Author Names
Priyanka K Chilhate, Lajwanti Lalwani
Reviewer Name
Julie Bottarini, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Chronic obstructive pulmonary disease (COPD) is a breathing problem with ongoing airflow issues and changes in how the chest moves. Different manual therapy methods, like releasing the diaphragm, manipulating the spine and joints, and treating soft tissues, have been used for people with COPD. This review looks into how these manual therapy approaches affect COPD patients. Articles were searched in Google Scholar, PubMed, and Elsevier using keywords such as COPD, manual therapy, thoracic excursion, and pulmonary function. Only studies conducted between 2015 and 2023, employing randomized controlled trials (RCTs), crossover RCTs, or comparative studies with COPD subjects, thoracic excursion, chest expansion, or pulmonary function tests (PFTs) as outcome measures, and involving physiotherapy interventions were included. Out of 82 articles searched, 10 met the inclusion criteria, comprising six RCTs, three crossover RCTs, and one comparative study. Data extraction was performed by one reviewer, encompassing intervention descriptions, inclusion/exclusion criteria, baseline data, and outcome values. The findings suggest that conventional physiotherapy combined with manual therapy techniques such as stretching, osteopathic manual therapy, manual diaphragmatic release, soft tissue therapy, and spinal manipulation have improved thoracic excursion and pulmonary function in COPD patients. Therefore, these manual therapy techniques are recommended for enhancing thoracic excursion and pulmonary function in COPD patients.
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?
No
Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
No
Were the included studies listed along with important characteristics and results of each study?
Yes
Was publication bias assessed?
No
Was heterogeneity assessed? (This question applies only to meta-analyses.)
N/A
Key Finding #1
Patients with COPD have better thoracic excursion and pulmonary function when receiving conventional physiotherapy in addition to manual therapy techniques like stretching, osteopathic manual therapy, manual diaphragmatic release technique, soft tissue, therapy and spinal manipulation.
Key Finding #2
Stretching exercises for respiratory muscles can reduce stress enhance muscular strength and coordination and facilitate better breathing.
Please provide your summary of the paper
This paper is a comprehensive narrative review of the use of manual therapy in treating patients with COPD. The authors conducted a comprehensive literature review. Only studies that used thoracic excursion, chest expansion, or pulmonary function tests as outcome measures and physiotherapy interventions in the treatment of COPD patients were included in this review. Only 10 studies met the inclusion criteria. The review concluded that patients with COPD had improved thoracic excursion and pulmonary function when receiving conventional physiotherapy in combination with manual therapy techniques such as stretching, osteopathic manual therapy, manual diaphragmatic release technique, soft tissue therapy, and spinal manipulation.
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 provided a synthesis of current literature on COPD and manual therapy intervention. Clinicians can utilize this paper to help guide their clinical judgement when treating patients with COPD. This paper demonstrates the positive effects of physical therapy treatment that includes the use of manual therapy on this patient population. The study acknowledges that further research is needed in this area, but current research supports the use of manual therapy within this population. Clinicians should continue to use clinical judgement on a case by case basis to ensure that these practices are safe to use on their individual patient.
Li Chen
Study Design: randomized controlled trials
Abstract:
Background:
Neck pain is a common problem, but the effectiveness of frequently applied conservative therapies has never been directly compared.
Objective:
To determine the effectiveness of manual therapy, physical therapy, and continued care by a general practitioner.
Design:
Randomized, controlled trial.
Setting:
Outpatient care setting in the Netherlands.
Patients:
183 patients, 18 to 70 years of age, who had had nonspecific neck pain for at least 2 weeks.
Intervention:
6 weeks of manual therapy (specific mobilization techniques) once per week, physical therapy (exercise therapy) twice per week, or continued care by a general practitioner (analgesics, counseling, and education).
Measurements:
Treatment was considered successful if the patient reported being “completely recovered” or “much improved” on an ordinal six-point scale. Physical dysfunction, pain intensity, and disability were also measured.
Results:
At 7 weeks, the success rates were 68.3% for manual therapy, 50.8% for physical therapy, and 35.9% for continued care. Statistically significant differences in pain intensity with manual therapy compared with continued care or physical therapy ranged from 0.9 to 1.5 on a scale of 0 to 10. Disability scores also favored manual therapy, but the differences among groups were small. Manual therapy scored consistently better than the other two interventions on most outcome measures. Physical therapy scored better than continued care on some outcome measures, but the differences were not statistically significant.
Conclusion:
In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.
NIH Risk of Bias Score: 6
Key Findings of the Study:
Manual therapy was significantly more effective than continued care by a general practitioner, with higher success rates for perceived recovery, reduced pain, and improved cervical spine range of motion.
Physical therapy showed some improvement over continued care but did not consistently outperform it for most outcomes.
Patients receiving manual therapy had fewer absences from work and used less analgesics compared to those in the physical therapy and continued care groups.
Reviewer Summary:
This study investigates the effectiveness of manual therapy, physical therapy, and continued care by general practitioners for managing nonspecific neck pain. The results suggest that manual therapy is the most effective intervention, with significantly higher success rates in terms of perceived recovery, improved cervical range of motion, and reduced functional disability compared to continued care. Physical therapy also showed moderate improvements, but the differences between it and manual therapy were smaller and less consistent. The study highlights the importance of patient-centered care, as manual therapy provided not only physical relief but also practical benefits, such as fewer work absences and less use of analgesics. However, the study does have some limitations, such as protocol deviations and issues with blinding, which could slightly affect the internal validity of the findings. Overall, manual therapy shows considerable potential for treating neck pain in general practice settings.
Author Names:
Negar Azhdari 1, Fahimeh Kamali 2 3, Omid Vosooghi 3, Payman Petramfar 4, Abbas Rahimijaberi 4
Reviewer Name:
Lauren Ciuba
Reviewer Affiliation(s):
Duke DPT
Paper Abstract
Backgrounds: Tension-Type Headache (TTH) is one of the most common types of headache. In patients with TTH, manual therapy can be used to treat myofascial pain.
Objectives: This study aimed to evaluate the effect of manual therapy on TTH in patients who did not respond to drug therapy.
Methods: A total of 24 patients with TTH were randomly enrolled into this prospective trial. The participants were divided into an intervention and a control group. The intervention group received the common medication and manual therapy, while the control group only received the common medication. Headache pain intensity, frequency, and duration, tablet count, and Neck Disability Index (NDI) were measured in both groups before, after, and one week after the intervention.
Results: There were significant differences between the two groups (treatment, control) regarding pain intensity (3.04, 6.75, P = 0.0001; effect size (ES) = 1.85), headache frequency (2.33, 5, P = 0.004; ES = 1.48) and duration (91.29, 284.74, P = 0.002; ES = 1.48), tablet count (1.83, 4.91, P = 0.01; ES = 1.04), and NDI (7.33, 20.16, P = 0.003; ES = 1.37). Within group differences were recorded in intervention group only for all dependent variables immediately after intervention and one week after the intervention (p < 0.05).
Conclusion: Manual therapy reduced headache pain intensity, frequency and duration, tablet count, and NDI score in patients with TTH.
Keywords: Medication; manipulation; physiotherapy.
Quality Assessment of Controlled Intervention Studies
Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Randomized clinical trial
Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes, the study used block randomization with a computer-generated schedule to ensure equal distribution of participants
Was the treatment allocation concealed (so that assignments could not be predicted)?
The article does not explicitly mention allocation concealment
Were study participants and providers blinded to treatment group assignment?
The study does not mention blinding of participants or providers
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, the two groups had no significant differences at baseline in pain intensity, frequency, duration, tablet count, or Neck Disability Index
Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
The study mentions no drop outs, therefore a 0% drop out rate
Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
There was no mention of drop outs
Was there high adherence to the intervention protocols for each treatment group?
Yes, the intervention group followed a structured manual therapy protocol
Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes, both groups received the same drug therapy, ensuring no confounding from other interventions
Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes, standardized measures such as Numerical Rating Scale (NRS) for pain intensity, frequency, duration, tablet count, and Neck Disability Index (NDI) were used consistently
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)?
The study primarily focused on predefined outcomes, such as pain intensity, frequency, duration, tablet count, and NDI
Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
The study does not explicitly mention using an intention-to-treat analysis, but all participants appear to have been analyzed in their assigned groups
Key Finding #1
Manual therapy significantly reduced headache pain and intensity
Key Finding #2
Headache frequency and duration significantly decreased in the intervention group compared to the control group
Key Finding #3
NDI scores improved significantly in the intervention group
Key Finding #4
The benefits of manual therapy persisted beyond the treatment period, as improvements in pain intensity, headache frequency, duration, tablet count, and NDI scores were maintained at the one-week follow-up assessment
Please provide your summary of the paper
This randomized clinical trial investigated the effects of manual therapy combined with standard medication on tension-type headaches (TTH) in patients who did not respond to drug therapy alone. The intervention group received manual therapy and medication, while the control group received only medication. Results showed significant improvements in pain intensity, headache frequency and duration, tablet count, and NDI scores in the intervention group. The findings suggest that manual therapy can be an effective adjunct treatment for TTH.
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 strong evidence that manual therapy can be a valuable non-pharmacological intervention for patients with TTH who do not respond to medication. Given the significant reduction in headache symptoms and medication use, manual therapy could help reduce the burden of medication overuse headaches (MOH). Implementing manual therapy techniques (myofascial release, vertebral mobilization, and friction massage) in clinical practice may provide patients with a safe and effective treatment alternative, reducing their reliance on medication
Author Names
Tuba K. Maden, Kezban Y. Bayramlar, and Yavuz Yakut
Reviewer Name
Kaila Claiborne
Reviewer Affiliation(s)
Doctor of Physical Therapy Program, Duke University
Paper Abstract
Objectives:
To investigate the influence of repeated cervical mobilization (CM) on balance and plantar loading distribution in patients with Multiple Sclerosis (MS).
Methods:
A total of 12 individuals were included in the cross over study designed as a cross sectional. The study was carried out from October 2019 until July 2020. Individuals received traditional treatment (TM) and cervical mobilization treatments (CM) 2 days a week for 4 weeks in a different order by random method. It was treated with joint traction and sliding techniques. Soft tissue mobilization techniques for myofascial relaxation were applied for CM in addition to TM. Romberg test (RT), Sharpened Romberg Test (SRT), and Functional Reach Test (FRT) were used to balance the assessment. Plantar loading distribution was evaluated with Pedobarography. The maximum and mean pressure in the foot, the percentages of pressure values in the fore and rear of the foot, and percentages of the bodyweight discharge onto right feet and left feet were recorded.
Results:
The forefoot loading increased after treatment in the CM group (p<0.05). The duration of RT and SRT increased, and average pressure decreased in the cervical mobilization group (p<0.05). The body weight discharge onto right feet and left feet approached 50% after cervical mobilization (p<0.05).
Conclusions:
Cervical mobilization techniques can positively change the balance and plantar loading distribution compared to traditional treatment. Cervical mobilization applications could be used to support neurological rehabilitation.
Shape
Multiple sclerosis (MS) is a demyelinating, inflammatory, chronic, and neurodegenerative central nervous system (CNS) disease.1 Motor findings (spasticity, weakness), sensory findings (numbness, tingling, loss of sensation), balance and coordination problems, fatigue, visual dysfunction, cognitive disorder, bulbar symptoms (dysarthria, dysphagia respiratory problems), bladder-bowel dysfunction can be observed in patients.2 Studies show that 80% of patients have different levels of sensory impairment.3 The sense of proprioception, which is part of the somatosensory system, has an important role in the regulation of the vestibular system. This sense is obtained from the receptors in the joints, muscles, tendons, and ligaments and constitutes the position perception of the extremities and the body. Proprioceptors present in different proportions in different body structures and tissues are especially rich in the cervical region.4 Studies have proved that different treatment methods such as vibration and Kinesio taping on the cervical region stimulate the proprioceptive system, and these methods improve visual and vestibular connections.5-7 Another method that can be applied to activate the proprioceptive system in this area is cervical mobilization techniques.
Manual techniques affect mechanotransduction, converting mechanical impulses into biological signals by myocytes and fibroblasts.8 Thus, silent gamma motor neurons are stimulated by inputs in muscle spindle afferents and smaller-diameter afferents.9 The cervical region is important for postural control, and cervical afferents provide input to cervicocollic, cervicooculler, and tonic neck reflex. So that postural stability, as well as head and eye movements, are controlled and maintained.10 Muscle spindles in the cervical region, especially in the suboccipital area are found in high densities.10 The application of manual therapy techniques to the cervical region increases motor control by increasing the proprioception transmitted from the vertebra segment to the central nervous system.11 These techniques also increase short-term motor neuron activity, resulting in increased performance in activities related to proprioception.12 It was known that the effects of mobilization techniques with neurophysiological effects on balance development, but studies investigating the effect of cervical mobilization are limited to orthopedic cases or healthy persons.9,13
Moreover, many studies in literature focused that manual therapy techniques diminish pain, improve range of motion, quality of life in groups without neurological disorders.14-16 In other words, both the sample variety in terms of disorders and the treatment effects were examined in a narrow range.
