Reviewer Name

Wes Pritzlaff, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study Design Multicenter randomized controlled trial. Background Cervicothoracic manual therapy has been shown to improve pain and disability in individuals with shoulder pain, but the incremental effects of manual therapy in addition to exercise therapy have not been investigated in a randomized controlled trial. Objectives To compare the effects of cervicothoracic manual therapy and exercise therapy to those of exercise therapy alone in individuals with shoulder pain. Methods Individuals (n = 140) with shoulder pain were randomly assigned to receive 2 sessions of cervicothoracic range-of-motion exercises plus 6 sessions of exercise therapy, or 2 sessions of high-dose cervicothoracic manual therapy and range-of-motion exercises plus 6 sessions of exercise therapy (manual therapy plus exercise). Pain and disability were assessed at baseline, 1 week, 4 weeks, and 6 months. The primary aim (treatment group by time) was examined using linear mixed-model analyses and the repeated measure of time for the Shoulder Pain and Disability Index (SPADI), the numeric pain-rating scale, and the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Patient-perceived success was assessed and analyzed using the global rating of change (GROC) and the Patient Acceptable Symptom State (PASS), using chi-square tests of independence. Results There were no significant 2-way interactions of group by time or main effects by group for pain or disability. Both groups improved significantly on the SPADI, numeric pain-rating scale, and QuickDASH. Secondary outcomes of success on the GROC and PASS significantly favored the manual therapy-plus-exercise group at 4 weeks (P = .03 and P<.01, respectively) and on the GROC at 6 months (P = .04). Conclusion Adding 2 sessions of high-dose cervicothoracic manual therapy to an exercise program did not improve pain or disability in patients with shoulder pain, but did improve patient-perceived success at 4 weeks and 6 months and acceptability of symptoms at 4 weeks. More research is needed on the use of cervicothoracic manual therapy for treating shoulder pain. Level of Evidence Therapy, level 1b. Prospectively registered March 30, 2012 at www.ClinicalTrials.gov (NCT01571674). J Orthop Sports Phys Ther 2016;46(8):617-628. doi:10.2519/jospt.2016.6319.

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

There were no significant two-way interactions of group by time or main effects by groups for pain (measured via NPRS) or disability (measured via SPADI and QuickDASH) at baseline, one week, four weeks, or six months post-treatment in individuals with shoulder pain either receiving exercise therapy alone (two sessions of cervicothoracic ROM exercises followed by six sessions of exercise therapy) or exercise therapy and high-dose cervicothoracic manual therapy (concurrent with cervicothoracic ROM exercises during first two sessions).

Key Finding #2

Patients with shoulder pain who received two sessions of cervicothoracic manual therapy in addition to cervicothoracic ROM and exercise therapy reported significantly higher patient-perceived success and acceptability of symptoms on the GROC and PASS at four weeks and six months and four weeks following treatment, respectively, compared to patients who did not receive cervicothoracic manual therapy.

Key Finding #3

Patients in both cervicothoracic manual therapy with exercise therapy and exercise therapy-only groups demonstrated improvement on the NPRS, SPADI, QuickDASH, GROC, and PASS from baseline to subsequent follow-ups.

Please provide your summary of the paper

This randomized control trial sought to compare the changes in pain (NPRS), disability (SPADI and QuickDASH), patient-perceived success (GROC), and acceptability of symptoms (PASS) across six months following treatment between individuals with shoulder pain receiving cervicothoracic manual therapy plus exercise therapy or exercise therapy alone. The data were analyzed utilizing validated measures outlined in the methods section. All patients started by receiving two sessions of cervicothoracic ROM exercises followed by six sessions of exercise therapy targeted at neuromuscular re-education, flexibility, and postural strengthening exercises for two sessions per week across four weeks (eight sessions total). The cervicothoracic manual therapy group also received five different HVLAT manipulations (up to 10) directed at the upper, middle, and lower thoracic spine and one lower cervical mobilization technique at the start of the first two sessions. While all patients met minimal clinically important differences on all outcome measures, there were no significant differences in pain or disability between groups; however, the group receiving cervicothoracic manual therapy demonstrated significantly greater patient-perceived success and acceptability of symptoms ratings at the four-week treatment session. These results suggest that cervicothoracic manipulations and mobilizations do not improve patient-reported outcomes compared to exercise alone in individuals with shoulder pain; however, it suggests that cervicothoracic manual therapy may promote patient-perceived success of treatment. The article thoroughly summarizes all cervicothoracic manual therapy, cervicothoracic ROM, and exercise therapy interventions in the appendices.

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

The results of this study may not change how neutral clinicians practice and may support the confirmation biases of clinicians who feel positively and negatively about manual therapy. For clinicians who view manual therapy neutrally or negatively, the results suggest that manual therapy does not add value to exercise therapy in improving a patient’s pain or disability outcomes. However, for clinicians who view manual therapy positively, the results suggest that manual therapy helps to improve patient perceptions of progress and success with equivalent pain and disability outcomes, so it should be included to improve patient satisfaction. These results have high external validity with transferability to the clinic as the inclusion criteria were broad and patients were recruited across the United States. The inclusion criteria include participants between ages 18 to 65, a primary complaint of shoulder pain (pain between neck and elbow), and greater than 20% disability as measured by the SPADI. While this study looked at patient-reported outcome measures, future studies may further analyze the effect of cervicothoracic manual therapy in addition to exercise in physical performance outcome measures, including but not limited to ROM and muscular endurance, strength, and power.

PNF and manual therapy treatment results of patients with cervical spine osteoarthritis

Author Names

Maicki, T., Bilski, J., Szczygieł, E., and Trąbkaa, R.

Reviewer Name

Beautiful Reed, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

PURPOSE: The aim of this study was to evaluate the effectiveness of PNF and manual therapy methods in the treatment of patients with cervical spine osteoarthritis, especially their efficacy in reducing pain and improving functionality in everyday life. Long-term results were also compared in order to determine which method of treatment is more effective.

SUBJECTS AND METHODS: Eighty randomly selected females aged 45–65 were included in the study. They were randomly divided into two groups of 40 persons. One group received PNF treatment and the other received manual therapy (MAN.T). To evaluate functional capabilities, the Functional Rating Index was used. To evaluate changes in pain, a shortened version of the McGill Questionnaire was used.

RESULT: The PNF group achieved a greater reduction in pain than the MAN.T group. The PNF group showed a greater improvement in performing daily activities such as sleeping, personal care, traveling, work, recreation, lifting, walking and standing as well as decreased intensity and frequency of pain compared to the MAN.T group.

CONCLUSION: The PNF method proved to be more effective in both short (after two weeks) and long (after three months) 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?

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

PNF and manual therapy had a statistically significant impact on reducing pain and improving the performance of daily activities of females with cervical spine pain

Key Finding #2

Individuals in the PNF group showed twice as much pain reduction on the McGill Questionnaire than the manual therapy group.

Key Finding #3

PNF was shown to have better short term and long term affects (according to the McGill Questionnaire and the Functional Rating Index) than manual therapy.

Please provide your summary of the paper

This is a randomized-controlled trial that tests the differences in improved outcomes between Proprioceptive Neuromuscular Facilitation (PNF) and Manual Therapy on patients with cervical spine osteoarthritis. The study states that the patients in both the PNF and manual therapy groups had statistically significant reductions in their pain and improvements in their activities of daily living. When comparing the two groups however, PNF resulted in twice as much of a reduction in pain than manual therapy. This data was taken after two weeks of treatment as well as three months post the treatment bout – both of which showed PNF had better effects on patient outcomes than manual therapy. A limitation of this study was that only females were tested.

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

This article helps demonstrate that manual therapy can have statistically significant reductions on pain and improvements in ADL’s for patients with cervical spine osteoarthritis. It also showcases however that PNF may be more impactful to patients with the same diagnosis. Based soley on this paper alone, it can be safe to assume that both manual therapy and PNF individually can have great positive impacts on patients throughout their treatment bout and even following. This article begs the questions of whether a combination of these techniques may result in even greater statistically significant patient outcomes than just the lone test groups. This article also approaches the concept of using deep neck muscle strengthening in this population, claiming that both PNF and manual therapy target the deep neck flexors, but in different ways. Deep neck flexor strengthening has been seen in some articles to decrease pain and disability in patients with chronic neck pain. This article discusses that perhaps the reason that more improvements were seen in the PNF group may be because PNF targets muscles in a three-dimensional fashion (i.e., diagonal and spiral patterns) while manual therapy addresses this same strengthening via one-dimension (i.e.,posterior to anterior mobilizations). Overall, this article helps cement the concept of using manual therapy or PNF as valid pain reducers in therapy.

Effect of manual therapy with exercise in patients with chronic cervical radiculopathy: a randomized clinical trial

Author Names

Alshami, A., & Bamhair, D.

Reviewer Name

Beautiful Reed, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

BACKGROUND: Research that has examined the effects of cervical spine mobilization on hypoesthesia and hypersensitivity characteristics in patients with cervical radiculopathy is scarce. The aim of this study was to examine the short-term effects of vertebral mobilization on the sensory features in patients with cervical radiculopathy.

METHODS: Twenty-eight participants with chronic cervical radiculopathy were randomly allocated to (1) an experimental group [cervical vertebral mobilization technique and exercise] or (2) a comparison group [minimal superficial circular pressure on the skin and exercise]. Participants received a total of 6 sessions for 3-5 weeks. Numeric Pain Rating Scale (NPRS), Neck Disability Index (NDI), pressure pain threshold (PPT), heat/cold pain threshold (HPT/CPT), and active cervical range of motion (ROM) were measured at baseline immediately after the first session and after the sixth session.

RESULTS: The experimental group showed improvements from baseline to session 6 in NPRS [mean difference 2.6; 95% confidence interval: -4.6, -0.7], NDI [14; -23.3, -4.3], and active cervical ROM in extension [14°; 2.3, 25.5], rotation [16°; 8.8, 22.5], and lateral flexion to the affected side [10°; 2.3, 16.8]. Improvements were also found in PPT at the neck [124 kPa; 57, 191.1] and C7 level at the hand [99 kPa; 3.6, 194.9]. There were no changes in the HPT and CPT at any tested area (P>0.050).

CONCLUSIONS: Cervical vertebral mobilization for patients with chronic cervical radiculopathy reduced localized mechanical, but not thermal, pain hypersensitivity.

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

Cervical vertebral mobilization in the manual therapy group found improvements in local mechanical pressure hypersensitivity, self-report measures on pain intensity and neck function, as well as active cervical ROM.

Key Finding #2

There were no improvements noted in the manual therapy group regarding changes in thermal pain thresholds (heat or cold).

Key Finding #3

The mean improvement of pain pressure thresholds (PPT) on the neck in the manual therapy group after session 6 was 124 kPa (kilopascal), which exceeded the minimal detectable change (MDC) of 87 kPa.

Key Finding #4

The findings of the numeric pain rating scale matched with those of pain pressure threshold (PPT) on the neck. Cervical vertebral mobilization resulted in pain reduction of 3.9 points over the study period which is more than the minimal clinically important difference (MCID) of 2.2 points.

Please provide your summary of the paper

This is a randomized-controlled trial that looked at the short-term effects of cervical manual therapy with exercise on the sensory features in patients with chronic cervical radiculopathy. Both self-reported measures of pain intensity and neck function as well as active ROM and mechanical/thermal pain thresholds were gathered through a 6-week treatment bout. Patients were divided into two groups that either received manual therapy (PA glides of the C-spine and upper limb neurodynamic mobilizations with lateral cervical glides) with exercise, or superficial circular pressure on the skin with exercise. The group with manual therapy found improvements in almost all measured outcomes, but not with thermal pain threshold testing.