The stimulation of the cervical region rich in proprioceptors increases somatosensory system activity so that it contributes to the improvement of balance. Balance and gait problems were frequently seen in MS patients.17 The foot, which carries the whole body weight and plays an important role in locomotion, provides a base of support for balance.18 Balance and plantar pressure were investigated together in our study since the sensorial inputs for balance are obtained from plantar pressure. In accord with the move, the base of support constantly changes during the walk, daily activities. As change base of support, plantar load distribution alters.18 Main plantar load on the forefoot has been associated with balance disorders and falls.19
An individual can provide balance by using toe pressure to correct the many postural disturbances that are experienced in everyday life.18 In addition, the plantar sensation obtained from the forefoot with the loading is essential in the control of balance. Moreover, ıt determined reduced peak pressure under the metatarsal head because of spasticity in MS.20It is unknown how plantar pressure distribution changes with rehabilitation in MS patients.
Based on this background, the literature supports the positive effect of cervical mobilization in neurological disorders. However, only one study investigated the effect of cervical mobilization in MS.21 Therefore, our study is planned to investigate the effects of repeated cervical mobilization on balance and plantar pressure in MS individuals.
NIH Risk of Bias Tool: Answer Only the Questions Specific to Tool Used, Delete All Other Tool Items, THEN DELETE THIS HIGHLIGHTED INSTRUCTIONS.
Quality Assessment of Controlled Intervention Studies
Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
yes
Was the method of randomization adequate (i.e., use of randomly generated assignment)?
partially
Was the treatment allocation concealed (so that assignments could not be predicted)?
No
Were study participants and providers blinded to treatment group assignment?
No
Were the people assessing the outcomes blinded to the participants’ group assignments?
No
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?
No
Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Partially
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 study revealed that participants who received cervical mobilization (CM) showed significant improvements in balance. This was measured using the Romberg Test and Sharpened Romberg Test, where participants were able to maintain their stance for longer durations after the intervention. These results indicate that CM positively influences postural stability in individuals with Multiple Sclerosis (MS)
Key Finding #2
Another key finding was the change in plantar pressure distribution. After CM, participants exhibited increased pressure on the forefoot and decreased pressure on the rearfoot. This redistribution suggests an improvement in the way weight is carried across the feet while standing, which may contribute to better stability and mobility.
Key Finding #3
The research also revealed that CM helped equalize the distribution of body weight between the left and right feet. Participants achieved a nearly even 50/50 weight split, which is considered ideal for maintaining balance during static standing and reducing fall risk.
Key Finding #4
Lastly, the average plantar pressure decreased after cervical mobilization. This reduction implies a more stable and efficient stance, reducing the risk of fatigue or instability during standing. Together, these findings highlight the potential of cervical mobilization as a beneficial intervention for improving balance and postural control in MS patients.
Please provide your summary of the paper
The study titled ”The effect of cervical mobilization on balance and static plantar loading distribution in patients with multiple sclerosis” explored how cervical mobilization impacts balance and foot pressure in people with Multiple Sclerosis. In this randomized crossover trial, 12 participants received both traditional therapy and CM in different sequences. The CM sessions were given twice a week over four weeks. Results showed that CM significantly improved balance, allowing participants to maintain standing positions more steadily. It also led to a more even distribution of weight across the feet, reducing pressure on the heels and improving posture. The study suggests that cervical mobilization could be a beneficial addition to rehabilitation programs for individuals with MS.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Cervical mobilization can be effectively integrated into clinical practice as a complementary treatment for patients with Multiple Sclerosis (MS) who experience balance and postural control issues. Physical therapists can incorporate gentle cervical mobilization techniques, such as joint traction and soft tissue mobilization, into routine therapy sessions to enhance balance and promote more even weight distribution during standing. Since the intervention is non-invasive, low-risk, and relatively easy to apply, it can be safely used alongside traditional therapy methods. Implementing this approach may improve patient outcomes by reducing fall risk, enhancing stability, and increasing overall mobility, making it a valuable addition to individualized treatment plans in both outpatient and inpatient neurological rehabilitation settings.
Author Names
Campbell, B; Snodgrass, S
Reviewer Name
Juliette Clavier, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Division of Physical Therapy
Paper Abstract
Study Design
Controlled laboratory study, with measurements taken before and after a standardized clinical intervention
Objectives
To determine if thoracic manipulation alters the posteroanterior (PA) spinal stiffness of the thoracic spine, and the factors associated with any potential changes in stiffness.
Background
Spinal manipulation is commonly used to treat thoracic pain and dysfunction. Therapists use manual assessment of PA spinal stiffness to determine the appropriateness and effectiveness of treatment, with potential changes in spinal stiffness possibly contributing to symptomatic improvement following manipulation.
Methods
Thoracic PA spinal stiffness was measured at 5 vertebral levels (manipulated level and 2 levels above and below), in 24 asymptomatic subjects, before and after manipulation. Five cycles of standardized mechanical PA force were applied to the spinous process while recording resistance to movement and concurrent displacement, with stiffness defined as the slope of the linear portion of the force-displacement curve. A 2-way repeated-measures analysis of variance determined differences between premanipulation and postmanipulation among multiple spinal levels. Linear regression determined the relationship between stiffness magnitude and its change following manipulation. Generalized linear mixed-models were used to determine if subject age, gender, spinal level, premanipulation stiffness, or manipulative thrust parameters were associated with postmanipulation stiffness.
Results
Thoracic spine PA stiffness differed between spinal levels (F4,92 = 21.1, P<.001) but was not significantly different following manipulation. The mean change in spinal stiffness correlated with stiffness magnitude at the manipulated spinal level only but not other levels (Pearson r, −0.65; P<.001). Greater postmanipulation stiffness was associated with being male (regression coefficient, 1.16; 95% CI: 0.52, 1.79; P<.001) and with higher premanipulation stiffness (regression coefficient, 0.63; 95% CI: 0.49, 0.77; P<.001). Manipulation force parameters were not associated with postmanipulation stiffness.
Conclusion
In asymptomatic individuals, thoracic PA spinal stiffness is not significantly different when measured before and after thrust manipulation, but any potential mechanical effects appear associated with the manipulated spinal level rather than other levels. J Orthop Sports Phys Ther 2010;40(11):685–693. doi:10.2519/jospt.2010.3271
Quality Assessment of Controlled Intervention Studies
Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
no
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)?
no
Were study participants and providers blinded to treatment group assignment?
no
Were the people assessing the outcomes blinded to the participants’ group assignments?
no
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)?
no
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?
no
Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
no
Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
yes
Key Finding #1
Thrust manipulation of the spine does not result in changes in posteroanterior thoracic spinal stiffness in those who do not have thoracic spine pain.
Key Finding #2
The specific spinal level at which thrust manipulation was performed did show changes in stiffness.
Please provide your summary of the paper
The researchers in this study aimed to assess the effect that thoracic manual therapy can have on posteroanterior spinal stiffness in those who do not currently have thoracic spine pain. Spinal stiffness was objectively measured using a special device made just for this study both before and after the thoracic spinal manipulation was performed. Participants were positioned in prone while a steel rod measured posteroanterior (PA) stiffness. A physical therapist then made their own assessments through PA glides and joint play assessments. Once the level of stiffness was identified, a standard supine thoracic thrust manipulation was performed by the therapist until cavitation was achieved or alleviation of stiffness was observed. There were no statistically different results between spinal stiffness before versus after manual therapy was performed.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Overall, the results of the study imply that positive results seen in patients receiving spinal manipulative therapy may not be due to changes in stiffness. However, this does not mean that manual therapy is not still beneficial to alleviate pain in those who have thoracic spine pain. This just might suggest that there are other mechanisms at play, other than changes in stiffness when performing manual therapy on the thoracic spine. I think this can be useful for clinicians to know when considering what patients will benefit from manual therapy techniques. For example, the amount of stiffness observed in a patient may not mean they will be a better candidate for manual therapy than someone else with less stiffness.
Author Names
Romero Del Rey, R., Saavedra Hernández, M., Rodríguez Blanco, C., Palomeque del Cerro, L., Alarcón Rodríguez, R.
Reviewer Name
Ashleigh Conn, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Division of Physical Therapy
Paper Abstract
Purpose: Our aim was to compare the efficacy of spinal manipulation of the upper cervical spine (C1-C2) on postural sway in patients with chronic mechanical neck pain with the application of a combination of cervical (C3-C4), cervicothoracic (C7-T1) and thoracic spine (T5-T6) thrust joint manipulation.
Methods: One hundred eighty-six (n = 186) individuals with chronic mechanical neck pain were randomised to receive an upper cervical spine manipulation (n = 93) or three different spinal manipulation techniques applied to the cervical spine, cervicothoracic joint and thoracic spine (n = 93). Measures included the assessment of stabilometric parameters using the Medicapteurs S-Plate platform. Secondarily, neck pain was analysed using the Numeric Pain Rating Scale.
Results: We observe a decrease in the length of the centre of pressure path, average speed, medio-lateral and antero-posterior displacement with statistically significant results (p < 0.05) in the upper cervical manipulation group. Both interventions are equally effective in reducing neck pain after fifteen days (p < 0.001).
Conclusion: The application of upper cervical thrust joint manipulation is more effective in improving stabilometric parameters in patients with chronic mechanical neck pain.
Trial registration: The study was registered in the Australian and New Zealand Clinical Trial Registry (no. ACTRN12619000546156).
Implications for rehabilitation
Patients who suffer from neck pain exhibit increased postural sway than asymptomatic subjects.
Both spinal manipulation treatments applied in this study are equally effective in reducing neck pain.
Spinal manipulation treatment on the upper cervical spine improves postural stability parameters.
Quality Assessment of Controlled Intervention Studies
Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes
Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes
Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
Were study participants and providers blinded to treatment group assignment?
No
Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Not reported
Was there high adherence to the intervention protocols for each treatment group?
Yes
Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
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?
Not reported
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
For patients with chronic mechanical neck pain, spinal manipulation on the upper cervical spine (C1-C2) alone is just as successful in reducing pain as combined manipulation of the cervical spine (C3-C7), cervicothoracic junction (C7-T1), and thoracic spine (T5-T6).
Key Finding #2
Upper cervical spine joint manipulation is most beneficial in enhancing stabilometric parameters that are involved in postural sway in individuals with chronic mechanical neck pain.
Please provide your summary of the paper
This randomized controlled trial explores how different spinal thrust joint manipulations affect pain intensity and postural sway in patients with chronic neck pain. Individuals with chronic neck pain often experience secondary complications that affect postural sway including headache, dizziness, limited range of motion, and nausea. Thus, the study aimed to compare two spinal thrust manipulation approaches to determine a holistic intervention that effectively reduces pain intensity and increases proprioceptive information to decrease postural sway. One hundred eighty-six adult participants with a history of chronic mechanical neck pain who attended physical therapy at a private clinic reported symptoms were caused or worsened by movement of the cervical spine or by sustained postures. Thus, all participants were randomized into two intervention groups, with 93 allocated to receive upper cervical spine (C1-C2) manipulation and 93 to receive cervicothoracic spine manipulations for 15 days. The upper cervical spine group received supine atlantoaxial joint manipulations in both directions. Meanwhile, the intervention group undergoing cervicothoracic spine manipulations received supine thoracic spine manipulations (T5-T6), mid-cervical spine manipulations (C3-C7), and cervicothoracic junction manipulations (C7-T1). The study collected baseline and final measurements of pain via the numerical pain rating scale and pain location via a body diagram. Additionally, the study evaluated postural sway at baseline and post-intervention using parameters, including the length of the COP path, the area of the COP path, average speed, mediolateral displacement (ML), and anteroposterior displacement (AP).
The results showed that performing upper cervical spine manipulations and cervicothoracic manipulations can both decrease neck pain in patients of this population. To improve postural sway specifically, upper cervical (atlantoaxial) joint manipulation was found to be more effective than cervicothoracic manipulation. Individuals in the cervicothoracic manipulation groups showed better postural stabilometric values besides the mediolateral displacement of COP. Better postural stabiometric values correlate to increased postural tone symmetry and less anteroposterior imbalance. The ineffectiveness of the cervicothoracic manipulations is likely because the intervention did not provide enough proprioceptive information to decrease postural sway.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Considering chronic mechanical neck pain is a prevalent condition in the general population, it is beneficial to find interventions that not only reduce the pain but also reduce the secondary complications of headache, dizziness, and limited range of motion that can ultimately cause postural sway. This paper guides a clinician to perform manipulations (cervical and cervicothoracic) to reduce pain intensity if the patient does not have contra-indications to manual therapy. Additionally, the findings suggest that performing upper cervical spine manipulations of the atlantoaxial joint can go beyond pain reduction and decrease postural sway by sending proprioceptive cues through the mechanoreceptors of the suboccipital muscles to the CNS and somatosensory system, thereby normalizing central sensory modulation. Resultantly, there is good evidence to support that a physical therapist can use upper cervical spine manipulations to reduce pain and correct postural imbalance in patients with chronic mechanical neck pain.
Due to the nature and study design of the study, these findings cannot be generalized to populations other than individuals with chronic neck pain. Additionally, since the study period was only 15 days, future research should investigate the long-term implications of upper cervical and cervicothoracic spine manipulations on pain intensity and postural sway.
Author Names: Kiran Satpute, Nilima Bedekar, Toby Hall
Reviewer Name: Karleigh Derleth, LAT, ATC, SPT
Reviewer Affiliation(s): Duke School of Medicine
Paper Abstract
Question
What is the effect of a 4-week regimen of Mulligan manual therapy (MMT) plus exercise compared with exercise alone for managing cervicogenic headache? Is MMT plus exercise more effective than sham MMT plus exercise? Are any benefits maintained at 26 weeks of follow-up?