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

This article helps demonstrate that manual therapy can have short-term positive effects on patients with cervical radiculopathy in several aspects including pain intensity, active mobility, self-reported neck function, and pain pressure thresholds. For patients with chronic cervical radiculopathy, physical therapists must be mindful that pain can be a serious limiter in that patients life. This article helps shine light on the importance manual therapy can have on improving not only a patients pain intensity, but their overall pain threshold. By raising the patients PPT, it tells us that a biologic/chemical change in a patients internal system response to pain is occurring with the use of manual therapy techniques. This can be a major game changer for a patient with chronic pain as a first step to improving their overall self-reported neck function.

Role of Manual Therapy for Neck Pain and Quality of Life in Head and Neck Cancer Survivors: A Systematic Review

Author Names

Pattanshetty, R., & Patil, S.

Reviewer Name

Hope Reynolds, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Pain is the one the most dreadful side effects of head and neck cancers and cancer related treatments affecting patients during and after the treatment adding to the problems affecting their ability to speak, swallow, breath and feeding. Manual therapy is standard set of physiotherapy treatments used for alleviating neck pain. It has found to be effective in small subset of cancer patients for relieving pain. Objectives: To highlight the use of various manual therapy techniques focusing in decreasing neck pain and improving quality of life in Head and Neck Cancer survivors that may suggest its safe utilisation in oncology rehabilitation. Materials and Methods: Electronic search was conducted in PubMed, Google Scholar, CINAHL, Pedro, and COCHRANE databases. Reference lists of the included studies and relevant reviews were manually searched. Studies that met the inclusion criteria were evaluated using McMaster critical review form for quantitative studies. A descriptive synthesis was undertaken due to the heterogeneity of the included studies. Results: Seven studies were assessed for risk of bias that comprised of three clinical trials, one case series and three case reports that applied Maitland’s mobilisation, Myofascial release, Muscle Energy Techniques to head and neck cancer survivors in various clinical settings. The outcomes highlighted decrease in pain, improvement in cervical range of motion and quality of life. Conclusion: This review recommends application of manual therapy to head and neck cancer survivors. However, authors caution application of manual therapy in terms of choosing a particular technique. Further, well designed larger sample size with randomisation and double blinding would help to generate better evidence for head and neck cancer survivors.

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

Various manual therapy techniques, including Maitland’s mobilization, myofascial release, and muscle energy techniques, applied to the cervical, upper thoracic, and shoulder regions have been shown to be effective in decreasing pain and improving cervical range of motion and quality of life in head and neck cancer survivors.

Key Finding #2

Both mobilization and soft tissue techniques may induce relaxation and lead to both immediate and long-term analgesic effects in this patient population.

Key Finding #3

The utilization of manual therapy techniques is considered safe and is recommended to treat neck pain and enhance physical function in head and neck cancer survivors, however, care should be taken based on individual considerations in choosing and applying these techniques.

Please provide your summary of the paper

Due to the associated treatments, head and neck cancer survivors often experience post-surgical scar tissue formation and muscle dysfunction leading to motion deficits in the neck and shoulder. Additionally, 80% of head and neck cancer survivors report pain as being the most disabling symptom leading to a decreased quality of life. Studies have shown that manual therapy techniques such as myofascial release (MFR) and muscle energy techniques (MET) can lead to improvements in shoulder movements, pain management, and quality of life. However manual therapy techniques are sometimes considered contraindicated in patients with cancer. Therefore, this systematic review sought to clarify the effectiveness of various manual therapy techniques on neck pain and its effect on quality of life in head and neck cancer survivors. The results showed that manual therapy techniques when applied to the shoulder and neck region are safe and effective in reducing pain and improving quality of life in head and neck cancer survivors. Specifically, MFR, MET, and Maitland’s mobilizations were shown to have direct impacts on patients’ pain thresholds, mobility restrictions, and mental health through their alleviating effects on complications related to radiation, post-operative scarring, and muscle guarding. However, more research and larger sample size clinical trials are needed to determine the specifics of how best to implement manual therapy interventions in this patient population and care should be taken when utilizing these techniques based on individual patient considerations.

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

It is recommended that manual therapy techniques such as Maitland’s mobilizations, myofascial release, and muscle energy techniques be utilized to reduce neck pain and improve range of motion and quality of life in head and neck cancer survivors. However, care should be taken in the choosing and application of these manual therapy techniques based on factors specific to each individual, their diagnosis, and their treatment history.

Effects of sling-based manual therapy on cervicothoracic junction in patients with neck pain and forward head posture: A randomized clinical trial

Author Names

Kim, S; An, C; Cha, Y; Kim, D

Reviewer Name

Dylan Scott, SPT

Reviewer Affiliation(s)

Duke University

Paper Abstract

Objective The purpose of this study was to investigate the effect of 4 weeks of sling-based manual therapy on the cervicothoracic junction (CTJ) area in patients with neck pain and forward head posture. Design Single-blind randomized controlled trial. Setting Outpatient, Chonbuk National University hospital, Republic of Korea. Subjects A total of 22 participants with neck pain (Numeric Pain Rating Scale >3) and forward head posture (craniovertebral angle <51) were randomly assigned to a CTJ group or a control group (n = 11 each). Intervention In the control group, joint mobilization and motor control training was applied for the upper cervical spine (C0–C1). The CTJ group applied the same intervention to the upper cervical spine and cervicothoracic junction (C7-T3). Main measures Numeric pain rating scale and neck disability index, craniovertebral angle, active range of motion, and muscle activity were evaluated before and after 4 weeks of intervention. Result The CTJ group participants showed significant improvement in the craniovertebral angle and cervical extension range after the intervention than the control group (P = 0.025, P = 0.001). While both groups presented significant differences after the intervention regarding Numeric pain rating scale, neck disability index, and muscle activity (sternocleidomastoid and anterior scalene muscle), there were no statistically significant differences between the groups (P > 0.05). Conclusion Our results suggest that the CTJ and the upper cervical region in patients with neck pain and forward head posture represent an area which if approached by manual therapy, improves cervical mobility and posture.

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?

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

Sling-based manual therapy significantly improved cervical and thoracic range of motion in patients with neck pain and forward head posture.

Key Finding #2

Patients who received sling-based manual therapy had significant reductions in pain intensity and disability related to neck pain compared to the control group.

Key Finding #3

The group receiving manual therapy using a sling showed a statistically significant improvement in cervical range of motion compared to the control group.

Key Finding #4

The improvements in pain, disability, and range of motion were maintained at 1-month follow-up, suggesting that the effects of sling-based manual therapy were lasting.

Please provide your summary of the paper

The study was conducted as a randomized clinical trial with 30 participants. The participants were randomly assigned to a sling-based manual therapy group or a control group. The intervention group received a sling-based manual therapy program for three weeks, while the control group received no intervention. The researchers measured the participants’ cervicothoracic junction range of motion, pain level, and muscle activity before and after the intervention. The results showed that the intervention group had significantly greater improvements in cervicothoracic junction range of motion and muscle activity compared to the control group. Additionally, the intervention group had significantly reduced pain levels compared to the control group. Based on these findings, the researchers concluded that sling-based manual therapy can be an effective intervention for patients with neck pain and forward head posture.

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

The results suggest that using a sling-based manual therapy approach can lead to significant improvements in cervical and thoracic range of motion, as well as significant reductions in pain in patients with neck pain and forward head posture. This approach can be implemented along with other interventions such as exercise and body mechanics modifications. Although further research is needed to determine the dosage and frequency of this treatment, it can be implemented in a variety of clinical settings and is a valuable treatment option for physical therapists to have.

Multimodal manual therapy vs. pharmacological care for management of tension type headache: A meta-analysis of randomized trials

Author Names

Mesa-Jiménez JA, Lozano-López C, Angulo-Díaz-Parreño S, Rodríguez-Fernández ÁL, De-la-Hoz-Aizpurua JL, Fernández-de-las-Peñas C.

Reviewer Name

Makayla Spade SPT

Reviewer Affiliation(s)

Duke school of Medicine Doctorate of Physical Therapy 2024

Paper Abstract

Background Manual therapies are generally requested by patients with tension type headache. Objective To compare the efficacy of multimodal manual therapy vs. pharmacological care for the management of tension type headache pain by conducting a meta-analysis of randomized controlled trials. Methods PubMed, MEDLINE, EMBASE, AMED, CINAHL, EBSCO, Cochrane Database of Systematic Reviews, Cochrane Collaboration Trials Register, PEDro and SCOPUS were searched from their inception until June 2014. All randomized controlled trials comparing any manual therapy vs. medication care for treating tension type headache adults were included. Data were extracted and methodological quality assessed independently by two reviewers. We pooled headache frequency as the main outcome and also intensity and duration. The weighted mean difference between manual therapy and pharmacological care was used to determine effect sizes. Results Five randomized controlled trials met our inclusion criteria and were included in the meta-analysis. Pooled analyses found that manual therapies were more effective than pharmacological care in reducing frequency (weighted mean difference –0.8036, 95% confidence interval –1.66 to –0.44; three trials), intensity (weighted mean difference –0.5974, 95% confidence interval –0.8875 to –0.3073; five trials) and duration (weighted mean difference –0.5558, 95% confidence interval –0.9124 to –0.1992; three trials) of the headache immediately after treatment. No differences were found at longer follow-up for headache intensity (weighted mean difference –0.3498, 95% confidence interval –1.106 to 0.407; three trials). Conclusion Manual therapies were associated with moderate effectiveness at short term, but similar effectiveness at longer follow-up for reducing headache frequency, intensity and duration in tension type headache than pharmacological medical drug care. However, due to the heterogeneity of the interventions, these results should be considered with caution at this stage.

Key Finding #1

At short term, manual therapies had moderate effectiveness, but at longer follow-up, they were similar to pharmacological medical drug therapies at reducing headache frequency, intensity and duration.

Key Finding #2

A pair of authors independently extracted data from each study. Based on the CONSORT statement (16), a standardized data extraction form was used to collect information on the population, interventions, study methods, results, and outcomes. Each study was evaluated on the following criteria: inclusion and exclusion criteria; randomization; sample size; dropouts; blinding of patients or assessors; outcome measures; interventions; results; follow-up periods. Each item of the data extraction form had to be agreed upon by both authors.

Key Finding #3

Pain frequency was expressed as days per month with pain, intensity was abstracted using the scale used by each study, and duration was expressed as hours per day with pain.

Please provide your summary of the paper

Chronic headaches were the subject of four studies, while frequent episodic TTH was the subject of one study. It took 4 to 6 weeks for treatment to take place with 5–12 manual therapy sessions. Various treatment approaches were used in manual therapy, including spinal manipulation, low-load stabilization exercises, release of soft tissue pressure, and corrective posture awareness. Pharmacological drug intervention followed accepted guidelines and was administered for the same time period than manual therapy. Most studies linked protective situation and severe remedy including non-steroidal antagonistic-instigative drugs. All studies contained required follow ups after the interventions, however 3 studies were reported 18 to 24 weeks after the interventions given. Manual analysis was more effective than pharmacological first-contact medical care in lowering migraine repetitiveness urgently subsequently invasion and care in dropping problem force rapidly later. However, even though manual remedy was effective for short term relief accompanying pharmacological first-contact medical care the distinctness was not statistically important. Manual analysis was still more persuasive than pharmacological first-contact medical care in lowering the hours per epoch accompanying migraine soon, that was statistically important (P < 0.001) and given the test of variety.

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

Manual therapy was found to be more effective and subjectively reported more relieving immediate compared to Pharmacological drug. However, manual therapy is a short term relief so that patients are needing pharmacological drug for long term relief. Manual therapy was still suggested than pharmacological first-contact medical care in lowering the hours per day accompanying migraine soon after, showing that it is statistically important (P < 0.001) and passing exam of divergency.