Design
A three-armed, parallel-group, randomised clinical trial with concealed allocation, blinded assessment of some outcomes and intention-to-treat analysis.
Participants
Ninety-nine people with cervicogenic headache as per International Classification of Headache Disorders (ICHD-3).
Interventions
Participants were randomly allocated to 4 weeks of: MMT with exercise, sham MMT with exercise or exercise alone.
Outcome measures
The primary outcome was headache frequency. Secondary outcomes were headache intensity, headache duration, medication intake, headache-related disability, upper cervical rotation range of motion, pressure pain thresholds and patient satisfaction. Outcome measures were collected at baseline and at 4, 13 and 26 weeks.
Results
MMT plus exercise reduced headache frequency more than exercise alone immediately after the intervention (MD between groups in change from baseline: 2 days/month, 95% CI 2 to 3) and this effect was still evident at 26 weeks (MD 4 days, 95% CI 3 to 4). There were also benefits across all time points in several secondary outcomes: headache intensity, headache duration, headache-related disability, upper cervical rotation and patient satisfaction. Pressure pain thresholds showed benefits at all time points at the zygapophyseal joint and suboccipital areas but not at the upper trapezius. The outcomes in the sham MMT with exercise group were very similar to those of the exercise alone group.
Conclusions
In people with cervicogenic headache, adding MMT to exercise improved: headache frequency, intensity and duration; headache-related disability; upper cervical rotation; and patient satisfaction. These benefits were not due to placebo effects.
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?
Unknown
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?
Yes
Key Finding #1
Mulligan Manual Therapy is helpful in reducing the number of cervicogenic headaches in a month.
Key Finding #2
There may be a potential benefit to reducing the intensity of cervicogenic headaches that do occur.
Key Finding #3
There is a possibility of clinical relevance in the decrease in headache disability for those who have underwent Mulligan Manual Therapy techniques.
Key Finding #4
Placebo was likely not a contributing factor in this study.
Please provide your summary of the paper
This study took 99 participants that were diagnosed with cervicogenic headaches were taken into this study. One group was given exercise only. One was given sham Mulligan manual therapy technique along with the exercise. The last was given real Mulligan manual therapy and exercise. The interventions took place over four weeks with a total of six sessions. Two sessions per week were completed for the first two weeks and one session per week for the last two weeks. The Mulligan technique consisted of a trial headache sustained natural apophyseal glide (SNAG), reverse headache SNAG, modified headache SNAG, and upper cervical traction were done in order. If there was pain or a headache triggered from any of these, the sequence would be stopped. The eercises consisted of cervical flexion loading exercises, scapular retraction in a prone position, static selfstretching exercises and active mobility exercises of the neck. The researchers were primarily interested in headache frequency, but also checked for headache intensity, duration, and medicine intake. At the conclusion of the study, they were able to find a clinically significant decrease in the frequency of headaches as they decreased by a minimum of three days per month. The secondary outcomes also showed benefits however it is unclear if they are of clinically relevant importance. It overall would be suggested that Mulligan manual therapy should be implemented into therapy for cervicogenic headaches.
Please provide your clinical interpretation of this paper. Include how this study may\ impact clinical practice and how the results can be implemented.
While cervicogenic headaches may not be the most stereotypical thing to see in a PT clinic, there is so much we as physical therapists can do to help reduce symptoms, severity, and intensity of these headaches. This study shows with the addition of the mulligan manual therapy technique, there may be an additional added benefit to reducing the frequency of headaches in a month. The addition of the manual technique adds in an extra 10 minutes which seems like a reasonable possibility to add into a session. Time is limited in a traditional outpatient clinic but replacing a few exercises with this manual technique could be clinically relevant and help our patients by reducing their total number of headaches. While there also may be questionable clinical significance on the results of intensity and duration of the headaches, there does show to be a general benefit to these outcomes as well. With more research, there may be a possibility to refine clinical significance.
Author Names: Esra Giray, Evrim Karadag-Saygi, Basak Mansiz-Kaplan, Duygu Tokgoz, Ozun Bayindir and Onder Kayhan
Reviewer Name: Hannah Dougherty
Reviewer Affiliation(s): Duke University Doctor of Physical Therapy Program
Paper Abstract:
Objective: To investigate the effects of kinesiology taping and different types of application techniques of kinesiology taping in addition to therapeutic exercises in the treatment of congenital muscular torticollis.
Design: Prospective, single blind randomized controlled trial.
Setting: An outpatient rehabilitation clinic in a tertiary university hospital.
Subjects: Infants with congenital muscular torticollis aged 3-12 months.
Interventions: Group 1 included 11 infants who only received exercises, Group 2 included 12 infants who received kinesiology taping applied on the affected side by using inhibition technique in addition to exercises. Group 3 included 10 infants who additionally received kinesiology taping applied on the unaffected side by using facilitation technique and on the affected side by using inhibition technique.
Main measures: Range of motion in lateral flexion and rotation of the neck, muscle function and degree of craniofacial changes were assessed at pretreatment, post treatment and, 1 month and 3 months’ post treatment.
Results: Friedman analysis of within-group changes over time revealed significant differences for all of the outcome variables in all groups except cervical rotation in Group 3 (P<0.05). No significant differences were found between groups at any of the follow-up time points for any of the outcome variables (P>0.05).
Conclusions: There is no any additive effect of kinesiology taping to exercises for the treatment of congenital muscular torticollis. Also, different techniques of applying kinesiology taping resulted in similar clinical outcomes.
Quality Assessment of Controlled Intervention Studies
Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes
Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes
Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
Were study participants and providers blinded to treatment group assignment?
No
Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
Was there high adherence to the intervention protocols for each treatment group?
Yes
Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes
Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
No
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 differences were found between groups at any of the follow-up time points in terms of cervical range of motion in lateral flexion and rotation, muscle function of lateral flexors of the neck and severity of plagiocephaly.”
Key Finding #2
“Different techniques of applying kinesiology taping yielded similar outcomes.”
Key Finding #3
“The application of kinesiology taping in addition to exercise program provided no superior effect.”
Key Finding #4
“…scientific evidence in favour of using kinesiology taping as a complementary treatment is extremely weak and limited.”
Please provide your summary of the paper
Giray and colleagues evaluated the effectiveness of kinesiology tape when used unilaterally and bilaterally in addition to exercise therapy for the treatment and management of congenital muscular torticollis. 33 infants ages 3-12 months were included in the study and were randomly assigned to one of three groups. Group one received exercise therapy only. Group two and three received both the exercise therapy and kinesiology tape for a three-week treatment period in the outpatient clinic. The infants in group two received kinesiology tape unilaterally on the affected side whereas the infants in group three had kinesiology tape applied bilaterally. Assessments of range of motion in lateral cervical flexion and cervical rotation, muscle function, and facial changes were made prior to treatment, post-treatment, and at one- and three-months post treatment. In this study, all three groups made improvements in all measurements. The researchers found kinesiology taping did not provide any higher benefit compared to exercise therapy in terms of range of motion and muscle function in infants with congenital muscular torticollis.1 Furthermore, no statistically significant differences were detected between different taping application techniques (unilateral or bilateral) in groups 2 and 3. Although kinesiology tape has become increasingly popular in rehabilitation, it does not offer any added benefit for infants with congenital muscular torticollis who are already undergoing exercise therapy for management.
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 limited clinical impact due to its small sample size and lack of significant findings regarding the effectiveness of kinesiology tape in the treatment of congenital muscular torticollis. The results suggest that kinesiology tape does not offer additional benefits beyond standard exercise therapy, therefore its use in clinical practice remains uncertain. Given these findings, clinicians should continue to prioritize established treatment approaches, such as stretching, positioning, and caregiver education. However, further research with a larger sample size is necessary to determine whether kinesiology tape could play a meaningful role in treatment. Until more conclusive evidence is available, its implementation in practice should be approached with caution.
Author Names
Sean P Riley, Stephen M Shaffer, Daniel W Flowers, Margaret A Hofbauer, Brian T Swanson
Reviewer Name
Julia Douglas
Reviewer Affiliation(s)
Duke DPT
Paper Abstract
Objectives: To establish a ‘trustworthy’ living systematic review (SR) with a meta-analysis of manual therapy for treating non-radicular cervical impairments.
Design: SR with meta-analysis.
Literature search: Articles published between January 2010 and September 2022 were included from: Cochrane Central Register of Controlled Trials (CENTRAL); CINAHL; MEDLINE; PubMed; PEDro, and ProQuest Nursing and Allied Health.
Methods: This SR included English-language randomized clinical trials (RCTs) of manual therapy involving adults used to treat non-radicular cervical impairments. The primary outcomes were pain and region-specific outcome measures. Cervicogenic headaches and whiplash were excluded to improve homogeneity. Two reviewers independently assessed RCTs. The prospective plan was to synthesize results with high confidence in estimated effects using GRADE.
Results: Thirty-five RCTs were screened for registration status. Twenty-eight were not registered or registered prospectively. In 5 studies, the discussion and conclusion did not match the registry, or this could not be determined. One study did not meet the external validity criterion, and another was rated as having a high risk of bias. One study met the inclusion and exclusion criteria, so practice recommendations could not be made. The remaining study did not identify any clinically meaningful group differences.
Discussion: Only one prospectively registered RCT met this SR’s strict, high-quality standards. The single identified paper provides initial high-quality evidence on this topic.
Conclusion: This SR establishes a foundation of trustworthiness and can be used to generate research agendas to determine the potential clinical utility of manual therapy directed at the cervical spine for non-radicular cervical complaints.
Quality Assessment of Systematic Reviews and Meta-Analyses
Is the review based on a focused question that is adequately formulated and described?
Yes
Were eligibility criteria for included and excluded studies predefined and specified?
Yes
Did the literature search strategy use a comprehensive, systematic approach?
Yes
Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
Yes
Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
Yes
Were the included studies listed along with important characteristics and results of each study?
Yes
Was publication bias assessed?
No
Was heterogeneity assessed? (This question applies only to meta-analyses.)
No
Key Finding #1
There is a lack of high-quality evidence discussing manual therapy as treatment for non-radicular cervical spine pain.
Key Finding #2
Although there is some statistically significant difference between cervical mobilization and sham manipulation, the differences are not clinically meaningful.
Key Finding #3
“Trustworthiness” is very important in systematic reviews, because it ensures that included studies main prospective registration and rigor.
Key Finding #4
There is a need for more high-quality evidence and future studies to provide more strong clinical recommendations for manual therapy in the cervical spine.
Please provide your summary of the paper
The aim of this paper is to develop a reliable and ongoing systematic review focused on manual therapy interventions for non-radicular cervical spine impairments. This review searched many data bases, with literature from January 2010 to September 2022 covered. Only high-quality randomized control trials that met specific standards were included in this systematic review. Out of all 35 RCTs, published within the 12-year timeframe, only one study met the inclusion criteria, as most studies lacked prospective validity. This review emphasized that the purpose of their strict inclusion criteria is aimed at creating “trustworthiness” to inform future clinical practice recommendations.
The lone study included in this systematic review compared the effects of cervical manipulation, mobilization, and sham manipulation in patients with chronic mechanical neck pain. While some statistically significant differences were found between mobilization and sham groups, these differences were not clinically meaningful. The authors call for more high-quality RCTs with prospective validity and minimal bias to create strong evidence-based guidelines for non-radicular cervical spine impairments.
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 emphasizes the need for high-quality research to guide clinical practice for manual therapy in non-radicular cervical spine impairments. Most previous studies lack prospective registration and methodological rigor, limiting confidence in their findings. Thus, clinicians should be cautious when interpreting the effectiveness of manual therapy for non-radicular cervical spine issues. Until more high-quality studies are available, clinicians should adopt a more evidence-informed approach that combines their clinical expertise with patient preference and best available evidence.
Author Names
Petersen, S; Domino, N; Postma, C; Wells, C; Cook, C
Reviewer Name
Lauren Dreusicke
Reviewer Affiliation(s)
Duke University DPT
Paper Abstract
Introduction: Scapulothoracic muscle weakness has been associated with neck pain (NP). Little evidence exists regarding lower trapezius (LT), middle trapezius (MT) and serratus anterior (SA) strength in this population. LT strength changes have been observed following thoracic manipulation in healthy subjects. The purpose of the present study was to examine scapulothoracic strength changes following cervical manipulation in subjects with NP.
Methods: Twenty-two subjects with NP and 17 asymptomatic control (AC) subjects underwent strength testing of the LT, MT and SA using a hand-held dynamometer. Subjects with NP were treated with passive intervertebral neck manipulation and neck range of motion exercises. The AC group received no intervention. Strength testing was
repeated after manipulation, then 48 and 96 hours later. Change scores were calculated for strength over time. Paired t-tests were done for strength change between painful and non-painful sides in the NP group. Independent t-tests were done for strength change between the NP group and AC group.
Results: There was no significant difference between groups for age, gender, hand dominance or body mass index. Mean (standard deviation) symptom duration for subjects in the NP group was 43.27 (62.71) months. There was no significant difference in strength change over time between painful and non-painful sides in the NP group for any muscle; however, there was a significant difference in strength change over time between those in the NP group and AC group for the LT (p < 0.01), SA (p < 0.01) and MT (p < 0.01).
Discussion: Scapulothoracic muscle strength improvements were observed in both extremities following passive intervertebral neck manipulation and neck range of motion exercises. Improvements lasted up to 96 hours following manipulation, even though no strengthening exercises were prescribed.
Conclusions: Manipulation and range of motion should be considered as a component of intervention programmes for patients with NP and scapulothoracic muscle weakness. Future studies should compare manipulation alone to exercise alone to determine impact on strength. Copyright © 2016 The Authors Musculoskeletal Care Published by John Wiley & Sons Ltd
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?
Yes
Key Finding #1
Neck pain (NP) group receiving interventions including cervical manual therapy and range of motion exercises demonstrated an increase in strength in all 3 scapulothoracic muscles lasting 96-hours after the initial visit.
Key Finding #2
No significant difference was found in the Neck Disability Index (NDI) between limbs on the painful and non-painful sides for any muscle examined for the NP group or AC group.
Key Finding #3
Both the painful and non-painful sides demonstrated comparable strength improvements in the neck pain (NP) group after receiving the interventions.
Please provide your summary of the paper
This randomized control trial examined the potential for scapulothoracic changes in strength after cervical manipulation techniques in patients exhibiting neck pain. This study was done on a subset of subjects from a larger RCT focusing on the comparison of two exercise programs prescribed in conjunction with a single session of manual
therapy. 17 participants were recruited for the asymptomatic control (AC) and 22 participants for the neck pain (NP) groups by advertisement in the community and word of mouth. Those in the NP group included neck pain of any duration in addition to a primary complaint of unilateral neck pain, complaints of neck motion limitations, demonstration of limited cervical ROM based on reports of pain limiting motion, cervical or thoracic segmental mobility restrictions, and neck/neck-related pain in the upper extremity with cervical or thoracic segment provocation. Patients in the AC group had no previous history of shoulder or neck pain. The Neck Disability Index (NDI) was completed by all participants at the first and last visit. Strength testing of the participants was conducted twice during the first visit, and once at each follow up visit on the lower trapezius, middle trapezius, and serratus anterior muscles using a microFET2 digital handheld dynamometer. Each muscle was tested twice with the side tested first and order of muscles tested on each patient randomly assigned with the mean of the 2 readings recorded. The NP group received a manual intervention of either a passive intervertebral thrust manipulation or non-thrust manipulation. The manual therapy intervention was applied at the first visit, while following visits utilized only
self-administered neck ROM exercises. The AC group received no intervention. The NP group also received an HEP of a segment-specific or general neck ROM exercise with instruction from the treating clinician and to complete it six times per day for 12 repetitions each time over the course of the study. Participants in the NP group demonstrated a trend of increased strength over time in the three measured muscles regardless of the painful or non-painful side. There was not a significant difference present in the change of NDI scores between limbs on either side for the NP group, but there was a significant difference found with a greater change in strength of the NP group over 96 hours than the AC group. Limitations include a small sample size consisting mostly of participants with relatively low levels of neck-related disability, excluding populations with higher levels of disability.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
With this study demonstrating how manual therapy of the cervical spine in combination with cervical ROM exercises could provide benefits to those with neck pain and scapulothoracic muscle strength impairments, clinicians can apply many aspects from the study trial and its design to their clinical practice. From handheld dynamometer methods to measure scapulothoracic strength, cervical manipulation techniques, and effective intervention choices for patients, all of these can be applied to any interested clinician’s treatment plan for a patient. With some patients expressing hesitancy towards manual therapy and manipulations around the cervical spine and neck region, having a
study to reference may ease their nerves surrounding the treatment of a potentially sensitive region for them. Additionally, these findings can build new clinician confidence of when to utilize cervical manipulations and mobilizations in treatment of their patients in combination with the provided interventions. The findings suggest that clinicians can incorporate manual therapy and exercises targeting scapulothoracic muscles and neck
ROM to effectively enhance their muscle strength in their patients with neck pain, aiding in the improvement of their patient’s outcomes.
Author Names
Seo J, Song C, Shin D. A
Reviewer Name
Joyel Edgecombe, SPT
Reviewer Affiliation(s)
Doctor of Physical Therapy Program, Duke University
Paper Abstract
BACKGROUND Neck pain is associated with computer work, poor posture, imbalanced neck muscles, and fatigue, particularly in office workers. This study from a single center aimed to compare the effects of thoracic spine mobility exercise and thoracic spine manipulation to improve cervical spine range of motion in 26 office workers who had chronic neck pain for more than 12 weeks. MATERIAL AND METHODS The participants were 26 office workers with neck pain lasting >12 weeks. These participants were randomly assigned to undergo TSME (n=13) or TSM (n=13). Both groups underwent cervical joint mobilization and deep cervical flexor muscle exercises for 25 min a day, twice weekly, for 6 weeks. The TSME group additionally performed TSME 15 min a day, twice a week, for 6 weeks, while the TSM group received TSM 2 times a day, twice a week, for 6 weeks. Cervical and thoracic spine ROM, numeric pain rating scale (NPRS), and neck disability index (NDI) were measured before and after interventions. The ROM of cervical and thoracic spine was measured using a dual inclinometer. RESULTS Both groups showed significant changes in cervical spine ROM, thoracic spine ROM, NPRS, and NDI after intervention compared to before intervention (P<0.05). Cervical spine right lateral flexion and right rotation differed significantly between the groups (P<0.05), while thoracic spine ROM, NPRS, and NDI did not. CONCLUSIONS TSME and TSM have similar effects in improving pain and disability in office workers with non-specific chronic 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)?
Not specified
Was the treatment allocation concealed (so that assignments could not be predicted)?
Not specified
Were study participants and providers blinded to treatment group assignment?
No
Were the people assessing the outcomes blinded to the participants’ group assignments?
Not specified
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?
No
Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Not specified
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
In both groups, all cervical spine ROM, including flexion, extension, right lateral flexion, left lateral flexion, right rotation, and left rotation, differed significantly after the intervention compared to before the intervention.
Key Finding #2
Both TSME (thoracic spine mobility exercises) and TSM (thoracic spine manipulation) groups showed significant changes in thoracic flexion and extension ROM post-intervention compared to before the intervention (P<0.05). However, inter-group comparisons showed no significant differences in thoracic flexion and extension between the 2 groups (Table 3).
Key Finding #3
The NPRS score was significantly reduced after the intervention compared to before the intervention in both the TSME (thoracic spine mobility exercises) and TSM (thoracic spine manipulation)
Please provide your summary of the paper
The objective of this study was to evaluate the effectiveness of thoracic spine manipulation (TSM) compared to mobility exercises (ME) in reducing pain and improving function in office workers with chronic neck pain. The study was a randomized controlled trial that included 26 participants who were divided into two intervention groups, one receiving TSM and the other performing ME. Outcome measures such as pain intensity using the VAS (Visual Analog Scale), disability using the NDI (Neck Disability Index), and cervical range of motion (ROM) were recorded before and after the interventions. The results showed significant improvements in both groups; however, participants who received TSM experienced greater immediate pain relief and increased cervical ROM compared to those performing ME. This suggests that TSM may be more effective for short-term pain reduction and mobility improvements in individuals with chronic 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.
Based on the findings from the study, the authors were able to conclude that both thoracic spine manipulation (TSM) and mobility exercises (ME) can be beneficial for those experiencing chronic neck pain. However, they noted that TSM helped to alleviate pain more quickly. Early on in a patient’s plan of care, who is experiencing chronic neck pain, it is fair to start a treatment session with TSM followed by ME, to help with pain reduction and mobility improvements.
Author Names: B W Koes, W J J Assendelft, G J M G van der Heijden, L M Bouter, P G Knipschild
Reviewer Name: Chad Fortin
Reviewer Affiliation(s): Duke DPT 2026
Objective-To assess the efficacy of spinal manipulation for patients with back or neck pain.
Design-Computer aided search for published papers and blinded assessment of the methods of the studies.
Subjects-35 randomised clinical trials comparing spinal manipulation with other treatments. Main outcome measures-Score for quality of methods (based on four main categories: study population, interventions, measurement of effect, and data presentation and analysis) and main conclusion of author(s) with regard to spinal manipulation.
Results-No trial scored 60 or more points (maximum score 100) suggesting that most were of poor quality. Eighteen studies (51%) showed favourable results for manipulation. In addition, five studies (14%) reported positive results in one or more subgroups. Of the four studies with 50-60 points, one reported that manipulation was better, two reported that manipulation was better in only a subgroup, and one reported that manipulation was no better or worse than reference treatment. Eight trials attempted to compare manipulation with some placebo, with inconsistent results.
Conclusions-Although some results are promising, the efficacy of manipulation has not been convincingly shown. Further trials are needed, but much more attention should be paid to the methods of study.
Quality Assessment of Systematic Reviews and Meta-Analyses
1. Is the review based on a focused question that is adequately formulated and described?
Yes
2. Were eligibility criteria for included and excluded studies predefined and specified?
Yes
3. Did the literature search strategy use a comprehensive, systematic approach?
Yes
4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion
and exclusion to minimize bias?
No
5. Was the quality of each included study rated independently by two or more reviewers using a
standard method to appraise its internal validity?
No
6. Were the included studies listed along with important characteristics and results of each
study?
Yes
7. Was publication bias assessed?
No
8. Was heterogeneity assessed? (This question applies only to meta-analyses.)
No
Key Finding #1
The studies utilized had poor methodological quality, and their strategies for collecting date should be reviewed.
Key Finding #2
Although the majority had favorable outcomes with spinal manipulation, there was still a strong group with either negative or neutral results, suggesting that the evidence in this paper is variable.
Key Finding #3
Nearly a fifth of the studies demonstrated consistent positive outcomes in subgroups, suggesting that there could be a great need for PT within specific patient groups.
Key Finding #4
More elaborate research using double blinded randomly controlled trials is required to better establish the effects of spinal manipulations on the neck and back.
Please provide your summary of the paper
The review suggests that while spinal manipulation for the low back and neck may be beneficial for some patients, the overall quality of evidence is low, and more rigorous research is required to determine its true effectiveness. The authors call for higher-quality studies to strengthen the evidence base for this treatment approach.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
I believe this study is somewhat dated in its nature, but is still valuable. That said, there exists a strong body of evidence showcasing the effectiveness of spinal manipulation, so I would hold this study with very little clinical utility, and assume it can be effective for most patients under the proper conditions.
Author Names
Fernández-de-la-Peas C, et. al.
Reviewer Name
Max Francisco- Duke DPT SPT
Reviewer Affiliation(s)
Duke DPT class of 2026
Paper Abstract
Design
A placebo, control, repeated-measures, single-blinded randomized study.
Objectives
To compare the immediate effects on pressure pain threshold (PPT) tested over the lateral elbow region following a single cervical high-velocity low-amplitude (HVLA) thrust manipulation, a sham-manual application (placebo), or a control condition; and to analyze if a different effect was evident on the side ipsilateral to, compared to the side contralateral to, the intervention.
Background
Previous studies investigating the effects of spinal manual therapy used passive mobilization procedures. There is a lack of studies exploring the effect of cervical manipulative interventions.
Methods
Fifteen asymptomatic volunteers (7 male, 8 female; aged 19–25 years) participated in this study. Each subject attended 3 experimental sessions on 3 separate days, at least 48 hours apart. At each session, subjects received either the manipulation, placebo, or control intervention provided by an experienced therapist. The manipulative intervention was directed at the posterior joint of the C5-6 vertebral level. PPT over the lateral epicondyle of both elbows was assessed preintervention and 5 minutes postintervention by an examiner blinded to the treatment allocation of the subject. A 3-way analysis of covariance (ANCOVA) with intervention, side, and time as factors, and gender as covariate, was used to evaluate changes in PPT.
Results
The analysis of variance detected a significant effect for intervention (F = 31.46, P<.001) and for time (F = 33.81, P<.001), but not for side (F = 0.303, P>.5). A significant interaction between intervention and time (F = 15.74, P<.001) was also found. Gender did not influence the comparative analysis (F = 0.252, P>.6). Post hoc analysis revealed that the application of a HVLA thrust manipulation produced a greater increase of PPT in both elbows, as compared to placebo or control interventions (P<.001). No significant changes in PPT levels were found after the placebo and control interventions (P>.6). Within-group effect sizes were large for PPT levels in both elbows after the manipulative procedure (d>1.0), but small after placebo or control intervention (d<0.1).
Conclusions
The application of a manipulative intervention directed at the posterior joint of the C5-6 vertebral level produced an immediate increase in PPT over the lateral epicondyle of both elbows in healthy subjects. Effect sizes for the HVLA thrust manipulation were large, suggesting a strong effect of unknown clinical importance at this stage, whereas effect sizes for both placebo and control procedures were small, suggesting no significant effect. J Orthop Sports Phys Ther 2007;37(6):325–329. doi:10.2519/jospt.2007.2542
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?
No
Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
Was there high adherence to the intervention protocols for each treatment group?
Yes
Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes
Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
No
Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Cannot Determine
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
A single session of cervical spine manipulation resulted in an immediate increase in pressure pain thresholds in healthy individuals, suggesting that even a single session of cervical manipulations can produce a pain-relieving effect.
Key Finding #2
Although this single session of cervical spine manipulation was able to affect pressure pain thresholds, the manipulation did not produce significant changes in motor performance, such as grip strength, indicating that the observed effects were primarily sensory rather than functional.