Manual therapy and exercise for neck pain: A systematic review

Author Names

Miller, J et al.

Reviewer Name

Emily Stadnick

Reviewer Affiliation(s)

2nd year SPT, Duke University School of Medicine DPT Program

Paper Abstract

Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematic review update assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. Computerized searches were performed to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardized mean differences (pSMD) were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias. Low quality evidence suggests clinically important long-term improvements in pain (pSMD-0.87(95% CI:−1.69,−0.06)), function/disability, and global perceived effect when manual therapy and exercise are compared to no treatment. High quality evidence suggests greater short-term pain relief [pSMD-0.50(95% CI:−0.76,−0.24)] than exercise alone, but no long-term differences across multiple outcomes for (sub)acute/chronic neck pain with or without cervicogenic headache. Moderate quality evidence supports this treatment combination for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash. Evidence regarding radiculopathy was sparse. Specific research recommendations are made.

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

There is low-quality evidence to support the use of manipulation, mobilization, and exercise for reducing long-term pain compared to no treatment for chronic neck pain.

Key Finding #2

There is high-quality evidence to support the use of manipulation or mobilization combined with exercise for greater short-term pain relief compared to exercise alone for patients with neck pain. Additionally, this combination of treatments can have effects on long-term pain, function, global perceived effect, patient satisfaction, and quality of life for patients with variable neck pain compared to solely exercising in various forms.

Key Finding #3

Moderate quality evidence shows that manipulation or mobilization combined with exercise has greater pain reduction and quality of life for patients with chronic neck pain compared to manipulation or mobilization alone.

Key Finding #4

For short-term follow-up for acute Whiplash Associate Disorder, there is moderate quality evidence to support using manipulations, exercise, and mobilizations compared to traditional care for pain reduction. There is low-quality evidence for this combination of treatments for long-term follow-ups for chronic neck pain or mixed duration.

Please provide your summary of the paper

This systematic review assesses 17 studies to determine the effectiveness of manipulation and exercise on adult patients who have varied causes and durations of neck pain. Effectiveness was decided based on improvements in pain, function/disability, quality of life, global perceived effect, and patient satisfaction. After determining the inclusion criteria, the systematic review determined low-quality evidence to support exercise combined with manipulation and mobilization to have a greater pain reduction over time compared to no treatment at all. High-quality evidence was found to support that exercise combined with manipulation and mobilization had greater short-term pain relief compared to only exercise as the intervention. Additionally, moderate quality evidence determined that manipulations, mobilizations, and exercise combined had a better short-term reduction in pain with follow-up for Whiplash Associated Disorder compared to traditional care. Overall, more research needs to be done to determine if using manual therapy with exercise can be used as high-quality evidence to improve pain, function/disability, quality of life, global perceived effect, and patient satisfaction for long-term conditions and variable patient populations.

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

More research is needed to determine the outcomes and effects of manual therapy in combination with exercise with variable populations and neck injury conditions. Additionally, the combination of manual therapy with exercise should be applied to other portions of the spine to determine the effects at differing spinous levels.

Are Manual Therapies, Passive Physical Modalities, or Acupuncture Effective for the Management of Patients with Whiplash-Associated Disorders or Neck Pain and Associated Disorders? An Update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the OPTIMa Collaboration

Author Names

Wong, J.; Shearer, H.; Mior, Silvano; Jacobs, C.; Pierre, C.; Randhawa, K.; Yu, H.; Southerst, D.; Varatharajan, s.; Sutton, D.;van der Velde, G.; Carroll, L.; Ameis, A.; Ammendolia, C.; Brison,R; Nordin, M.; Stupar, M.; Taylor-Vaisey, Anne.

Reviewer Name

Gabrielle Stanley, Duke SPT2

Reviewer Affiliation(s)

University of California, Davis B.S. Human Development 2019

Paper Abstract

In 2008, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) found limited evidence on the effectiveness of manual therapies, passive physical modalities, or acupuncture for the management of whiplash-associated disorders (WAD) or neck pain and associated disorders (NAD). This review aimed to update the findings of the Neck Pain Task Force, which examined the effectiveness of manual therapies, passive physical modalities, and acupuncture for the management of WAD or NAD. Sample The sample includes randomized controlled trials, cohort studies, and case-control studies comparing manual therapies, passive physical modalities, or acupuncture with other interventions, placebo or sham, or no intervention. Outcome Measures The outcome measures were self-rated or functional recovery, pain intensity, health-related quality of life, psychological outcomes, or adverse events. We systematically searched five databases from 2000 to 2014. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with a low risk of bias were stratified by the intervention’s stage of development (exploratory vs. evaluation) and synthesized following best evidence synthesis principles. Funding was provided by the Ministry of Finance.We screened 8,551 citations, and 38 studies were relevant and 22 had a low risk of bias. Evidence from seven exploratory studies suggests that (1) for recent but not persistent NAD grades I–II, thoracic manipulation offers short-term benefits; (2) for persistent NAD grades I–II, technical parameters of cervical mobilization (eg, direction or site of manual contact) do not impact outcomes, whereas one session of cervical manipulation is similar to Kinesio Taping; and (3) for NAD grades I–II, strain-counterstrain treatment is no better than placebo. Evidence from 15 evaluation studies suggests that (1) for recent NAD grades I–II, cervical and thoracic manipulation provides no additional benefit to high-dose supervised exercises, and Swedish or clinical massage adds benefit to self-care advice; (2) for persistent NAD grades I–II, home-based cupping massage has similar outcomes to home-based muscle relaxation, low-level laser therapy (LLLT) does not offer benefits, Western acupuncture provides similar outcomes to non-penetrating placebo electroacupuncture, and needle acupuncture provides similar outcomes to sham-penetrating acupuncture; (3) for WAD grades I–II, needle electroacupuncture offers similar outcomes as simulated electroacupuncture; and (4) for recent NAD grades III, a semi-rigid cervical collar with rest and graded strengthening exercises lead to similar outcomes, and LLLT does not offer benefits.

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?

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?

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

Mobilization, manipulation, and clinical massage are effective interventions for the management of neck pain.

Key Finding #2

Electroacupuncture, strain-counterstrain, relaxation massage, and some passive physical modalities (heat, cold, diathermy, hydrotherapy, and ultrasound) are not effective and should not be used to manage neck pain.

Please provide your summary of the paper

Of the 38 studies reviewed, evidence suggests that For recent, non chronic Neck Pain Associated Disorder (NAD) thoracic manipulation does offer increase in range of motion and decrease in pain, however these improvements only exist in the short term. For chronic NAD, specific parameters of cervical mobilization are not statistically significant, rather, general mobilization of the thoracic spine has proven beneficial. However, no more beneficial than Kinesio Taping. This study also claims that the following interventions have been unsuccessful in treating NAD: gentle/swedish massage, acupuncture, and rigid cervical collars.

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 is incredibly helpful in guiding best practice recommendations for treating general neck pain. This study promotes the use of manual therapy in conjunction with exercise to improve range of motion, decrease pain, and reap the long and short term benefits respectively. One thing should be noted, however, upon addressing the results of this study. Only 38 studies of over 8,000 citations met the criteria of low-risk bias. This meta-analysis therefore was only a representation of a fraction of the articles that are out there. Not only that, but this most recent reputable source for how to address backspin was published over six years ago. While I applaud the findings of this research in pushing the field of physical therapy forward, I believe it is time for a more up to date, meta-analysis, and less bias ridden data, that can be used to give us better practice guidelines for NDA.

Scapular Kinematics Pre- and Post-Thoracic Thrust Manipulation in Individuals With and Without Shoulder Impingement Symptoms: Randomized Controlled Study

Author Names

Haik, Melina N., PT, MS, Alburquerque-Sendin, Francisco, PT, PhD, Silvia, Caroline Z., PT, Siqueira-Junior, Aristides L., PT, Ribeiro , Ivana L., PT, Camargo, Paula R., PT, PhD

Reviewer Name

Paula Stonehouse Salinas

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

STUDY DESIGN: Randomized controlled trial with immediate follow-up. OBJECTIVES: To evaluate the immediate effects of a low-amplitude, high-velocity thrust thoracic spine manipulation (TSM) on pain and scapular kinematics during elevation and lowering of the arm in individuals with shoulder impingement syndrome (SIS). The secondary objective was to evaluate the immediate effects of TSM on scapular kinematics during elevation and lowering of the arm in individuals without symptoms. BACKGROUND: Considering the regional interdependence among the shoulder and the thoracic and cervical spines, TSM may improve pain and function in individuals with SIS. Comparing individuals with SIS to those without shoulder pathology may provide information on the effects of TSM specifically in those with SIS. METHODS: Fifty subjects (mean ± SD age, 31.8 ± 10.9 years) with SIS and 47 subjects (age, 25.8 ± 5.0 years) asymptomatic for shoulder dysfunction were randomly assigned to 1 of 2 interventions: TSM or a sham intervention. Scapular kinematics were analyzed during elevation and lowering of the arm in the sagittal plane, and a numeric pain rating scale was used to assess shoulder pain during arm movement at preintervention and postintervention. RESULTS: For those in the SIS group, shoulder pain was reduced immediately after TSM and the sham intervention (mean ± SD preintervention, 2.9 ± 2.5; postintervention, 2.3 ± 2.5; P<.01; moderate effect size [Cohen d = 0.2]). Scapular internal rotation increased 0.5° ± 0.02° (P = .04; small effect size [Cohen d< 0.1]) during elevation of the arm after TSM and sham intervention in the SIS group only. Subjects with and without SIS who received TSM and asymptomatic subjects who received the sham intervention had a significant increase (1.6° ± 2.7°) in scapular upward rotation postintervention (P<.05; small effect size [Cohen d<0.2]), which was not considered clinically significant. Scapular anterior tilt increased 1.0° ± 4.8° during elevation and lowering of the arm postmanipulation (P<.05; small effect size [Cohen d<0.2]), in the asymptomatic subjects who received TSM. CONCLUSION: Shoulder pain in individuals with SIS immediately decreased after a TSM. The observed changes in scapular kinematics following TSM were not considered clinically important. LEVEL OF EVIDENCE: Therapy, level 4. J Orthop Sports Phys Ther 2014;44(7):475-487 Epub 22 May 2014. doi:10.2519/jospt.2014.4760 KEY WORDS: manipulation, manual therapy, rehabilitation, spine

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

TSM shoulder pain during elevation and lowering of the arm decreases immediately after a single session of TSM or sham TSM directed to the midthoracic spine in subjects with SIS.

Key Finding #2

Self-reported shoulder pain in the symptomatic individuals seemed to be decreased independently of the intervention applies (TSM or sham).

Key Finding #3

A greater number of subjects reported pain relief after TSM (60%) than after the sham intervention (36%).

Key Finding #4

TSM may immediately improve scapular upward rotation independently of shoulder symptoms.