Please provide your summary of the paper
The study “Immediate Effects on Pressure Pain Threshold Following a Single Cervical Spine Manipulation in Healthy Subjects” investigated the short-term effects of cervical spine manipulation on pain perception. The researchers conducted a randomized controlled trial (RCT) with healthy participants, measuring their pressure pain threshold before and after a single spinal manipulation intervention. The primary goal was to determine whether the manipulation could induce immediate pain-relieving effects.
The results of the study show that manual therapy may be a viable option in increases in pain tolerance. The study indicated that the cervical spine manipulations led to a statistically significant increase in pressure pain thresholds, meaning that participants experienced a reduced sensitivity to pain following the manipulation. However, no corresponding improvements in grip strength or motor function were observed. This suggests that the primary benefit of spinal manipulation for healthy patients is related to sensory modulation rather than increases in functional abilities.
While the study provides evidence for the immediate pain-relieving effects of cervical spine manipulation, it does not establish long-term benefits or efficacy in clinical populations. Additionally, these patients presented with no pain, so more research would be beneficial with patients that present with baseline pain to see if these findings translate to different patient populations that need pain-relieving interventions.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study’s findings are relevant to clinicians considering spinal manipulation as part of pain management strategies. The observed pain-relieving effects suggest that spinal manipulation may serve as a non-invasive method to temporarily reduce pain sensitivity. However, the lack of motor function improvement implies that manipulation alone may not be sufficient for rehabilitation purposes. Clinicians should use cervical spine manipulations in conjunction with patient education and therapeutic exercise, to increase patient outcomes. Additionally, since the study was conducted on healthy subjects, caution is needed when generalizing the results to patient populations with existing musculoskeletal conditions. Finally, this study was designed in a way that reduces tester bias and seems to be a valid study that is easily repeatable
Author Names
Galindez-Ibarbengoetxea, X. et al
Reviewer Name
Max Francisco- Duke DPT SPT
Reviewer Affiliation(s)
Duke DPT class of 2026
Paper Abstract
Background: Cervical high-velocity low-amplitude (HVLA) manipulation technique is among the oldest and most frequently used chiropractic manual therapy, but the physiologic and biomechanics effects were not completely clear.
Objective: This review aims to describe the effects of cervical HVLA manipulation techniques on range of motion, strength, and cardiovascular performance.
Methods/design: A systematic search was conducted of the electronic databases from January 2000 to August 2016: PubMed (n = 131), ScienceDirect (n = 101), Scopus (n = 991), PEDro (n = 33), CINAHL (n = 884), and SciELO (n = 5). Two independent reviewers conducted the screening process to determine article eligibility. The intervention that included randomized controlled trials was thrust, or HVLA, manipulative therapy directed to the cervical spine. Methodological quality was assessed using the Cochrane risk-of-bias tool. The initial search rendered 2145 articles. After screening titles and abstracts, 11 articles remained for full-text review.
Results: The review shows that cervical HVLA manipulation treatment results in a large effect size (d > 0.80) on increasing cervical range of motion and mouth opening. In patients with lateral epicondylalgia, cervical HVLA manipulation resulted in increased pain-free handgrip strength, with large effect sizes (1.44 and 0.78, respectively). Finally, in subjects with hypertension the blood pressure seemed to decrease after cervical HVLA manipulation. Higher quality studies are needed to develop a stronger evidence-based foundation for HVLA manipulation techniques as a treatment for cervical conditions.
NIH Risk of Bias tool
Quality Assessment of Systematic Reviews and Meta-Analyses
Is the review based on a focused question that is adequately formulated and described?
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?
Not addressed
Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
Not addressed
Were the included studies listed along with important characteristics and results of each study?
Yes
Was publication bias assessed?
Not addressed
Was heterogeneity assessed? (This question applies only to meta-analyses.)
Not applicable
Key Finding #1
The review found that high-velocity low-amplitude (HVLA) cervical manipulations can lead to immediate improvements in range of motion and improvements in muscle strength performance in certain populations. This suggests that HVLA techniques can have positive short-term benefits for musculoskeletal function.
Key Finding #2
This study shows that cervical HVLA have the potential to positively influence blood pressure and heart rate variability, but the evidence is inconsistent and inconclusive. Further research is needed to determine whether these techniques have meaningful and reliable cardiovascular effects.
Please provide your summary of the paper
Cervical HVLA techniques are commonly used in manual therapy to enhance musculoskeletal function. This systematic review examines the effects of these manipulations on ROM, strength performance, and cardiovascular outcomes. The review provides an explanation and analysis of existing studies to determine the efficacy and implications of cervical HVLA.
One of the key findings of this review is the significant improvement in ROM and muscle strength performance following cervical HVLA manipulation. Several studies included in the review indicate that these manual therapy techniques lead to immediate, short-term gains in functional movement. These improvements may be attributed to neuromuscular adaptations, increased joint mobility, and reduced muscular inhibition, which can be particularly beneficial in rehabilitation and sports performance settings.
While some studies included in this systematic review suggest that cervical HVLA may influence cardiovascular parameters such as blood pressure and heart rate variability, the overall evidence remains inconsistent. This review highlights discrepancies in study designs and outcome measures, making it difficult to draw conclusions regarding the cardiovascular impact of these techniques. The need for further, more standardized, research in this area is emphasized, particularly with standardized protocols and larger sample sizes to validate any potential physiological effects.
The review acknowledges several limitations, including variability in study designs, inconsistent reporting of results, and a lack of long-term follow-up data. These factors make it difficult to fully determine the ability of the sustained benefits or risks of cervical HVLA techniques. Future research should focus on employing standardized methodologies, including randomized controlled trials, to establish clearer evidence on both musculoskeletal and cardiovascular outcomes.
Cervical HVLA techniques have demonstrated possible positive effects on ROM and strength performance, reinforcing their use in manual therapy for musculoskeletal conditions. However, their cardiovascular effects remain uncertain, necessitating further high-quality investigations. This review underscores the importance of evidence-based practice in the application of HVLA techniques and highlights the need for continued research to clarify their full range of benefits and risks.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study highlights the potential benefits of cervical HVLA techniques in improving range of motion and muscle strength performance, which can be valuable for rehabilitation. By demonstrating immediate functional improvements, the findings support the use of HVLA as a therapeutic intervention for patients experiencing restricted mobility or neuromuscular deficits. However, the review also discusses the need for further research on its cardiovascular effects, in order to ensure that clinicians apply these techniques safely and effectively. Understanding both the benefits and limitations of HVLA can help healthcare providers make evidence-based decisions to optimize patient outcomes to provide each patient with the most individualized plan.
Author Names
Häkkinen, A., Salo, P., Tarvainen, U., Wirén, K., & Ylinen, J.
Reviewer Name
Abby Frazier, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Objective: To study the effect of manual therapy and stretching on neck function in women with chronic neck pain.
Methods: A total of 125 women were randomized into 2 groups. Group 1 received manual therapy twice a week for 4 weeks followed by stretching exercises. Group 2 performed stretching 5 times a week for 4 weeks followed by manual therapy. Neck function was assessed by isometric neck strength and mobility measurements, and spontaneous neck pain during the past week and strain-evoked pain during the neck strength trials using a visual analogue scale.
Results: Both neck muscle strength (11-14%) and mobility (7-15%) improved similarly in both groups, with the exception of greater passive flexion-extension mobility (p = 0.019) in group 1 at week 4. Pain during the neck strength trials decreased from the baseline to week 4 by 26-35% and to week 12 by 39-61% similarly in both groups. Average neck pain during the past week decreased by 64% and 53% in groups 1 and 2, respectively, during the first 4 weeks, remaining rather stable thereafter. The decreases in neck pain during both the past week and strength trials showed association with the changes in neck strength results (r = 0.20-0.29).
Conclusion: Both manual therapy and stretching were effective short-term treatments for reducing both spontaneous and strain-evoked pain in patients with chronic neck pain. It is possible that the decrease in pain reduced inhibition of the motor system and in part improved neck function. However, the changes in neck muscle strength were minor, showing that these treatments alone are not effective in improving muscle strength.
Quality Assessment of Controlled Intervention Studies
Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes
Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes
Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
Were study participants and providers blinded to treatment group assignment?
No
Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
Was there high adherence to the intervention protocols for each treatment group?
Cannot Determine, Not Reported, or Not Applicable
Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Cannot Determine, Not Reported, or Not Applicable
Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
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
Neck muscle strength improved in both intervention groups at the 4-week follow-up.
Key Finding #2
Strain-evoked neck pain decreased in both groups at the 4- and 12-week follow-ups.
Key Finding #3
Spontaneous neck pain decreased in both groups at the 4-week follow-up.
Key Finding #4
Neck mobility increased in both groups at the 4-week follow-up, with the exception of group 1 having greater passive flexion-extension mobility than group 2.
Please provide your summary of the paper
One aim of the study was to compare the effectiveness of manual therapy versus stretching in improving neck mobility and strength in women with chronic neck pain. Additionally, the study sought to discover associations between neck function and spontaneous or strain-evoked neck pain in these individuals. The study consisted of 125 participants who were randomized into two groups. Group one had manual therapy performed twice a week for four weeks then switched to neck stretching exercises five times per week, with the final follow-up being at 12 weeks. Group two received the same therapies but in the reverse order. Measurements were gathered at both the 4- and 12-week marks. This included neck strength, measured by an isometric neck strength testing machine, passive cervical range of motion, measured with a 3D motion-testing device, and pain during strength testing and spontaneous pain, using the visual analog scale. The study found that neck strength improved similarly (11-14%) in both groups after 4 weeks; however, no improvement was seen from the 4 to 12-week period. Neck pain during strength testing decreased in both groups at the 4-week (26-35%) and 12-week (39-61%) marks. The findings for neck mobility showed that both groups demonstrated similar increases in neck mobility (7-15%) at week 4; however, group one had better mobility in passive flexion extension in 4 weeks. Lastly, spontaneous pain improved in group one (64%) and group two (53%) after the initial 4 weeks and then plateaued. Overall, the use of stretching and manual therapy effectively improved pain, mobility, and strength in patients with chronic neck pain 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.
The results of this study can help guide short-term management of chronic neck pain. Commonly, individuals with chronic pain are limited by fear of their pain worsening, so finding ways to reduce pain levels to eliminate that fear is essential. The results of this study provide clinicians with two strategies, manual therapy and stretching, to reduce pain levels in these patients before continuing with other forms of therapy. Additionally, the results support manual therapy and stretching as ways to improve neck strength and mobility, which clinicians can follow in treating these patients.
Despite the positive findings, the increase in neck strength, while significant, was minimal, and it is important that clinicians do not use either manual therapy or stretching as the only form of physical therapy for chronic neck pain. Instead, these techniques should be used in conjunction with other methods of strengthening and range of motion exercises. Lastly, the effectiveness of these interventions was mainly seen in the short term, so clinicians should be mindful when treating and educating patients that these interventions may not provide the same long-term benefits that were experienced short term.
Author Names
Jennifer Chu, Diane D Allen, Sarah Pawlowsky, Betty Smoot
Reviewer Name
Sarah Freeman
Reviewer Affiliation(s)
Duke DPT
Paper Abstract
Objectives:
Spinal manual therapy (SMT) is commonly used for treatment of musculoskeletal pain in the neck, upper back, or upper extremity. Some authors report a multi-system effect of SMT, including peripheral alterations in skin conductance and skin temperature, suggesting that SMT may initiate a sympathetic nervous system (SNS) response. The focus of this evidence-based review and meta-analysis is to evaluate the evidence of SNS responses and clinically relevant outcomes following SMT to the cervical or thoracic spine.
Methods:
A systematic search used the terms: ‘manual therapy’, ‘SMT’, ‘spinal manipulation’, ‘mobilization’, ‘SNS’, ‘autonomic nervous system’, ‘neurophysiology’, ‘hypoalgesia’, ‘pain pathophysiology’, ‘cervical vertebrae’, ‘thoracic vertebrae’, ‘upper extremity’, and ‘neurodynamic test’. Data were extracted and within-group and between-group effect sizes were calculated for outcomes of skin conductance, skin temperature, pain, and upper extremity range of motion (ROM) during upper limb neurodynamic tests (ULNTs).
Results:
Eleven studies were identified. Statistically significant changes were seen with increased skin conductance, decreased skin temperature, decreased pain, and increased upper extremity ROM during ULNT.
Discussion:
A mechanical stimulus at the cervical or thoracic spine can produce a SNS excitatory response (increased skin conductance and decreased skin temperature). Findings of reduced pain and increased ROM during ULNT provide support to the clinical relevance of SMT. This evidence points toward additional mechanisms underlying the therapeutic effect of SMT. The effect sizes are small to moderate and no long-term effects post-SMT were collected. Future research is needed to associate peripheral effects with a possible centrally-mediated response to SMT.
Keywords: Spinal manual therapy, Sympathetic nervous system, Cervical spine, Thoracic spine
NIH Risk of Bias Tool: Answer Only the Questions Specific to Tool Used, Delete All Other Tool Items, THEN DELETE THIS HIGHLIGHTED INSTRUCTIONS.
Quality Assessment of Systematic Reviews and Meta-Analyses
Is the review based on a focused question that is adequately formulated and described?
Yes
Were eligibility criteria for included and excluded studies predefined and specified?
Yes
Did the literature search strategy use a comprehensive, systematic approach?
Yes
Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
Yes
Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
Yes
Were the included studies listed along with important characteristics and results of each study?
Yes
Was publication bias assessed?
Yes
Was heterogeneity assessed? (This question applies only to meta-analyses.)
Yes
Key Finding #1
All 11 studies demonstrated positive impacts of SMT with results of decreased resting pain, increased skin conductance, decreased skin temperature, and increased upper extremity ROM.
Key Finding #2
Individuals who were asymptomatic still reported reduced mechanosensitivity and increased upper extremity ROM after the cervical or thoracic manipulations.
Key Finding #3
Though the majority of individuals in these studies reported some degree of reduced resting pain following SMT intervention, not all findings are considered statistically significant as not all values are greater or equal to the MCID for pain reduction.
Please provide your summary of the paper
The purpose of this study was to review and analyze the effects of spinal manual therapy at the thoracic and cervical levels on peripheral SNS responses. For this study, researchers included previous studies that utilized SMT and measured it’s impact on skin conductance and temperature in the hands, as well as pain reduction at rest and overall ROM in the upper extremity. Articles were excluded if they only assessed pain during movement, or if passive mobilization was conducted anywhere other than the thoracic or cervical spine regions. After performing a comprehensive search and excluding articles that did not meet the required parameters, the results of 11 studies were cross examined. The results of these 11 studies revealed that spinal manual therapy at the cervical and thoracic regions do have an impact on peripheral SNS responses in both symptomatic and asymptomatic individuals. The 11 studies all showed some level of reduction in resting pain and improvements in ROM of the UE, as well as increased skin conductance and reduced skin temperature. Several limitations of the study were discussed. Firstly, some of the studies had other interventions that were performed simultaneously with the SMT, which could impact the results. Also, the time in-between interventions varied drastically between trials which could alter the similarities in the data.
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 is clinically significant as it not only demonstrates the musculoskeletal benefits that yield from spinal manual therapy, but it also highlights the physio neurological benefits as well. The results from this study can help clinicians and researchers alike better understand and better treat Upper Quarter Syndromes and peripheral issues without possibly aggravating the specific peripheral area of discomfort. This meta-analysis could result in further exploration of the impacts of manual therapy on SNS response in other regions of the body, as well as looking into the long-term effects of spinal manipulation on these peripheral responses and results.
Author Names: Donald J. Hunter, Darren A. Rivett PhD, Sharmaine McKiernan PhD, Renae Luton, Suzanne J. Snodgrass PhD
Reviewer Name: Jessica Fullerton
Reviewer Affiliation(s): Duke University, Doctor of Physical Therapy Program
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
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?
No
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?
NA
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)?
No
Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Pain and disability outcome measures showed significant improvements above the MCID when incorporating MET with or without STM on the thoracic spine in patients with SIS.
After a one year follow up, significant improvements in pain and disability were still found demonstrating long term benefits.
Due to the long-term benefits, safety, and feasibility of the intervention, MET with or without STM on the thoracic spine can be used as an intervention in patients with SIS.
Thoracic posture and/or mobility was hypothesized to have an effect SIS due to its increased prevalence of thoracic kyphosis and decreased thoracic mobility but was not shown to be improved with the interventions performed in this study.
Paper Summary:
This study looked to investigate the effects of thoracic manual therapy on pain and disability in patients with shoulder impingement. The results found that muscle energy technique (MET) with or without soft tissue massage (STM) on the thoracic spine improves pain and disability in 40+ year old patients with shoulder impingement syndrome (SIS). With a one year follow up, pain and disability outcome measures still showed improvement which gives support behind its implementation in treatment with patients with SIS. While this study only used patients 40+ years of age, which is a common age for this condition, it’s also common in overhead athletes. I think further investigation and studies focusing on other populations including younger athletes would be beneficial to determine its effect. Quality, easy to use, outcome measures including VAS, DASH and SPADI were utilized which can further be implemented in other studies and in clinic to determine specific effects on patients and other populations. It was interesting there was no improvement in thoracic mobility with direct manual therapy on the thoracic spine. While this study did not involve a manipulation of the thoracic spine itself, I wonder if there would be any improvements in pain and disability with a thoracic manipulation or mobilization. Thoracic mobility may not be improved with a manipulation technique, but neither was it improved with MET or STM, so possibly the neurophysiologic mechanism and endorphin release of a manipulation would further lead to decreased disability and pain in patients with SIS. Other studies mentioned focused on HVLA manipulations on the thoracic spine in this population with no improvements shown between the manipulation group and a sham group, but further studies could focus on this as each patient is different and responds differently or a mobilization technique could further be tested.
Clinical Interpretation:
Due to the improvements in pain and disability measures throughout treatment, discharge, and after a one-year follow up in 40+ year old patients with SIS after application of MET and STM on the thoracic spine, clinic implementation of these interventions in the population treated would be beneficial. While this study was only focused on 40+ year old patients, which is a good proportion of patients with this condition, using this intervention on a population that was not tested in this study would be safe and may possibly show similar effects; this study was safe and feasible allowing it to be used in many clinics and tested on more patients. The long-term benefits of MET and STM on SIS patients could be a potential early therapeutic intervention prior to the introduction of surgery or injections. These results can be implemented throughout the treatment sessions with or without exercise as exercise prescription was not recorded in this study. While this study did not demonstrate thoracic mobility improvements, its focus on the thoracic spine and comments on the mobility deficits in patients with SIS highlights a holistic approach into treating patients with SIS which is beneficial in physical therapy programs and treatment. Further thoracic mobility exercises, thoracic self-mobilizations, and thoracic spine mobilization/manipulations should further be studied and tested for effects on pain and disability in patients with SIS when implementing more thoracic mobility interventions in physical therapy treatment sessions. The MET only group appeared to have a significant improvement after a 1 year follow up, so if the therapist had to choose, incorporation of MET may be more beneficial than MET+STM, but it’s important to recognize each patient is different and effects might vary per patient. This study can impact clinical practice by maximizing treatment effect and decreasing pain and disability in 40+ year old patients with SIS with the implementation of MET and STM on the thoracic spine in physical therapy sessions.
Author Names: Samar M. Alansari, Enas F. Youssef, and Alsayed A. Shanb
Reviewer Name: Maria Gonzalez
Reviewer Affiliation(s): Duke University School of Medicine, Doctor of Physical Therapy
Paper Abstract
This study aimed to evaluate the efficacy of manual therapy on reducing pain and improving psychological status in patients with neck pain. Participants were randomly assigned to either a manual therapy group or a control group. The intervention consisted of a structured manual therapy program, while the control group received no intervention. The manual therapy group showed significant improvements in both pain intensity and psychological status compared to the control group. This means manual therapy was found to be effective in reducing pain and improving psychological outcomes in patients with neck pain.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
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?
N/A
Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
n/a
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)?
n/a
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
Manual Therapy’s Dual Impact: The study showed how manual therapy can be used to alleviate physical pain but improve one’s psychological well-being.
Key Finding #2
Pain Reduction: The Visual Analog Scale used, showed that the participants had significant decrease in pain intensity when compared to the control group.
Key Finding #3
Improvement in Psychological Status: The Depression, Anxiety, and Stress Scale (DASS-21), showed that manual therapy can improve psychological outcomes. They found reductions in depression, anxiety and stressed in the manual therapy group in comparison to the control group.
Key Finding #4
Support for Manual Therapy as an Effective Treatment: As there is an increased interest in manual therapy, this study further shows how it can be an effective intervention when treating chronic pain. It has the potential to improve pain and psychological outcomes.
Paper Summary
Neck pain is a common problem that affects a large portion of the population, causing discomfort or distress. It has been suggested that manual therapy has a positive effect in reducing pain and improving psychological status. This study aimed to evaluate efficacy of manual therapy on reducing pain and improving psychological status in patients with neck pain. A randomized clinical trial with patients with chronic neck pain was done. Participants were randomly assigned to either the manual therapy group or the control group. The control group did not receive any form of manual therapy. Outcomes collected were pain intensity using a Visual Analog Scale (VAS) and psychological status using the Depression, Anxiety, and Stress Scale (DASS-21). Assessments were done before and after the interventions were implemented. The study found that manual therapy was effective in reducing pain and improving psychological outcomes. The manual therapy group had improvements in both pain intensity and psychological status compared to the control group. They had decrease in pain scores, levels of depression, anxiety and stress after the intervention. This further confirms that using manual therapy can be valuable when treating neck pain as it has the additional benefit for psychological well-being.
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 the growing evidence supporting the use of manual therapy for managing musculoskeletal pain, specifically neck pain. This study shows that treating both physical and psychological symptoms together can improve the patients’ overall outcomes. By this study using the Visual Analog Scale (VAS) and the Depression, Anxiety, and Stress Scale (DASS-21), it can be taken into consideration to make these outcome measures standardized for tracking of patient progress and ensure that the treatment and interventions being done are effective in addressing both pain and psychological outcomes. This study should encourage further research into combining physical therapy interventions with psychological treatments for chronic pain. A patient’s psychological status can have direct effect on their pain, so further research can be done as to how clinicians can address both psychological and physical outcomes together. Though the study has some positives, it did have a small group of participants and long-term effects of manual therapy were not evaluated. This requires further studies to be done to compare the short-term and long-term effects of manual therapy has on psychological variables in patients with neck pain.
Author Names: Adrian Kużdzał, Filipe Manuel Clemente, Sebastian Klich, Adam Kawczyński, Robert Trybulski
Reviewer Name: Devin Hage
Reviewer Affiliation(s): Duke University, Student of Physical Therapy
Paper Abstract:
This study aimed to compare the effects of manual therapy combined with dry needling (MTDN) to a control group, focusing on the impact on pressure pain threshold (PPT), muscle tone (MT), muscle stiffness (MS), muscle strength, and range of motion in the neck muscles of adult combat sports athletes. A randomized controlled study design was employed, with one group of athletes (n = 15) receiving MTDN intervention, while the other group (n = 15) underwent a control treatment (CG) involving a quasi-needle technique combined with manual therapy. Both groups participated in three sessions, either in the MTDN intervention or the control condition. All athletes, who were experiencing neck pain, were evaluated at rest, after one session, after three sessions, and again 72 hours after the third session. Muscle tone (MT) and muscle stiffness (MS) were measured using myotonometry, pressure pain threshold (PPT) was assessed with an algesiometer, muscle strength was evaluated using a handheld dynamometer, and range of motion was measured with an electronic goniometer. Group comparisons revealed significantly higher MT in CG compared to MTDN after the 3rd session (p < 0.001; d = 1.50). Additionally, CG showed significantly greater MS than MTDN after the 3rd session (p < 0.001; d = 1.75) and at 72 hours post-session (p < 0.001; d = 2.45). Conversely, MTDN exhibited significantly greater PPT than CG at 72 hours post-session (p < 0.001; d = 1.80). Our results suggest that MTDN is significantly more effective in improving muscle tone, stiffness, and acute pain compared to manual therapy alone. However, no significant impact was observed on maximal strength or neck range of motion. A combined approach may offer benefits by more rapidly reducing neck pain and better preparing muscle properties for future activities.
Quality Assessment of Controlled Intervention Studies
Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT:
Yes
Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes
Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
Were study participants and providers blinded to treatment group assignment?
No
Were the people assessing the outcomes blinded to the participants’ group assignments?
Not sure
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:
Manual therapy combined with dry needling (MTDN) was significantly more effective than manual therapy alone in reducing muscle tone, stiffness, and acute pain in combat sports athletes suffering from neck pain.
Key Finding #2
MTDN resulted in a significantly greater increase in the pressure pain threshold (PPT) at 72 hours post-treatment compared to the control group, indicating its effectiveness in short-term pain relief.
Key Finding #3
Despite improvements in muscle tone and stiffness, MTDN did not show a significant impact on maximal muscle strength or range of motion in lateral flexion and rotation of the neck.
Key Finding #4
The effects of MTDN on reducing muscle stiffness continued to improve up to 72 hours post-treatment, suggesting that the intervention provides longer-lasting benefits compared to manual therapy alone.
Please provide your summary of the paper
The study investigates the effects of combining manual therapy and dry needling (MTDN) on neck pain, muscle tone, stiffness, and recovery in combat sports athletes. Using a randomized controlled design, 30 athletes with acute neck pain were divided into two groups: one receiving MTDN (intervention group) and the other receiving manual therapy alone (control group). The athletes were assessed at rest, after one session, after three sessions, and 72 hours post-treatment using various biomechanical and pain measurement tools.
The results showed that MTDN was significantly more effective than manual therapy alone in reducing muscle tone, stiffness, and pain (pressure pain threshold, PPT). Improvements in muscle stiffness and pain relief persisted up to 72 hours post-treatment, indicating a sustained recovery effect. However, no significant improvements were found in maximal muscle strength or range of motion for either treatment.
The study suggests that MTDN may be a superior recovery method for combat sports athletes experiencing neck pain, though it may not enhance strength or flexibility. The findings highlight MTDN as a useful tool for short-term pain relief and muscle recovery, but further research is needed to determine its long-term 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 provides valuable insights for physical therapists treating individuals experiencing acute myofascial neck pain. The findings suggest that incorporating dry needling alongside manual therapy offers superior benefits compared to manual therapy alone, particularly in reducing muscle tone, stiffness, and pain (pressure pain threshold, PPT).