Please provide your summary of the paper

This article studied the effects of low-amplitude, high-velocity thrust thoracic spine manipulation (TSM) on pain and scapular kinematics during elevation and lowering of the arm in individuals with shoulder impingement syndrome. There were 50 subjects with SIS and 47 subjects asymptomatic for shoulder dysfunction. They were randomly assigned to one of the four groups: (1) TSM impingement group, (2) Sham impingement group, (3) TSM asymptomatic group and (4) Sham asymptomatic group. The symptomatic shoulder was evaluated in the impingement groups and a randomly determined shoulder was assessed in the asymptomatic groups. Scapular kinematics were assessed using three-dimensional measurements during elevation and lowering of the arm in the sagittal plane. The numeric pain rating scale (NPRS) was used to assess shoulder pain during arm movement. For interventions, a PT targeted the midthoracic spine implementing a thrust technique for the TSM intervention and if no cavitation was detected with the manipulation, it was repeated up to 3 times. For the sham intervention, the PT held the subject in the same position for a few seconds, but no thrust manipulation was applied. 3 trials were performed preintervention and postintervention. For each analysis, time (pre and post – intervention) and angle (30, 60, 90, 120) were within-subject factors and intervention (TSM and sham) was the between-subject factor. The following outcome measures were used: DASH questionnaire and WORC index. Results showed the following. Pain and function scores: The 2 impingement groups, the NPRS was not significant for intervention by time, but there was a significant decrease in pain score postintervention, independent of the intervention applied. There was no significant difference in pain in the asymptomatic groups. 3D Scapular Kinematics: Impingement group: For scapular internal rotation, the impingement group only had a significant difference in the main effect of time during elevation of the arm, in which internal rotation increased after the interventions. For scapular upward rotation, there was only a significant 2-factor interaction of intervention by time during elevation and lowering of the arm. No significant difference for scapular tilt. Asymptomatic group: No significant difference for scapular internal rotation. For scapular upward rotation, the asymptomatic group only showed a significant intervention-by-time interaction for both elevation and lowering of the arm. For arm elevation, the TSM asymptomatic significantly increased 2.2º and sham intervention only 1.0º. For lowering the arm, the TSM asymptomatic significantly increased 1.9º and sham intervention only 0.7º. For scapular tilt, there was a significant interaction of intervention by time during both elevation and lowering of the arm for TSM 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 shows that independent of exercise and other manual therapy techniques, TSM is a valid method to use to help treat SIS. The TSM technique chosen directed the midthoracic (T3-T7) region, rather than single vertebral levels. I believe this technique is more comprehensive and straightforward for clinicals to use rather than having to isolate a single vertebral level. This way they do not have to find the “right” spot to manipulate and can work on the entirety of the thoracic spine. With training, this technique is easy to use and based on the results proves helpful for pain relief. It was concluded that TSM shoulder pain during elevation and lowering of the arm decreases immediately after a single session of TSM or sham TSM directed to the midthoracic spine in subjects with SIS. Self-reported shoulder pain in the symptomatic individuals seemed to be decreased independently of the intervention applied (TSM or sham). A greater number of subjects reported pain relief after TSM (60%) than after the sham intervention (36%), suggesting that a change in pain score may be clinically important in subjects who received the TSM intervention. This information proves helpful for clinical practice and can be implemented by institutionalizing the technique into practice, whether the patient has impingement symptoms or not, as it may lead to small improvements in both pain and function.

Manual Therapy versus Therapeutic Exercise in Non-specific Chronic Neck Pain: A Randomized Controlled Trial

Author Names

Bernal-Utrera, C.; Gonzalez-Gerez J,; Anarte-Lazo, E; Rodriguez-Blanco C.

Reviewer Name

Katherine Terkoski SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background Nonspecific chronic neck pain is a fairly common disorder that causes a great impact, and it is greatly influenced by psychosocial factors. Among a number of treatment modalities described for its management, the most common approach is based on manual therapy and specific therapeutic exercise, which have shown a moderate effect on subjects with chronic non-specific neck pain. However, the effect times of these treatments have not been accurately detailed. Our study aims to break down and compare the effects of two experimental treatments based on manual therapy and therapeutic exercise. Methods The short-term and mid-term changes produced by different therapies on subjects with non-specific chronic neck pain were studied. The sample was randomized divided into three groups: manual therapy, therapeutic exercise, and placebo. As dependent variables of our research, we studied (a) pain, based on the visual analog scale and the pressure pain threshold, and (b) cervical disability, through the Neck Disability Index (NDI). Outcomes were registered on week 1, week 4, and week 12. The findings were analyzed statistically considering a 5% significance level (P ≤ 0.05). Results No statistically significant differences (P 0.05) were obtained between the experimental groups, if they exist against the control group. Nonetheless, we found that manual therapy improved perceived pain before than therapeutic exercise, while therapeutic exercise reduced cervical disability before than manual therapy. Effect size (R2) shows medium and large effects for both experimental treatments.Conclusion There are no differences between groups in short and medium terms. Manual therapy achieves a faster reduction in pain perception than therapeutic exercise. Therapeutic exercise reduces disability faster than manual therapy. Clinical improvement could potentially be influenced by central processes.

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?

Cannot Determine, Not Reported, or Not Applicable

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

There were no significant differences between experimental groups.

Key Finding #2

Manual therapy improved perceived pain before therapeutic exercise.

Key Finding #3

Therapeutic exercise reduced cervical disability before manual therapy.

Please provide your summary of the paper

This study aimed to investigate the effects of manual therapy and therapeutic exercise on nonspecific chronic neck pain. The sample was randomized into three groups: manual therapy, therapeutic exercise, and placebo. Dependent variables included pain (visual analog scale and pressure pain threshold) and cervical disability (neck disability index). Outcomes were reported on weeks 1, 4, and 12. There was no statistically significant differences between experimental groups but there were against the control group. Results showed that manual therapy improved perceived pain quicker while therapeutic exercise reduced cervical disability quicker. Effect size showed medium and large effects for both experimental treatments.

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

The study found significant changes with respect to the control group, but no changes between experimental groups. They found that the experimental groups were effective in different ways, indicating a need for combining the two in treatment protocols moving forward. Two things missing from the article were an experimental group combining manual therapy and exercise as well as a follow up with the subjects long term. My key takeaway from the article is that manual therapy can be effective in increasing patient buy-in, which may increase the patient’s willingness to participate in other interventions such as therapeutic exercise. A combination of these interventions appears to be most beneficial, but more research is needed to investigate this concept as well as its effects over time.

Thoracic Manual Therapy Improves Pain and Disability in Individuals With Shoulder Impingement Syndrome Compared With Placebo: A Randomized Controlled Trial With 1-Year Follow-up

Author Names

Hunter, D; Rivett, D; McKiernan, S; Luton, R; Snodgrass, S.

Reviewer Name

Katherine Terkoski SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective To investigate whether muscle energy technique (MET) to the thoracic spine decreases the pain and disability associated with shoulder impingement syndrome (SIS). Design Single-center, 3-arm, randomized controlled trial, single-blind, placebo control with concealed allocation and a 12-month follow-up.Setting Private osteopathic practice. Participants Three groups of 25 participants (N=75) 40 years or older with SIS received allocated intervention once a week for 15 minutes, 4 consecutive weeks. Interventions Participants were randomly allocated to MET to the thoracic spine (MET-only), MET plus soft tissue massage (MET+STM), or placebo. Main Outcome Measures Primary outcome measure: Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Secondary outcome measures: Shoulder Pain and Disability Index (SPADI) questionnaire; visual analog scale (VAS) (mm/100): current, 7-day average, and 4-week average; Patient-Specific Functional Scale (PSFS); and Global Rating of Change (GROC). Measures recorded at baseline, discharge, 4-week follow-up, 6 months, and 12 months. Also baseline and discharge thoracic posture and range of motion (ROM) measured using an inclinometer. Statistical analysis included mixed-effects linear regression model for DASH, SPADI, VAS, PSFS, GROC, and thoracic posture and ROM. Results MET-only group demonstrated significantly greater improvement in pain and disability (DASH, SPADI, VAS 7-day average) than placebo at discharge (mean difference, DASH=−8.4; 95% CI, −14.0 to −2.8; SPADI=−14.7; 95% CI, −23.0 to −6.3; VAS=−15.5; 95% CI, −24.5 to −6.5), 6 months (−11.1; 95% CI, −18.6 to −3.7; −14.9; 95% CI, −26.3 to −3.5; −14.1; 95% CI, −26.0 to −2.2), and 12 months (−13.4; 95% CI, −23.9 to−2.9; −19.0; 95% CI, −32.4 to −5.7; −17.3; 95% CI, −30.9 to −3.8). MET+STM group also demonstrated greater improvement in disability but not pain compared with placebo at discharge (DASH=−8.2; 95% CI, −14.0 to −2.3; SPADI=−13.5; 95% CI, −22.3 to −4.8) and 6 months (−9.0; 95% CI, −16.9 to −1.2; −12.4; 95% CI, −24.3 to −0.5). For the PSFS, MET-only group improved compared with placebo at discharge (1.3; 95% CI, 0.1-2.5) and 12 months (1.8; 95% CI, 0.5-3.2); MET+STM at 12 months (1.7; 95% CI, 0.3-3.0). GROC: MET-only group improved compared with placebo at discharge (1.5; 95% CI, 0.9-2.2) and 4 weeks (1.0; 95% CI, 0.1-1.9); MET+STM at discharge (1.2; 95% CI, 0.5-1.9) and 6 months (1.2; 95% CI, 0.1-1.3). There were no differences between MET-only group and MET+STM, and no between-group differences in thoracic posture or ROM. Conclusions MET of the thoracic spine with or without STM improved the pain and disability in individuals 40 years or older with SIS and may be recommended as a treatment approach for SIS.

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?

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)?

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)?

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

MET-only group demonstrated significantly greater improvement in pain and disability than placebo group.

Key Finding #2

MET+STM group demonstrated greater improvement in disability but not pain compared with placebo group.

Key Finding #3

There were no differences between MET-only group and MET+STM group.

Key Finding #4

There were no differences in thoracic posture or ROM.

Please provide your summary of the paper

The study aimed to investigate whether muscle energy technique (MET) to the thoracic spine decreases pain and disability associated with shoulder impingement syndrome. Three groups of 25 participants 40 years or older with shoulder impingement syndrome received their allocated intervention once a week for 15 minutes for 4 consecutive weeks. The intervention groups included MET to thoracic spine (MET-only), MET plus soft tissue massage (MET+STM), or placebo. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand. Secondary outcome measures included the Shoulder Pain and Disability Index, Visual Analog Scale, Patient-Specific Functional Scale, and Global Rate of Change. Measures were recorded at baseline, discharge, 4 week follow up, 6 months, and 12 months. At baseline and discharge, thoracic posture and ROM were measured using an inclinometer. Results showed the MET-only group demonstrated significantly greater improvement in pain and disability than the placebo group. The MET+STM group demonstrated greater improvement in disability but not pain compared with placebo group. There were no differences between MET-only group and MET+STM group and there was no difference in thoracic posture or ROM.

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 provides good direction for clinical management of patients with shoulder impingement syndrome. One aspect of the study that I thought was beneficial was the followup with their patients. It was interesting to see how their patients were doing up to 1 year post since their intervention took place only over 4 weeks. While I enjoyed reading this study, there were a few things I thought they could improve on. The researchers noted that the interventions did not have an effect on thoracic posture or mobility, however, I am curious if they saw any improvement in shoulder ROM since they only commented on shoulder pain and disability. Overall, I thought this was a high quality study providing good insight into how the thoracic spine can impact shoulder impingement syndrome.

Evidence-Based Treatment Recommendations for Neck and Low Back Pain Across Europe: A Systematic Review of Guidelines

Author Names
Corp, N., Mansell, G., Stynes, S., Wynne-Jones, G., Morsø, L., Hill, J. C., & van der Windt, D. A.

Reviewer Name
Li Chen, PMP, SPT

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

Abstract

Background and objective
This systematic review synthesized evidence from European neck and low back pain (NLBP) clinical practice guidelines (CPGs) to identify recommended treatment options for use across Europe.

Databases and Data Treatment
Comprehensive searches of thirteen databases were conducted, from 1st January 2013 to 4th May 2020 to identify up-to-date evidence-based European CPGs for primary care management of NLBP, issued by professional bodies/organizations. Data extracted included; aim and target population, methods for development and implementation and treatment recommendations. The AGREE II checklist was used to critically appraise guidelines. Criteria were devised to summarize and synthesize the direction and strength of recommendations across guidelines.

Results
Seventeen CPGs (11 low back; 5 neck; 1 both) from eight European countries were identified, of which seven were high quality. For neck pain, there were consistent weak or moderate strength recommendations for: reassurance, advice and education, manual therapy, referral for exercise therapy/programme, oral analgesics and topical medications, plus psychological therapies or multidisciplinary treatment for specific subgroups. Notable recommendation differences between back and neck pain included, i) analgesics for neck pain (not for back pain); ii) options for back pain-specific subgroups—work-based interventions, return to work advice/programmes and surgical interventions (but not for neck pain) and iii) a greater strength of recommendations (generally moderate or strong) for back pain than those for neck pain.

Conclusions
This review of European CPGs identified a range of mainly non-pharmacological recommended treatment options for NLBP that have broad consensus for use across Europe.

Significance
Consensus regarding evidence-based treatment recommendations for patients with neck and low back pain (NLBP) from recent European clinical practice guidelines identifies a wide range of predominantly non-pharmacological treatment options. This includes options potentially applicable to all patients with NLBP and those applicable to only specific patient subgroups. Future work within our Back-UP research team will transfer these evidence-based treatment options to an accessible clinician decision support tool for first contact clinicians.

Key Findings

Non-pharmacological treatments were consistently recommended for NLBP, including advice, education, exercise therapy, manual therapy, and psychological interventions.

Neck pain guidelines had weaker evidence and fewer treatment recommendations compared to low back pain guidelines, with analgesics recommended for neck pain but not for low back pain.

Subgroup-specific treatments were suggested, such as multidisciplinary treatments and surgical referrals, but clear criteria for their use were often lacking.

Summary
This systematic review analyzes 17 European clinical practice guidelines (CPGs) for managing neck and low back pain (NLBP). The CPGs, which span eight European countries, highlight a strong preference for non-pharmacological treatments. For neck pain, consistent but weak recommendations include reassurance, education, manual therapy, exercise therapy, and a variety of medications. NLBP treatment guidelines are more robust, recommending primarily non-pharmacological interventions, such as exercise, work-based programs, and psychological therapies. Surgical options are discussed for specific subgroups of back pain sufferers but not for neck pain. While some guidelines are high-quality, many lack practical implementation details and consistency in how they assess evidence strength.

Clinical Implications
The key takeaway for clinicians is the strong consensus supporting non-pharmacological treatments for NLBP, such as education, reassurance, exercise, and manual therapies. While neck pain management often relies on weaker evidence, especially for pharmacological options, low back pain guidelines emphasize more robust, evidence-backed non-drug treatments.

Be less trigger-happy with the prescriptions. Move the patient. Educate the patient. And if all else fails, refer for multidisciplinary care. Let’s not make surgery the first option unless it’s absolutely necessary. Advice on staying active should be tailored to individual patients, and when guidelines are unclear, clinicians will need to make informed judgment calls. Recognizing when specific subgroups need targeted interventions, like psychological support or surgical options, can further refine treatment plans.

This study serves as a strong call for a more patient-centered, evidence-based approach to managing NLBP, focusing on holistic care over quick fixes and “one size fits all” solutions.

The Immediate Effects of Soft Tissue Mobilization Versus Therapeutic Ultrasound for Patients With Neck and Arm Pain With Evidence of Neural Mechanosensitivity: A Randomized Clinical Trial

Author Names: Costello M, Puentedura E’, Cleland J, Ciccone CD.

Reviewer Name: Natanael Casiano-Agosto, SPT

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

Paper Abstract: To investigate the immediate effects of soft tissue mobilization (STM) versus therapeutic ultrasound (US) in patients with neck and arm pain who demonstrate neural mechanical sensitivity. While experts have suggested that individuals with neck and arm pain associated with neural tissue mechanical sensitivity may benefit from STM, there has been little research to investigate this hypothesis. Twenty-three patients with neck and arm pain and a positive upper limb neurodynamic test (ULNT) were randomly assigned to receive STM or therapeutic US during a single session. Outcome measures were collected immediately before and after treatment, and at 2-4 day follow-up. Primary outcomes were the Global Rating of Change (GROC), range of motion (ROM) during the ULNT, and pain rating during the ULNT. Secondary measures included the Neck Disability Index (NDI), Patient-Specific Functional Scale (PSFS), Numeric Pain Rating Scale (NPRS), and active range of shoulder abduction motion combined with the wrist neutral or wrist extension. A greater proportion of patients in the STM group reported a significant improvement on the GROC immediately after treatment (P = 0·003, STM = 75%, US = 9%), and at 2-4 day follow-up (P = 0·027, STM = 58%, US = 9%). Patients who received STM demonstrated greater improvements in ROM during ULNT (P = 0·026), PSFS (P = 0·007), and shoulder active ROM combined with wrist extension (P = 0·028). Improvements in Numeric Pain Rating Scale and pain during the ULNT were observed only in the STM group. There was no difference between groups for the NDI or shoulder abduction ROM with wrist neutral. Patients with neck and arm pain demonstrated greater improvements in ULNT ROM, GROC, and PSFS, and pain following STM than after receiving therapeutic US.

Key Finding #1

Patients who received STM reported greater improvements in the Global Rating of Change immediately after treatment and at 2–4-day follow-up compared to those who received therapeutic US.

Key Finding #2

The STM group demonstrated greater improvements in range of motion during the Upper Limb Neurodynamic Test and shoulder active ROM combined with wrist extension compared to the US group

Key Finding #3

Patients in the STM group showed greater improvements in their PSFS scores at the 2–4 day follow-up compared to the US group.

Please provide your summary of the paper

The research paper examines the immediate effects of soft tissue mobilization (STM) compared to therapeutic ultrasound (US) in patients experiencing neck and arm pain with neural mechanosensitivity. The study involved 23 patients who were randomly assigned to receive either STM or US during a single session. The results indicated that patients who underwent STM reported greater improvements in pain, range of motion (ROM), and functional scales than those who received US. Specifically, STM resulted in significant improvements in the Global Rating of Change (GROC), Patient-Specific Functional Scale (PSFS), Upper Limb Neurodynamic Test Range of Motion (ULNT ROM), and shoulder active ROM combined with wrist extension. The study concludes that STM is more effective than US for providing immediate relief and short-term benefits in patients with neck and arm pain related to neural mechanosensitivity. However, the study had some limitations, including a small sample size and the lack of blinding for the treating therapist, which could introduce bias. Additionally, the study only conducted one treatment session, which may have prevented it from capturing the long-term outcomes for each treatment group, and its effects from multiple treatment sessions.

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

The clinical implications of this paper suggest an effective treatment approach for physical therapists managing patients with neck and arm neural mechanosensitivity. Incorporating STM early in a treatment session allows therapists to take advantage of its immediate effects in reducing patient sensitivity. This strategy facilitates the introduction of more aggressive therapies during the same session, which the patient may not have tolerated otherwise. Additionally, in follow-up visits within a 2 to 4-day timeframe, patients may be able to tolerate more activities due to the benefits of the STM intervention

Manual Therapy Versus Therapeutic Exercise in Non-Specific Chronic Neck Pain: A Randomized Controlled Trial

Author Names
Carlos Bernal-Utrera, Juan Jose Gonzalez-Gerez , Ernesto Anarte-Lazo, Cleofas RodriguezBlanco

Reviewer Name

Karleigh Derleth, ATC, LAT, SPT

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

Paper Abstract
Abstract Background Nonspecific chronic neck pain is a fairly common disorder that
causes a great impact, and it is greatly influenced by psychosocial factors. Among a
number of treatment modalities described for its management, the most common
approach is based on manual therapy and specific therapeutic exercise, which have shown
a moderate effect on subjects with chronic non-specific neck pain. However, the effect
times of these treatments have not been accurately detailed. Our study aims to break
down and compare the effects of two experimental treatments based on manual therapy
and therapeutic exercise. Methods The short-term and mid-term changes produced by
different therapies on subjects with non-specific chronic neck pain were studied. The
sample was randomized divided into three groups: manual therapy, therapeutic exercise,
and placebo. As dependent variables of our research, we studied (a) pain, based on the
visual analog scale and the pressure pain threshold, and (b) cervical disability, through the
Neck Disability Index (NDI). Outcomes were registered on week 1, week 4, and week 12.
The findings were analyzed statistically considering a 5% significance level (P ≤ 0.05).
Results No statistically significant differences (P 0.05) were obtained between the
experimental groups, if they exist against the control group. Nonetheless, we found that
manual therapy improved perceived pain before than therapeutic exercise, while
therapeutic exercise reduced cervical disability before than manual therapy. Effect size
(R2) shows medium and large effects for both experimental treatments. Conclusion There
are no differences between groups in short and medium terms. Manual therapy achieves a
faster reduction in pain perception than therapeutic exercise. Therapeutic exercise reduces
disability faster than manual therapy. Clinical improvement could potentially be influenced
by central processes. Trial registration Brazilian Clinical Trial Registry, RBR-2vj7sw.
Registered on 28 November 2018.

NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes
2. Was the method of randomization adequate (i.e., use of randomly generated
assignment)?
Yes
3. Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
4. Were study participants and providers blinded to treatment group assignment?
Yes
5. Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
9. Was there high adherence to the intervention protocols for each treatment group?
Yes
10.Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes
11.Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
12.Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
Yes
13.Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Yes
14.Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
No

Key Finding #1
VAS scoring decreased throughout the study and at a follow up point for both manual
therapy and therapeutic exercise.
Key Finding #2
Generally, both experimental groups exhibited differences in regard to the variables of VAS, NDI, and PPT, but did not show enough of a significant difference from each other to favor one group over the other.
Key Finding #3
The study suggests that these interventions could be used as an individual technique and not necessarily combined with other techniques.
Key Finding #4
This study demonstrates beneficial treatment options in the short and medium term, but not in the long term, which is an expressed limitation of the study.

Please provide your summary of the paper
This paper explores the potential differences between manual therapy and therapeutic exercises. This was done by separating out the sample size into three groups, manual therapy, therapeutic exercise, and a control group. The manual therapy group received high thoracic manipulation on T4, cervical articular mobilization, and suboccipital muscle inhibition. The therapeutic exercise group received cranio-cervical flexion in supine and sitting, co-contraction of deep and superficial neck flexors, rotators, and lateral flexors, and eccentric for extensors and flexors. The final control group received the PT simulating the technique of suboccipital inhibition without actual therapeutic intervention. To measure the results, the researchers used the visual analog scale(VAS), the neck disability index (NDI), and the pressure pain threshold(PPT). Numbers were recorded at Week 1, Week 4, and Week 12. After examining the results, it can be seen that both experimental groups of manual therapy as well as therapeutic exercises demonstrated a significant difference in the above variables. The control group did not show any significant changes. Differences noted included that exercise may reduce disability earlier than manual as well
as manual may reduce pain perception before exercise. Possible limitations addressed included the study not addressing long term pain which is often associated with chronic pan, as well as a smaller sample size. Ultimately, the researchers believe in the benefit of performing these interventions on their own as well as the potential for combination based approaches.

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 helps to encourage that some type of intervention is more beneficial than not providing care. While just manual therapy can be just as effective as therapeutic exercise, it brings up the question of if the therapeutic benefit would increase with combined therapy. As is, often PTs approach cases with a multifocal approach to ensure best results. A future study could be conducted to see the specific significance of combined manual and exercise therapy.