From a clinical perspective, this indicates that MTDN may be an effective intervention for short-term pain relief and recovery in individuals who experience acute bouts of muscle tightness and localized pain due to training or competition demands. The sustained reduction in muscle stiffness up to 72 hours post-treatment suggests that MTDN can facilitate faster recovery, potentially allowing athletes to return to training more quickly with reduced discomfort.
However, it is important to recognize the limitations of this approach. The study found no significant improvement in isometric strength or range of motion, meaning that MTDN should not be solely relied upon for improving functional strength or flexibility. Instead, it should be considered as a complementary treatment alongside targeted strength training, stretching, and mobility exercises.
For combat sports athletes with acute neck pain, MTDN can be used as part of a broader rehabilitation strategy. It is particularly useful for reducing pain and stiffness before high-intensity training or competition, but it should be supplemented with functional training to address strength and mobility deficits. Though the findings highlight MTDN as a useful tool for short-term pain relief and muscle recovery, further research is needed to determine its long-term benefits.
Author Names: Gauri Milind Ghan, V Sarath Babu
Reviewer Name: Christina Hernandez
Reviewer Affiliation(s): Duke DPT
Paper Abstract:
Introduction: Forward head posture is the most frequently observed postural deviations and is said to be associated with shortening of posterior cervical extensors and weakening of the anterior deep cervical flexors. Manual therapy has the potential to achieve reflexogenic changes in muscle and enhance the motor activity and strength.
Purpose of the study: To evaluate the immediate effect of grade IV cervicothoracic Maitland mobilization on deep neck flexors strength in individuals with forward head posture.
Study design: A Single-blinded randomized placebo-controlled trial.
Method: Sixty individuals were randomly divided into two groups. Placebo-controlled (PBO) group (n = 30) received the grade I and experimental (EXP) group (n = 30) received grade IV posteroanterior central and unilateral Maitland mobilization from the upper cervical to the upper thoracic spine. Outcome measure: Clinical Cranio-cervical flexion test (CCFT) was used to measure the motor activity and the strength of deep neck flexors.
Results: The strength of deep neck flexors effectively increased (p = <0.0001) after advocating grade IV mobilization.
Conclusion: This study concluded that grade IV central and unilateral posteroanterior Maitland mobilization demonstrated significant increase in the deep neck flexors strength in individuals with forward head posture.
Quality Assessment of Controlled Intervention Studies
Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
randomized controlled trial
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?
no
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)?
no
Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
yes
Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
yes
Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
no
Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
yes
Key Finding #1: Grade IV central and unilateral posteroanterior Maitland mobilization significantly increased deep neck flexor strength in individuals with FHP
Key Finding #2: In this study, the experimental group getting the grade IV mobilization intervention showed to benefit and gain strength in deep neck flexors compared to the placebo group receiving grade I mobilizations. (p<0.0001)
Key Finding #3: Many people that have a forward head posture have associated weakness in deep neck flexors and shortened posterior cervical muscles. This has shown to also lead to MSK disorders such as neck pain, headaches, and temporomandibular issues.
Key Finding #4: The Craniocervical Flexion Test outcome measure used a pressure biofeedback unity to assess muscle activation and performance index. This measure showed a measurable improvement post-mobilization in the experiment group.
Please provide your summary of the paper:
The authors of this study, analyze the effectiveness of the Grade IV Cervicothoracic Maitland mobilization to improve deep neck flexor strength in individuals with forward head posture (FHP). The study was a randomized controlled trial (RCT) involving 60 participants with FHP between the ages of 18-30 years old. The experimental group received Grade IV mobilization, while the placebo group received Grade I mobilization. The Grade IV Maitland mobilization was applied to C1-C3 aiming to reduce joint restrictions and increase deep neck flexor strength. After interventions, the Craniocervical Flexion Test (CCFT) was immediately assessed to measure the muscle activation and performance index after mobilization. Results showed that there was a significant improvement in deep neck flexor strength observed among the individuals receiving the experimental group, while there were no significant changes found in the placebo group. Researchers suggest that the improvements are due to an activation of mechanoreceptors and arthrokinetic reflexes that improved muscle activation. The mobilizations also likely reduced inhibitory effects from possible dysfunctional joints leading to improved muscle performance.
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 assessed the immediate effects of mobilizations, so it would be helpful to assess the long-term effects of the mobilizations, as well. Overall, the study provided helpful information to clinicians and the positive effects of Grade IV mobilizations on the upper cervical region in patients with forward head posture and reduced muscle performance, and supported that manual therapy mobilizations implemented into rehabilitation can address and improve posture-related imbalances.
Author Names
Romeo A, Vanti C, Boldrini V, Ruggeri M, Guccione AA, Pillastrini P, Bertozzi L
Reviewer Name
Michael Hils, SPT
Reviewer Affiliation(s)
Duke University
Paper Abstract
Abstract
Background
Cervical radiculopathy (CR) is a common cervical spine disorder. Cervical traction (CT) is a frequently recommended treatment for patients with CR.
Purpose
The purpose of this study was to conduct a review and meta-analysis of randomized controlled trials (RCTs) on the effect of CT combined with other physical therapy procedures versus physical therapy procedures alone on pain and disability.
Data Sources
Data were obtained from COCHRANE Controlled Trials Register, PubMed, CINAHL, Scopus, ISI Web of Science, and PEDro, from their inception to July 2016.
Study Selection
All RCTs on symptomatic adults with CR, without any restriction regarding publication time or language, were considered.
Data Extraction
Two reviewers selected the studies, conducted the quality assessment, and extracted the results. Meta-analysis employed a random-effects model. The evidence was assessed using GRADE criteria.
Data Synthesis
Five studies met the inclusion criteria. Mechanical traction had a significant effect on pain at short- and intermediate-terms (g = –0.85 [95% CI = –1.63 to –0.06] and g = –1.17 [95% CI = –2.25 to –0.10], respectively) and significant effects on disability at intermediate term (g = –1.05; 95% CI = –1.81 to –0.28). Manual traction had significant effects on pain at short- term (g = –0.85; 95% CI = –1.39 to –0.30).
Limitations
The most important limitation of the present work is the lack of homogeneity in CR diagnostic criteria among the included studies.
Conclusions
In light of these results, the current literature lends some support to the use of the mechanical and manual traction for CR in addition to other physical therapy procedures for pain reduction, but yielding lesser effects on function/disability.
Key Finding 1
Current literature somewhat supports that cervical traction (whether mechanical or manual), in combination with physical therapy procedures to treat cervical radiculopathy, significantly improves pain and may improve disability too, although less so than the improvement to pain.
Key Finding 2
Mechanical traction (combined with physical therapy procedures) provided significant improvement in pain both in the short-term (0-3 months) and mid-term (3-6 months) when compared to physical therapy procedures alone, based on moderate quality evidence.
Key Finding 3
Manual traction (combined with physical therapy procedures) provided significant improvements to disability in the mid-term (3-6 months) when compared to physical therapy procedures alone. Manual traction also brought about improvements in pain and disability in the short-term (0-3 months), but this was based on low quality evidence.
Key Finding 4
There is a lack of homogeneity in defining cervical radiculopathy amongst studies which examine cervical traction with physical therapy procedures as compared to physical therapy procedures alone.
Summary of Paper
In this systematic review and meta-analysis, the authors investigate cervical traction [CT] in conjunction with physical therapy as compared to physical therapy alone, particularly as it impacts pain and disability outcomes in patients with cervical radiculopathy [CR]. An original 22,027 articles were found using broad search criteria looking for radicular symptoms and/or upper extremity pain, in the neck or cervical spine, with discussion of traction, physical therapy, and/or manual therapy. These were narrowed through the elimination of duplicates, reading titles, reading abstracts, and finally ensuring that the remaining RCTs had collected data comparing CT with therapy to therapy alone in adult patients with CR. Moreover, the authors examined mechanical and manual CT separately, noting any differences, and assessed the quality of research in the included studies by using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and PEDro scale. Of the 5 studies that qualified, 4 looked at short-term outcomes (0-3 months) for pain and disability, and 2 looked at mid-term (3-6 months) and long-term (6-12 months) outcomes for pain and disability.
The authors found that mechanical traction provided significant improvement in pain both in the short-term and mid-term, based on moderate quality evidence. Improvements in pain and disability occurred with manual traction in the short-term, specifically immediately following the first treatment, but this was based on low quality evidence. However, manual traction provided significant improvements to disability in the mid-term. Overall, the authors found that pain was significantly reduced in the short-term and mid-term by both manual and mechanical traction when combined with other physical therapy interventions. This contradicts earlier studies (cited in the Discussion) which had used low-quality evidence to demonstrate that there is no difference in pain relief from placebo traction versus active traction. Notably the authors acknowledge that the greatest limitation in this meta-analysis and systemic review is the lack of a homogeneity in defining CR amongst the included studies. Overall, the authors conclude that current literature somewhat supports that cervical traction (whether mechanical or manual), in combination with usual physical therapy to treat CR, improves pain and may improve disability too, although less so than the improvement to pain. The authors also agree that more, high quality evidence is needed to further validate these possible advantages of CT as an adjunct to usual physical therapy treatment for patients with CR.
Please provide your clinical impression of this paper. Include how this study may impact clinical practice and how the results may be implemented.
The consideration for the quality of evidence, including the multi-faceted approach to the evaluation of quality, offers confidence in the conclusions of this meta-analysis and systematic review. The implementation of CT for patients with CR, particularly patients with higher pain scores and pain irritability, in combination with best physical therapy practices seems recommendable based on this review. Although, in general any patient with CR and associated pain may benefit from the short-term and mid-term pain relief that CT appears to offer. From a pragmatic standpoint, a couple of considerations are the time and labor required to perform this intervention. However, particularly in patients who have demonstrated and understanding and consistency in performing their home-exercise program [HEP], the pain relief and possible improvements to function for CR make this adjunct intervention worth consideration for in-session use.
Quality Assessment of Systematic Reviews and Meta-Analyses
1. Is the review based on a focused question that is adequately formulated
and described?
Yes
2. Were eligibility criteria for included and excluded studies predefined and
specified?
Yes
3. Did the literature search strategy use a comprehensive, systematic
approach?
Yes
4. Were titles, abstracts, and full-text articles dually and independently
reviewed for inclusion and exclusion to minimize bias?
Yes
5. Was the quality of each included study rated independently by two or more
reviewers using a standard method to appraise its internal validity?
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.)
Yes
Author Names
Przemysław T Wielemborek, Katarzyna Kapica-Topczewska, Marek Bielecki, Rafał Kułakowski, Dagmara Mirowska-Guzel, Jan Kochanowicz, Alina Kułakowska
Reviewer Name
Riley Hobson, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Purpose: The objective of this study was to assess the efficacy of manual therapy, specifically using the Maitland concept, in treating carpal tunnel syndrome (CTS), and to compare its effectiveness with surgical decompression of the median nerve. Methods: A total of 69 patients were enrolled and divided into two groups: a control group (undergoing surgery) and treatment group (receiving manual therapy). Subgroups were formed based on gender, considering factors such as grip strength. Inclusion criteria comprised active symptoms of CTS and electrophysiological evidence of nerve lesion. Exclusion criteria included diabetes, thyroid diseases, trauma to the upper limb, and pregnancy. Baseline and 10-12 month post-intervention assessments encompassed EQ-5D-5L, CTS6, DASH, grip strength and electrophysiological studies. The treatment group (43 patients) underwent five weekly manual therapy sessions. A physiotherapist individually assessed and treated patients, emphasizing passive techniques and prescribing home self-neuromobilization. The control group (26 patients) underwent carpal tunnel release surgery. Results: Both surgical and manual therapy interventions significantly reduced symptom severity (p < 0.001). Manual therapy improved hand function in females (p < 0.001) and showed positive trends in the control group. The treatment group demonstrated higher grip strength, with significant improvements in females (p < 0.001). Quality of life also improved in females (p < 0.001). No significant differences in distal motor latency through sensory latency showed positive trends in females. Conclusions: This research offers a comprehensive understanding of the effectiveness of manual therapy and surgical release in treating CTS. The findings suggest that both interventions can result in improvements in grip strength and quality of life with variations based on gender and specific outcome measures. Keywords: Maitland therapy; carpal tunnel syndrome; manual therapy; open carpal tunnel release.
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 assignments?
No
Were the people assessing the outcomes blinded to the participant’s group assignments?
No
Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, comorbid conditions)?
No
Was the overall dropout rate from the study at endpoint 20% or lower of the number allocated to treatment?
NR
Was the differential dropout rate (between treatment groups) at the endpoint 15 percentage points or lower?
NR
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?
No
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
Surgical release and manual therapy interventions were both effective in reducing symptom severity, and improving grip strength and quality of life in individuals with CTS.
Key Finding #2
Variations exist in the effectiveness of both surgical release and manual therapy based on gender.