A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache

Author Names

Gwendolen, J et.al

Reviewer Name

Dylan Chruma

Reviewer Affiliation(s)

Duke DPT Class ’26

Paper Abstract

Study design: A multicenter, randomized controlled trial with unblinded treatment and blinded outcome assessment was conducted. The treatment period was 6 weeks with follow-up assessment after treatment, then at 3, 6, and 12 months. Objectives: To determine the effectiveness of manipulative therapy and a low-load exercise program for cervicogenic headache when used alone and in combination, as compared with a control group. Summary of background data: Headaches arising from cervical musculoskeletal disorders are common. Conservative therapies are recommended as the first treatment of choice. Evidence for the effectiveness of manipulative therapy is inconclusive and available only for the short term. There is no evidence for exercise, and no study has investigated the effect of combined therapies for cervicogenic headache. Methods: In this study, 200 participants who met the diagnostic criteria for cervicogenic headache were randomized into four groups: manipulative therapy group, exercise therapy group, combined therapy group, and a control group. The primary outcome was a change in headache frequency. Other outcomes included changes in headache intensity and duration, the Northwick Park Neck Pain Index, medication intake, and patient satisfaction. Physical outcomes included pain on neck movement, upper cervical joint tenderness, a craniocervical flexion muscle test, and a photographic measure of posture. Results: There were no differences in headache-related and demographic characteristics between the groups at baseline. The loss to follow-up evaluation was 3.5%. At the 12-month follow-up assessment, both manipulative therapy and specific exercise had significantly reduced headache frequency and intensity, and the neck pain and effects were maintained (P < 0.05 for all). The combined therapies was not significantly superior to either therapy alone, but 10% more patients gained relief with the combination. Effect sizes were at least moderate and clinically relevant. Conclusion: Manipulative therapy and exercise can reduce the symptoms of cervicogenic headache, and the effects are maintained.

Key Finding #1

Over a 12-month follow-up period treatments such as manipulative therapy and specific low-load exercise significantly reduced the frequencies and intensities of cervicogenic headaches and neck pain.

Key Finding #2

Over 12 months, participants in active treatment showed a reduction in medication use compared to the control group who showed an increase in use. Overall, MT can help dependencies on medication for managing cervicogenic headaches.

Key Finding #3

This was a study that looked at the effectiveness of manipulative therapy and low load exercise with managing cervicogenic headaches through a RCT of 200 subjects. In the end both MT and exercise reduced headache frequency, intensity and neck pain, with effects maintained over a 12 month period. The findings supported the use of PT as an effective treatment and management plan for cervicogenic headaches.

Please provide your summary of the paper

This study shows us that MT and exercise are effective treatments for managing cervicogenic headaches, leading to sustained relief in patients. The combination of both may still provide additional clinical benefits for some patients. In conclusion, this study shows us PT that we can implement this plan of care for those patients suffering with cervicogenic headaches.

Effect of Thoracic Manipulation on Neck Pain in the Mobility Group: A Randomized Controlled Trial

Author Names

Yoshida R, Ichikawa K, Nagahori H, Tazawa T, Kuruma H

Reviewer Name

Wesley Jenq

Reviewer Affiliation(s)

Duke School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background and aims: Thoracic spine manipulation (TSM) increases the thoracic spine’s range of motion (ROM), effectively reducing pain intensity and disability in patients with mechanical neck pain. We aimed to determine the effect of TSM on neck pain intensity and functional impairment in patients classified under the “mobility” category in Childs’ classification. Methods: In this randomized controlled trial, patients with mechanical neck pain who met the inclusion criteria were randomly assigned to either the TSM (n = 21) or sham manipulation (n = 20) group. The primary outcomes were pain during neck rotation and subjective improvement assessed using the Numerical Pain Rating Scale (NPRS) and Global Rating of Change (GROC), respectively. The secondary outcomes were NPRS at rest, disability (assessed using the Neck Disability Index [NDI]), and ROM of the cervical and thoracic spine rotation. Outcome measurements were performed at baseline, immediately after treatment, 1 week after treatment, and at the 4-week follow-up. Linear mixed models were used to analyze the NPRS, NDI, and ROM. The GROC was analyzed using a chi-square test for the percentage recording ≥+4; the means of each group were compared using an unpaired t-test. Results: The NPRS with neck rotation, neck and thoracic ROM, and NDI showed significant interactions between the groups. The NPRS with neck rotation was significantly lower in the TSM group than in the sham group at all time points after the treatment (p < 0.001). There was no difference between the groups in the proportion showing moderate (≥+4) improvement according to the GROC; however, there was a significant difference in the mean values (p = 0.013). Conclusion: Incorporating TSM into treatment protocols may improve clinical outcomes in patients with neck pain, potentially leading to better pain management and functional recovery. Therefore, physiotherapists should consider TSM as a viable and effective intervention to improve patient outcomes in neck pain rehabilitation.

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Yes

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

yes

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

yes

Were study participants and providers blinded to treatment group assignment?

yes

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

yes

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

yes

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

Don’t know

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)?

yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Don’t know

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

yes

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

yes

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

yes

Key Finding #1

Thoracic spinal manipulations significantly reduced neck pain during rotation at all time points after intervention.

Key Finding #2

Thoracic spinal manipulation group had significantly improved NDI and GROC scores.

Key Finding #3

There was no significant difference in NPRS scores between the sham group and the manipulation group.

Key Finding #4

Cervical and thoracic ROM significantly improved in the TSM group compared to the sham group.

Please provide your summary of the paper

This randomized controlled trial seeks to analyze the effectiveness of thoracic spinal manipulation on neck pain in the mobility type. Participants were randomly separated into two groups 1) manipulation group and 2) sham group. The five measurements taken were: NPRS, GROC, NDI, cervical ROM and thoracic ROM. These measures were taken immediately after the intervention, 1 week post, and 4 weeks post. The researchers found significant improvements in NDI scores, GROC scores, cervical ROM and thoracic ROM in the manipulation group compared to the sham group. There was no significant difference in NPRS scores, suggesting thoracic spinal manipulations may not affect neck pain at rest. This study suggests thoracic spinal manipulations as a viable intervention for patients with mobility-type 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.

The results of this study support thoracic spinal manipulations as a method of intervening with neck pain in the mobility group. Significant improvements were found with neck pain with rotation. No significant difference was found with neck pain at rest. The study may impact clinical practice by applying thoracic spinal manipulations to patients with mobility type neck pain. It would serve to provide patients with less pain and improvements in ROM measurements and outcome measure scores (NDI, GROC).

Dry Needling Versus Trigger Point Compression of the Upper Trapezius: A Randomized Clinical Trial With Two-Week and Three-Month Follow-Up

Author Names

Ziaeifar M, Arab AM, Mosallanezhad Z, Nourbakhsh MR

Reviewer Name

Kayin Fails

Reviewer Affiliation(s)

Duke DPT

Paper Abstract

Objectives: The purpose of this randomized controlled trial was to investigate the long-term clinical effect of dry needling with two-week and three-month follow up, on individuals with myofascial trigger points in the upper trapezius muscle. Methods: A sample of convenience (33 individuals) with a trigger point in the upper trapezius muscle, participated in this study. The individuals were randomly assigned to two groups: trigger point compression (N = 17) or dry needling (N = 16). Pain intensity, neck disability, and disability of the arm, hand, and shoulder (DASH) were assessed before treatment, after treatment sessions, and at two-week and three-month follow ups. Results: The result of repeated measures ANOVA showed significant group-measurement interaction effect for VAS (p = .02). No significant interaction was found for NPQ and DASH (p > .05). The main effect of measurements for VAS, NPQ, and DASH were statistically significant (p < .0001). The results showed a significant change in pain intensity, neck disability, and DASH after treatment sessions, after two weeks and three months when compared with before treatment scores in both groups. There was no significant difference in the tested variables after two-week or three-month as compared to after treatment sessions between the two groups. However, pain intensity after treatment sessions was significantly different between the two groups (p = .02). Discussion: Dry needling and trigger point compression in individuals with myofascial trigger point in the upper trapezius muscle can lead to three-month improvement in pain intensity and disability.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Yes

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

Yes

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

Yes

Were study participants and providers blinded to treatment group assignment?

Yes

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

Cannot Determine, Not Reported, or Not Applicable

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

Yes

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

Cannot Determine, Not Reported, 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?

Yes

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

Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Cannot Determine, Not Reported, or Not Applicable

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

Yes

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

Yes

Key Finding #1

No significant interaction was found for NPQ and DASH

Key Finding #2

The results showed a significant change in pain intensity, neck disability, and DASH after treatment sessions, after two weeks and three months when compared with before treatment scores in both groups.

Key Finding #3

There was no significant difference in the tested variables after two-week or three-month as compared to after treatment sessions between the two groups.

Key Finding #4

Please provide your summary of the paper

The study found that both dry needling and trigger point compression treatment provided beneficial long-term improvements in individuals with myofascial trigger points in the upper trapezius. Dry needling showed a greater immediate effect on pain relief, but both treatments resulted in similar outcomes over a three-month period.

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

My clinical interpretation of this paper is that both methods can be beneficial for increasing a patient’s pain threshold and disability over three months. Whether to use dry needling or trigger point compression treatment to address myofascial pain in the upper trapezius can be decided by the provider or the patient’s preference. Dry needling was shown to have the quickest benefit, but it is the most invasive of the two. If a patient is apprehensive about needling, trigger point compression treatment is a good alternative. A skilled clinician should be able to provide the most optimal treatment for their patient.

Does Upper Cervical Manual Therapy Provide Additional Benefit in Disability and Mobility over a Physiotherapy Primary Care Program for Chronic Cervicalgia? A Randomized Controlled Trial

Article Full Title

Does Upper Cervical Manual Therapy Provide Additional Benefit in Disability and Mobility over a Physiotherapy Primary Care Program for Chronic Cervicalgia? A Randomized Controlled Trial

Author Names

González-Rueda, V; Hidalgo-Garcia, C; Rodríuez-Sanz, J; Bueno-Gracia, E; Pérez-Bellmunt, P; Rodriguez-Rubio, P; Lopez-de-Celis, C

Reviewer Name

Mallory Martlock

Reviewer Affiliation(s)

Duke hybrid orthopedic residency

Paper Abstract

Introduction: Neck pain is a condition with a high incidence in primary care. Patients with chronic neck pain often experience reduction in neck mobility. However, no study to date has investigated the effects of manual mobilization of the upper cervical spine in patients with chronic mechanical neck pain and restricted upper cervical rotation. Objective: To evaluate the effect of adding an upper cervical translatoric mobilization or an inhibitory suboccipital technique to a conventional physical therapy protocol in patients with chronic neck pain test on disability and cervical range of motion. Design: Randomized controlled trial. Methods: Seventy-eight patients with chronic neck pain and restricted upper cervical rotation were randomized in three groups: Upper cervical translatoric mobilization group, inhibitory suboccipital technique group, or control group. The neck disability index, active cervical mobility, and the flexion–rotation test were assessed at baseline (T0), after the treatment (T1), and at three-month follow-up (T2). Results: There were no statistically significant differences between groups in neck disability index. The upper cervical translatoric mobilization group showed a significant

increase in the flexion–rotation test to the more restricted side at T1 (F = 5.992; p < 0.004) and T2 (F = 5.212; p < 0.007) compared to the control group. The inhibitory suboccipital technique group showed a significant increase in the flexion–rotation test to the less restricted side at T1 (F = 3.590; p < 0.027). All groups presented high percentages of negative flexion–rotation tests. (T1: 69.2% upper neck translator mobilization group; 38.5% suboccipital inhibition technique group, 19.2% control group; at T2: 80.8%; 46.2% and 26.9% respectively). No significant differences in the active cervical mobility were found between groups. Conclusion: Adding manual therapy to a conventional physical therapy protocol for the upper cervical spine increased the flexion–rotation test in the short- and mid-term in patients with chronic neck pain. No changes were found in the neck disability index and the global active cervical range of motion.

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Yes

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

Yes

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

Yes

Were study participants and providers blinded to treatment group assignment?

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)?

Yes

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

Yes

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

Yes

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

Yes

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

Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Yes

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

Not sure

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

Not sure

Key Finding #1

Adding upper cervical manual therapy techniques to a protocol of physical therapy demonstrated statistically significant differences in flexion-rotation test range of motion.

Key Finding #2

The results of this randomized control trial strengthen the use of multimodal treatment therapies in the primary care approach for chronic neck pain.

Please provide your summary of the paper

This paper looked at patients with a clinical diagnosis of chronic mechanical neck pain who were over 18 years old, and had a positive flexion-rotation test (asymmetry of >10deg between sides or less than 32 deg in any direction). The researchers looked at neck disability (NDI) and cervical mobility (AROM in all planes, in sagittal plane for upper cervical mobility and flexion-rotation test for passive upper cervical ROM) as the primary outcome measures of the study. All patients received 15 sessions of treatment focused on superficial thermotherapy, cervical stretching and self traction, thoracic mobilization and pain education. The upper cervical translatoric mobilization and inhibitory suboccipital technique groups received 6 sessions of upper cervical spine translatoric mobilizations and pressure inhibition technique respectively. Results showed that there was no statistically significant difference between each of the groups with respect to the NDI and global active cervical range of motion. However, adding upper cervical translatoric mobilization increased upper cervical spine range of motion in short and mid term patients with chronic mechanical neck pain and restricted upper cervical range of motion. Adding in the inhibitory suboccipital technique to a conventional PT protocol improve the flexion rotation test in the short term.

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 impacts clinical practice by providing evidence based strategies for improving upper cervical range of motion in patients with mechanical neck pain. The interventions that were used in the study were straight forward and easy to implement in patient care. The interventions were both self provided by the patient and also included interventions provided by the PT. This allows the patient to be autonomous and independent in their care while also allowing for the PT to provide benefit to their care.

Effects of Manual Therapy Combined With Therapeutic Exercise on Brain Structure in Patients With Chronic Nonspecific Neck Pain: A Randomized Controlled Trial Running Title: Brain Changes Following Neck Pain Interventions

Article Full Title

Effects of manual therapy combined with therapeutic exercise on brain structure in patients with chronic nonspecific neck pain: A randomized controlled trial

Running title: Brain changes following neck pain interventions

Author Names

Rungtawan Chaiklaa ∙ Munlika Sremakaewa ∙ Suwit Saekhob ∙ Suchart Kothanc ∙ Sureeporn Uthaikhup

Reviewer Name

Yanfei Li, PT, DPT, CSCS

Reviewer Affiliation(s)

Hybrid Orthopedic Physical Therapy Residency Program, Duke University Physical Therapy Division

Paper Abstract

This trial aimed to investigate the effects of 10-week manual therapy combined with exercise compared to routine physical therapy on brain structure and clinical outcomes in patients with neck pain. Fifty-two participants with chronic nonspecific neck pain were randomized into either an intervention group or a control group (a 1:1 ratio). The intervention group received cervical mobilization and cervical and scapular exercises. The control group received routine physical therapy. The primary outcomes were cortical thickness and volume. Secondary outcomes were neck pain intensity, disability, psychological symptoms, cervical range of motion and cervical flexor muscle strength. Outcome measures were taken at baseline and post-treatment. There was no loss to follow-up. Compared to baseline, significant differences in cortical thickness were observed at post-treatment in both groups, including prefrontal cortex (PFC), anterior cingulate cortex (ACC), primary somatosensory cortex (S1), primary motor cortex (M1) and precuneus (p<0.05). The intervention group exhibited greater increases in cortical thickness in the ACC and M1 compared to controls (p<0.05). The secondary outcomes were improved in both groups (p<0.05). There were differences in brain structure (S1, PFC and insula) between participants who experienced ≥50% reduction in pain intensity and those with <50% reduction (p<0.05). Changes in brain structure were correlated with changes in pain intensity and neck disability (r =−0.31 to −0.44, p<0.05). The study suggests that patients with chronic nonspecific neck pain who experienced significant improvements in pain intensity exhibited greater changes in cortical structure following a 10-week intervention, particularly with a combination of manual therapy and exercise.

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

YES

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

YES

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

YES

Were study participants and providers blinded to treatment group assignment?

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

YES

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

YES

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

YES

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

YES

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

YES

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

YES

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

YES

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

YES

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

YES

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

Can not determine

Key Finding #1

Greater Brain Structural Changes in the Intervention Group. The manual therapy + exercise group showed greater increases in cortical thickness in the anterior cingulate cortex (ACC) and primary motor cortex (M1) compared to the control group, suggesting a stronger neuroplastic response to treatment.

Key Finding #2

Significant Clinical Improvements. Both groups experienced improvements in pain intensity, neck disability, and range of motion, but the intervention group had significantly better outcomes in these areas.

Key Finding #3

Brain Changes Correlate with Pain Reduction. Patients who achieved a ≥50% reduction in neck pain intensity showed more pronounced brain structure changes in areas associated with pain processing (primary somatosensory cortex, prefrontal cortex, and insula), indicating a link between brain adaptations and symptom improvement.

Please provide your summary of the paper

The study investigated the effects of manual therapy combined with therapeutic exercise compared to routine physical therapy on brain structure and clinical outcomes in patients with chronic nonspecific neck pain. 52 individuals with chronic nonspecific neck pain were randomized into an intervention group (manual therapy + exercise) or a control group (routine physical therapy). The results shows a combination of manual therapy and exercise led to greater clinical improvements and brain structural changes, highlighting the potential neuroplastic effects of physical therapy interventions for chronic neck pain. However, long-term follow-up and functional neuroimaging studies is still needed to clarify how these brain changes translate to sustained clinical benefits.

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 reinforces what many experienced physical therapists observe in practice, manual therapy combined with specific exercise leads to better pain relief, functional improvements, and long term outcomes compared to passive treatments alone. The findings show hands-on techniques help modulate pain sensitivity while exercise restores movement control and reduces disability. The study’s MRI evidence of brain structural changes further supports the idea that chronic pain is not just a peripheral issue but involves central adaptations, which we often see in patients who struggle with chronic symptoms. Clinically, this reinforces the need to shift away from passive modalities and focus on active, patient-centered treatments that address both biomechanical dysfunction and central pain processing for pain relief.

Effectiveness of Manual Therapy in Dizziness Intensity and Cervical Range of Motion in Patients With Cervicogenic Dizziness: A Systematic Review

Author Names

Casado-Sánchez A, Sancio-Fernández D, Seijas-Otero D, Abuín-Porras V, Alonso-Pérez JL, Sosa-Reina MD. 

Reviewer Name

Karla Alvarado

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy Student

Paper Abstract

ABSTRACT

Cervicogenic dizziness appears in 35-40% of patients affected with neck pain.. Conservative physical therapy treatment for this pathology is increasingly present in the scientific literature, However, there is limited evidence regarding the long-term effects of manual therapy on dizziness intensity and cervical range of motion (ROM). This research aims to address these gaps by analyzing the existing evidence to determine the efficacy of manual therapy for patients with cervicogenic dizziness.

Objective

To determine the effect of manual therapy in dizziness intensity and cervical range of motion in patients affected with cervicogenic dizziness.

Material and methods

A bibliographic search was carried out in the following databases: Pubmed, PEDro, WOS, Scopus and CINAHL from February to March 2022 and an update was carried out during March 2024. Randomized clinical trials were included with a minimum sample of 20 subjects, published in English, conducted on human subjects, with the presence of a group diagnosed with cervicogenic dizziness (CD) that received manual therapy treatment, and required to have a score on the PEDro scale ≥ 7. For the evaluation of the methodological quality, PEDro scale was used. For risk of bias assessment, the Cochrane RoB 2.0 tool was applied. The main outcomes studied were: dizziness intensity and cervical range of motion (ROM). Pain intensity, frequency of dizziness and functionality were also studied as secondary outcomes.

Results

After applying the inclusion and exclusion criteria, a total of 8 articles were included for qualitative analysis. The mean score on the PEDro scale was 8.12 points. Most articles reflected a decrease in the intensity of dizziness and an increase in ROM in the short term, describing inconsistencies in the long term.

Conclusion

Scientific evidence supports the effect of manual therapy in patients with cervicogenic dizziness in terms of modifying the intensity of dizziness and cervical ROM, at least in the short term. While short-term benefits are consistent, long-term effects remain uncertain. Further research is recommended to explore lasting outcomes and optimize treatment approaches.

Quality Assessment of Systematic Reviews and Meta-Analyses

Is the review based on a focused question that is adequately formulated and described?

Yes

Were eligibility criteria for included and excluded studies predefined and specified?

Yes

Did the literature search strategy use a comprehensive, systematic approach?

Yes

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

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?

Yes

Was publication bias assessed?

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

Key Finding #1

Manual therapy can provide short-term relief of cervicogenic dizziness intensity.

Key Finding #2

Manual therapy can improve cervical range of motion, but only in the short term.

Please provide your summary of the paper

Manual therapy is a form of conservative treatment used for people who experience cervicogenic headaches. Cervicogenic dizziness is characterized by a sense of imbalance that happens due to the response of particular head movements or postures .Usually cervicogenic dizziness is often linked to neck pain or muscle tightness in the cervical region, which can affect a person’s overall range of motion in the neck. Cervicogenic dizziness is characterized by a sense of imbalance that resulting from particular head movements or postures. An estimated 35–40% of the population are affected by cervicogenic dizziness. This systematic review study aimed to determine how manual therapy can improve dizziness intensity and cervical range of motion. There were a total amount of 140 female and 138 males participated, bringing the total number of participants to 312. Although further research is needed to evaluate long-term effects, the findings of this study specifically support manual therapy as an effective short-term intervention for reducing dizziness intensity and enhancing cervical range of motion.

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

According to the systematic review’s conclusions, manual therapy can effectively help alleviate cervicogenic dizziness severity on a short-term basis and also enhance cervical range of motion. Results suggest clinicians can implement manual therapy techniques to provide short-term relief for patients experiencing dizziness originating from the cervical spine. Due to limited data on long-term benefits, manual therapy for cervicogenic dizziness intensity should be used in conjunction with other evidence-based interventions.

Manual Therapy in Cervical and Lumbar Radiculopathy: A Systematic Review of the Literature

Author Names
Tomasz Kuligowski, Anna Skrzek, Błażej Cieślik

Reviewer Name
Hana Alvey, SPT, CSCS, CPT

Reviewer Affiliation(s)
Duke University School of Medicine

Paper Abstract
The aim of this study was to describe and update current knowledge of manual therapy accuracy in treating cervical and lumbar radiculopathy, to identify the limitations in current studies, and to suggest areas for future research. The study was conducted according to PRISMA guidelines for systematic reviews. A comprehensive literature review was conducted using PubMed and Web of Science databases up to April 2020. The following inclusion criteria were used: (1) presence of radiculopathy; (2) treatment defined as manual therapy (i.e., traction, manipulation, mobilization); and (3) publication defined as a Randomized Controlled Trial. The electronic literature search resulted in 473 potentially relevant articles. Finally, 27 articles were accepted: 21 on cervical (CR) and 6 in lumbar radiculopathy (LR). The mean PEDro score for CR was 6.6 (SD 1.3), and for LR 6.7 (SD 1.6). Traction-oriented techniques are the most frequently chosen treatment form for CR and are efficient in reducing pain and improving functional outcomes. In LR, each of the included publications used a different form of manual therapy, which makes it challenging to summarize knowledge in this group. Of included publications, 93% were either of moderate or low quality, which indicates that quality improvement is necessary for this type of research.