Please provide your summary of the paper
Carpal tunnel syndrome (CTS) is a condition affecting the median nerve, often associated with repetitive hand and wrist movements. Symptoms include pain, numbness and tingling in the hand, and difficulty moving the wrist, hand, and fingers. Thus, this condition can have a significant impact on quality of life and ability to perform activities of daily living. CTS can be treated surgically by performing a median nerve decompression, or more conservatively with physical therapy. Physical therapy intervention includes lifestyle modification, range of motion and stretching, and strengthening surrounding structures. Manual therapy may also be used to decrease pain and increase function of the affected extremity. This study compared surgery and manual therapy interventions on the following outcomes: EQ-5D-5L (quality of life), CTS6 (symptom severity), DASH (patient reported measure of upper limb function), hand grip dynamometry, and median nerve electrophysiological study. Both groups were assessed on these outcomes at baseline and 10–12 months post-intervention. The surgery group underwent a carpal tunnel release, and the manual therapy group received treatments 1x/week for 5 weeks which utilized the Maitland concept. Both groups demonstrated significant improvements in symptom severity, grip strength, and quality of life. A limitation to this study is there were significantly more female participants than males which may skew results as females experienced greater improvements than the males.
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 suggests that both carpal tunnel release and manual therapy using the Maitland method are effective at reducing symptom severity, and improving quality of life and grip strength in patients with carpal tunnel syndrome. Manual therapy as a conservative treatment for CTS may be more cost effective and less invasive. Recommendation is to use manual therapy intervention to treat CTS initially, then consider surgical interventions if adequate results have not been achieved. It is also important to include other physical therapy interventions for the management of this condition, and consider lifestyle modifications for optimal patient outcomes.
Author Names
Madiha Saddique, Mazhar Ali Bhutto, Saman Jahangir, Ayesha Sadiq, Muhammad Saad Shafiq, Ibraheem Zafar, Ramsha Masood, Muhammad Waqas Malik
Reviewer Name
Evonne Iau, SPT
Reviewer Affiliation(s)
Duke University Department of Physical Therapy
Paper Abstract
BACKGROUND: Hypomobility of the cervicothoracic (CT) junction has been suggested neck discomfort as one of its causes. There are, however, few trials that have contrasted the impact of CT junction mobilisation against a successful neck pain intervention. The treatment of distant spinal segments using thoracic spine manipulation is non-specific and is founded on the notion of interregional reliance. Recent studies have examined the usefulness of segment-specific spinal mobilisation in the cervical spine, although no firm findings could be drawn from earlier research. The aforementioned factors call for research intothe effectiveness of a particular CT junction mobilisation vs a general thoracic manipulation intervention in neck discomfort.
MATERIAL AND METHODS: Participants in a randomised clinical trial with mechanical neck soreness and Cervicothoracic junction dysfunction were randomly assigned to the mid-thoracic (T3-T6) manipulation group or the C7-T1 stage Maitland mobilisation
group. The results of the cervical flexion, extension, facet flexion, and rotation degrees of movement (ROM) before and after the intervention have been measured the use of a cervical range of motion (CROM) device. The severity of self-stated ache become
measured using the numerical pain score scale (NPRS). After the intervention, a one-way ANCOVA was used to evaluate the outcomes.
RESULTS: For the study, 48 individuals have been enrolled, with a median age of 36.Forty eight±12.Forty eight for the thoracic manipulation organization and 34.25± 12.24 for the CT junction organization. After treatment, there were no discernible differences in cervical variety of movement (ROM) or self-said ache depth among thegroups (p-value = 0.07, 0.96, 003, 0.40, 0.30, 0.31 for flexion, extension, bilateral side bending, and rotation, respectively), nor in neck pain depth (p = 0.67). The cervical ROM and pain, however, extensively stepped forward in both businesses whilst in comparison within-institution, pre- and post.
CONCLUSION: This preliminary investigation showed that thoracic manipulation had the same effects on the outcomes of cervical range of motion and neck discomfort as level-specific Cervicothoracic mobilisation in patients with non-specific neck pain when it was compared to remote mid-thoracic manipulation.
KEYWORDS: Cervicothoracic Mobilization, Thoracic manipulation, Non-specific neck pain, ROM, 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?
No
Were the people assessing the outcomes blinded to the participants’ group assignments?
No
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?
CD, NR, NA
Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
CD, NR, NA
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
Neck pain patients did not respond better to thoracic manipulation following a single CT junction mobilization treatment.
Key Finding #2
Treating remote thoracic segments may not be more helpful than segment-specific mobilizations for patients with mechanical neck discomfort.
Key Finding #3
Previous studies did not find a distinction between segment-specific and standard mobilizations in the cervical spine.
Key Finding #4
Conclusions about the necessity of segment-specific mobilizations in the cervical spine cannot be concluded.
Please provide your summary of the paper
This study looks at the effect of thoracic manipulations compared to cervicothoracic manipulations on nonspecific, mechanical neck pain. Participants between 18-60 years old with mechanical neck soreness and cervicothoracic junction (CTJ) dysfunction were randomly assigned to a mid-thoracic treatment group (T3-T6) or CTJ mobilization group. The study lasted for six months; however, each participant only received the manipulation once. A cervical ROM device and the numerical pain score scale was used to measure outcomes. There was no difference between groups. Thoracic manipulation had the same effects on the outcomes of cervical range of motion and neck discomfort as level-specific CTJ mobilisation in patients with non-specific neck pain.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
For practicing clinicians, the results of this paper indicate that it may not be necessary to target a specific level on the cervicothoracic spine for a patient with nonspecific, mechanical neck pain. The study suggests that there is no difference between a mid-thoracic manipulation or a CTJ manipulation for treating mechanical neck pain.
Author Names: Castien, R. F., van der Windt, D. A., Grooten, A., & Dekker, J.
Reviewer Name: Madison Irick
Reviewer Affiliation(s): Duke University Doctor of Physical Therapy Division ‘26
Abstract:
Objective: To evaluate the effectiveness of manual therapy (MT) in participants with chronic tension-type
headache (CTTH).
Subjects and Methods: We conducted a multicentre, pragmatic, randomised, clinical trial with partly blinded outcome assessment. Eighty-two participants with CTTH were randomly assigned to MT or to usual care by the general practitioner (GP). Primary outcome measures were frequency of headache and use of medication. Secondary outcome measures were severity of headache, disability and cervical function.
Results: After 8 weeks (n = 80) and 26 weeks (n = 75), a significantly larger reduction of headache frequency was found for the MT group (mean difference at 8 weeks, −6.4 days; 95% CI −8.3 to −4.5; effect size, 1.6). Disability and cervical function showed significant differences in favour of the MT group at 8 weeks but were not significantly different at 26 weeks.
Conclusions: Manual therapy is more effective than usual GP care in the short- and longer term in reducing symptoms of CTTH. Dutch Trial Registration no. TR 1074.
NIH Risk of Bias Tool:
Quality Assessment of Controlled Intervention Studies
1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or
an RCT?
Yes, the study was a randomized clinical trial.
2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes, participants were either assigned to manual therapy (MT) or usual care (UC) groups.
Allocation was carried out by an independent administrative assistant.
3. Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes, the treatment allocation was concealed using numbered and sealed envelopes and was
opened in the presence of the independent administrative assistant.
4. Were study participants and providers blinded to treatment group assignment?
No, the study was unblinded since the participants and providers knew their treatment group
assignments.
5. Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes, some outcomes were assessed by a blinded research assistant, particularly for the secondary
outcomes.
6. Were the groups similar at baseline on important characteristics that could affect outcomes
(e.g., demographics, risk factors, co-morbid conditions)?
Yes, baseline characteristics of both groups were similar.
7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number
allocated to treatment?
Yes, the total drop-out rate was 8.5% (7/82 participants).
8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage
points or lower?
Yes, the drop-out rates between the treatment groups were similar (MT: 7.3%, UC: 9.8%).
9. Was there high adherence to the intervention protocols for each treatment group?
Yes, the MT group received an average of 6.6 treatments (range: 4-9 sessions), demonstrating
good adherence.
10. Were other interventions avoided or similar in the groups (e.g., similar background
treatments)?
No, some participants in the UC group received additional therapy, including physiotherapy and
acupuncture.
11. Were outcomes assessed using valid and reliable measures, implemented consistently across
all study participants?
Yes, the study used valid and reliable measures such as the Headache Disability Inventory (HDI),
Headache Impact Test-6 (HIT-6), and numerical pain rating scales.
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, the study aimed for 80% power to detect a difference of ≥3 headache days between groups,
with an estimated sample size of 35 per group (accounting for 15% dropout).
13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses
were conducted)?
Yes, the study protocol was pre-registered (Dutch Trial Register no. TR 1074), and subgroup
analyses (e.g., CTTH with/without migraine) were planned.
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?
Yes, researchers utilized an intention-to-treat analysis.
Key Findings of Study:
1. Manual therapy significantly led to a reduction in headache frequency.
2. Manual therapy led to greater reductions in headache intensity and disability as measured by the Headache Impact Test-6 (HIT-6) and Headache Disability Inventory (HDI).
3. Manual therapy decreased the need for additional healthcare services and sick leave.
4. Manual therapy led to significant improvements in cervical range of motion, neck muscle endurance, and pain pressure threshold, however, the effects were not sustainable over time.
Reviewer Summary:
The study demonstrated that manual therapy (MT) may serve as an effective intervention for Chronic Tension-Type Headaches (CTTH), leading to significant reductions in headache frequency, intensity, and disability compared to usual care (UC). However, some limitations exist. While outcome assessors were partially blinded, participants and treatment providers were aware of their assignments, introducing potential bias. The utilization of self-reported headache diaries may have led to recall bias or reporting inaccuracies. Although MT improved cervical function, its effects decreased at 26 weeks, likely due to UC participants seeking additional treatments such as physiotherapy and acupuncture. Additionally, the study’s moderate sample size (82 participants) limits generalizability, demonstrating the need for larger, more diverse trials to ensure reliability and reproducibility. In clinical practice, MT appears to be a promising alternative or adjunct to UC for CTTH, especially for patients who are unresponsive to conventional care. Early implementation of MT may reduce the need for additional healthcare services, which could be cost-effective for patients. Based on the results, physical therapists can educate patients on MT’s benefits, physicians may refer CTTH patients for MT as a nonpharmacological treatment, and healthcare systems could establish clinical guidelines promoting earlier MT intervention for CTTH treatment.
Author Names
Robert Boyles, Patrick Toy, James Mellon, Margaret Hayes, Bradley Hammer
Reviewer Name
Cheng Hua Jiang
Reviewer Affiliation(s)
Duke DPT
Paper Abstract
Study design: Systematic review of randomized clinical trials.
Objective: Review of current literature regarding the effectiveness of manual therapy in the treatment of cervical radiculopathy.
Background: Cervical radiculopathy (CR) is a clinical condition frequently encountered in the physical therapy clinic. Cervical radiculopathy is a result of space occupying lesions in the cervical spine: either cervical disc herniations, spondylosis, or osteophytosis. These affect the pain generators of bony and ligamentous tissues, producing radicular symptoms (i.e. pain, numbness, weakness, paresthesia) observed in the upper extremity of patients with cervical nerve root pathology. Cervical radiculopathy has a reported annual incidence of 83·2 per 100 000 and an increased prevalence in the fifth decade of life among the general population.
Results: Medline and CINAHL via EBSCO, Cochrane Library, and Google Scholar were used to retrieve the randomized clinical trial studies for this review between the years of 1995 and February of 2011. Four studies met inclusion criteria and were considered to be high quality (PEDro scores of ⩾5). Manual therapy techniques included muscle energy techniques, non-thrust/thrust manipulation/mobilization of the cervical and/or thoracic spine, soft-tissue mobilization, and neural mobilization. In each study, manual therapy was either a stand-alone intervention or part of a multimodal approach which included therapeutic exercise and often some form of cervical traction. Although no clear cause and effect relationship can be established between improvement in radicular symptoms and manual therapy, results are generally promising.
Conclusion: Although a definitive treatment progression for treating CR has not been developed a general consensus exists within the literature that using manual therapy techniques in conjunction with therapeutic exercise is effective in regard to increasing function, as well as AROM, while decreasing levels of pain and disability. High quality RCTs featuring control groups are necessary to establish clear and effective protocols in the treatment of CR.
Quality Assessment of Systematic Reviews and Meta-Analyses
Is the review based on a focused question that is adequately formulated and described?
Yes
Were eligibility criteria for included and excluded studies predefined and specified?
Yes
Did the literature search strategy use a comprehensive, systematic approach?
Yes
Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
Yes
Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
Yes
Were the included studies listed along with important characteristics and results of each study?
Yes
Was publication bias assessed?
Yes
Was heterogeneity assessed? (This question applies only to meta-analyses.)
Yes
Key Finding #1
Manual therapy techniques in conjunction with exercise have been found to be effective in managing pain related to cervical radiculopathy.
Key Finding #2
Clear protocols for treating cervical radiculopathy are difficult to develop as more studies are needed.
Please provide your summary of the paper
This systematic review took a look at four different papers using manual therapy techniques to treat cervical radiculopathy. Techniques included soft tissue mobilization, neural mobilization, and thrust/non-thrust techniques. Unfortunately, no clear relationship could be drawn between manual techniques and radicular pain, but results indicate potential benefits that need further investigation.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
One of the limitations of this paper is that the papers reviewed did not specify the exact technique used to treat radicular pain. This makes it difficult to quantify what intervention truly has an effect on reducing radicular pain. However, the papers evaluated suggest that manual therapy with the addition of exercise has promising data to aid in the management of radicular pain. With more data, protocols for cervical radiculopathy can be created, which easily allows clinicians to implement them as long as new findings are made available.