Quality Assessment of Controlled Intervention Studies
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?
YES

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.)
N/A

Key Finding #1
Traction-oriented techniques are most commonly used as the manual therapy techniques for CR.

Key Finding #2
A multi-modal approach with a traction component is most efficient for CR.

Key Finding #3
There is no single method of physical therapy or manual therapy technique that is recommended for treating CR.

Please provide your summary of the paper:
Cervical Radiculopathy (CR) can result from many pathologies, including but not limited to disc herniations, stenosis, spina instability, and trauma. Pain is most often referred symptoms down the upper extremity rather than localized at the neck. Other symptoms can be muscle weakness, paraesthesia, impaired reflexes, or other altered sensory and motor symptoms. One of the interventions for CR is manual therapy. Different forms of manual therapy are joint-related, soft-tissue-related, neural-tissue-related, exercise-related, or a mixed-methods approach. This systematic review summarized the findings of research articles focused on manual therapy’s effect on CR-related pain, symptoms, and outcome measures like the Neck Disability Index (NDI) and ROM. This review found that the technique used most was manual traction (or distraction) of the cervical spine. Though not proven superior to other manual techniques, it and other techniques showed equal effectiveness with functional outcomes. Neural-related mobilizations, joint-related mobilizations, and exercise programs all had positive effects on functional outcomes, which supports a multimodal approach with CR patients. In summary, a multimodal approach and traction technique is most efficient for treating patients with CR, and there is no single way to treat a patient with CR.

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 confirms the positive effects of manual therapy on functional outcomes when working with patients with CR. As of now, it also shows that multiple forms of manual therapy are effective, and that no technique is superior to another. In light of this research, a physical therapist can confidently utilize manual therapy with CR patients in their clinic, and it provides another treatment approach to help meet the various needs of the diverse patient populations in phyiscal therapy clinics.

Efficacy of Dry Needling as an Adjunct to Manual Therapy for Patients With Chronic Mechanical Neck Pain: A Randomised Clinical Trial

Author Names

Gallego-Sendarrubias GM, Rodríguez-Sanz D, Calvo-Lobo C, Martín JL.

Reviewer Name

Andrew Aronesty

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective:

Chronic mechanical neck pain is associated with musculoskeletal tissue alterations. Active trigger points in the trapezius and levator scapulae muscles are common in patients with chronic mechanical neck pain. In this study, we compared the effect of dry needling (DN) combined with manual therapy (MT) to sham dry needling (SDN) combined with MT on pain, pain pressure threshold, cervical range of motion and neck disability in patients with chronic mechanical neck pain.

Methods:

A randomised, single-blind clinical trial was carried out involving 101 participants with chronic mechanical neck pain, divided into an intervention group (DN+MT, n=47) and a control group (SDN+MT, n=54). Participants received two treatment sessions. The intervention group received MT in conjunction with DN of the most mechano-sensitive myofascial trigger point (MTrP). The control group received MT plus SDN. Outcomes measures were: pain intensity (numeric pain rating scale, NPRS), pressure pain threshold (PPT), cervical range of motion (ROM) and neck disability (neck disability index, NDI).

Results:

This study found that between-group differences in pain intensity were statistically significant (P<0.01). Pain decreased after the first intervention in the DN+MT group (3.47±0.25 points on the NPRS) and even more so after the second intervention (4.76±0.24 points on the NPRS). After 4 weeks, pain intensity differed from baseline by 4.89±0.27 points on the NPRS. Statistically significant differences (P<0.001) in PPT were also found between the intervention group and the control group. After the first intervention, a significant increase in PPT within the DN+MT group (3.09±0.8 kg/cm2) was observed. Cervical ROM also showed highly statistically significant differences. After 4 weeks, a statistically significant reduction (P<0.001) in NDI was observed between the two groups.

Conclusion:

Our results show that DN+MT is efficacious and significantly better than SDN+MT at reducing pain intensity, PPT, neck disability and cervical ROM in patients with chronic mechanical neck pain.

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Yes

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

Yes

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

Yes

Were study participants and providers blinded to treatment group assignment?

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)?

Yes

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

Yes

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

Yes

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

Yes

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

Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Yes

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

Yes

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

Yes

Key Finding #1

The combination of manual therapy and dry needling for cervical pain outperformed manual therapy and sham dry needling in terms of the NPRS, the NDI, pain pressure threshold and cervical ROM.

Key Finding #2

N/A

Please provide your summary of the paper

This single-blinded randomized controlled trial investigated the combined effect of manual therapy plus dry needling on pain, disability, and range of motion in chronic neck pain patients. To do this, the study used a sample of 101 subjects with neck pain lasting at least 3 months and randomly divided them into two groups. The first group received manual therapy for 50 minutes and then received dry needling for 5 minutes. The second received the same 50-minute manual therapy session followed by sham dry needling (no penetration of the skin). There were two intervention sessions, 7 days apart, and a 1-month follow-up. Outcomes were the numeric pain rating scale (NPRS), the neck disability index (NDI), pain pressure threshold and cervical range of motion. All were taken before and after the intervention and at follow-up. The results of the study show significant improvements in all outcomes in favor of the manual therapy plus dry needling group, with cervical ROM improving above the minimal detectable change (5 degrees). The authors note several limitations, namely the lack of blinding of the provider/assessor (it was the same therapist for each), lack of generalization due to only certain muscles being dry needled, and a potentially overestimated sample size.

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 lends support to the practice of combining manual therapy and dry needling techniques for chronic neck pain patients. While the outcomes were in favor of this approach, the results should be taken with caution due to some of the limitations of the study. In particular, the fact that it was the same therapist who performed the interventions who assessed the outcomes makes the results of this study potentially biased. Furthermore, while the outcomes were said to be gathered in a standardized way, the authors do not give a detailed description of the assessment process which creates concerns for the reproducibility of the study. While it is reasonable to say that a combined approach is not likely harmful and may even be beneficial, a clinician should still consider individual factors and time and resources when determining whether to use it. Given, however, the fact that the dry needling portion was stated to only last 5 minutes, there may not be a large opportunity cost for a physical therapist to add it alongside manual therapy. Clinicians may consider adding dry needling in combination with manual therapy but should not take the results of this study to mean that this approach is better in all cases.

Benefits and Harms of Spinal Manipulative Therapy for Treating Recent and Persistent Nonspecific Neck Pain: A Systematic Review With Meta-analysis

Authors: Silvia Minnucci, PT, MSc, OMPT, et al.

Reviewer Name: Cierra Berry, SPT, ERA-C

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

Abstract:

OBJECTIVE: We aimed to estimate the benefits and harms of cervical spinal manipulative therapy (SMT) for treating neck pain.

DESIGN: Intervention systematic review with meta-analysis of randomized controlled trials (RCTs).

LITERATURE SEARCH: We searched the MEDLINE, Cochrane CENTRAL, Embase, CINAHL, PEDro, Chiropractic Literature Index bibliographic databases, and grey literature sources, up to June 6, 2022.

STUDY SELECTION CRITERIA: RCTs evaluating SMT compared to guideline-recommended and nonrecommended interventions, sham SMT, and no intervention for adults with neck pain were eligible for our systematic review. Prespecified outcomes included pain, range of motion, disability, health-related quality of life.

DATA SYNTHESIS: Random-effects meta-analysis for clinically homogenous RCTs at short-term and long-term outcomes. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 Tool. We used the Grading of Recommendations, Assessment, Development, and Evaluations approach to judge the certainty of evidence.

RESULTS: We included 28 RCTs. There was very low to low certainty evidence that SMT was more effective than recommended interventions for improving pain at short term (standardized mean difference [SMD], 0.66; 95% confidence interval [CI]: 0.35, 0.97) and long term (SMD, 0.73; 95% CI: 0.31, 1.16), and for reducing disability at short-term (SMD, 0.95; 95% CI: 0.48, 1.42) and long term (SMD, 0.65; 95% CI: 0.23, 1.06). Transient side effects only were found (eg, muscle soreness).

CONCLUSION: There was very low certainty evidence supporting cervical SMT as an intervention to reduce pain and improve disability in people with neck pain. J Orthop Sports Phys Ther 2023;53(9):510-528. Epub: 10 August 2023. doi:10.2519/jospt.2023.11708

Quality Assessment for Systematic Reviews and Meta-Analyses: (yes/no/cannot determine, not reported, n/a)

Is the review based on a focused question that is adequately formulate and described? Yes

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

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

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

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

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

Was publication bias assessed? Yes

Was heterogeneity assessed? (only applies to meta-analyses) Yes

Key Findings:

Primary Analysis: When cervical SMT and CPG recommended interventions were compared, seventeen trials on pain at short term, nine at the long term, twelve on disability at short term, eight at long term, eight on flexion and extension at short term and long-term favoring cervical spinal manipulation therapy depicted statistically significant effects.

Secondary Analysis: One trial found a statistically significant effect favoring SMT on ROM at short term (high-evidence certainty); extension, right lateral rotation, left lateral flexion, left rotation when cervical spinal manipulation was compared with the “sham cervical SMT”.

Tertiary Analysis: Low-moderate evidence certainty was found when cervical thrust manipulation vs cervical mobilization were compared for the short and long term effects on pain, disability, health-related quality of life, and flexion-extension at short term.

Summary

This study assessed the short- and long-term benefits and negative implications for cervical spinal manipulation therapy on pain, cervical range of motion, disability, and health-related quality of life. Researchers reviewed and completed a meta-analysis of twenty-eight articles that met the inclusion criteria with sample sizes ranging between eighteen to two hundred and seventy participants. They completed three analyses: Cervical SMT vs. CPG recommended interventions, SMT vs. CPT Non-recommended Interventions, Cervical SMT vs Sham Cervical SMT, Cervical SMT vs No Intervention, Cervical Thrust Manipulation vs Cervical Mobilization. The results varied between trials, but there was statistical significance favoring cervical SMT more than CPG recommended interventions. However, there was no clinical difference between the benefits of cervical thrust manipulation and cervical mobilizations.

Clinical Interpretation. Include how this study may impact clinical practice and how the results can be implemented.

This study will give clinicians insight on the added or limited benefits for incorporating cervical manipulation into the plan of care for patient with nonspecific neck pain. With the consideration of the clinician/patient’s experience with SMT and contextual factors, it can be used in conjunction with the CPG recommended interventions. Cervical mobilizations can also be equally effective to include apart of treatment. Cervical SMT and mobilizations has the ability to both short and/or long-term benefits on pain, disability, quality of life and cervical range of motion. However, clinicians should carefully, consider the bias that exists within the study. Out of the twenty-eight articles that are analyzed, twenty-two were identified as ‘high risk’ for bias for all the investigated outcomes.

What Really Happens When We Use Manual Therapy? A Fresh Look at the Mechanisms Behind Hands-On Approaches
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Why Individualized Treatment Effects Matter More Than Averages in Musculoskeletal Care
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Spinal Manipulation: Lack of Precision Doesn’t Mean Lack of Skill
By: Mark Shepherd, PT, DPT, DSc Spinal thrust manipulation has been used for centuries, with evidence supporting its inclusion in neck and low back guidelines.1,2…
Advantages and Disadvantages of Research Metrics used to Evaluate a Researcher’s Impact or Influence
By: Chad E Cook PT, PhD, FAPTA Background: Each year, in Duke University’s Division of Physical Therapy, I teach a class on research methodology. One…
“It’s Not You, It’s Us…”: Heterogeneity of Treatment Effects as a Challenge to Effectiveness Trials.
By: Damian L Keter, PT, DPT, PhD Background: Comparative effectiveness studies are the cornerstone of medicine and health sciences research. They have a goal of…

Cervicothoracic

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