Author Names
Corso, M., Mior, S., Batley, S., Tuff, T., da Silva-Oolup, S., Howitt, S., Srbely, J.
Reviewer Name
Jordan Keeley, MA, SPT
Reviewer Affiliation(s)
Duke University School of Medicine – Doctor of Physical Therapy Division
Paper Abstract
Introduction: The effectiveness of spinal manipulative therapy (SMT) for improving athletic performance in healthy athletes is unclear. Assessing the effect of SMT on other performance outcomes in asymptomatic populations may provide insight into the management of athletes where direct evidence may not be available. Our objective was to systematically review the literature on the effect of SMT on performance-related outcomes in asymptomatic adults.
Methods: MEDLINE, CINAHL, SPORTDiscus, and Cochrane Central Register of Controlled Trials were systematically searched from 1990 to March 23, 2018. Inclusion criteria was any study examining a performance-related outcome of SMT in asymptomatic adults. Methodological quality was assessed using the SIGN criteria. Studies with a low risk of bias were considered scientifically admissible for a best evidence synthesis. We calculated the between group mean change and 95% confidence intervals.
Results: Of 1415 articles screened, 20 studies had low risk of bias, seven were randomized crossover trials, 10 were randomized controlled trials (RCT) and three were RCT pilot trials. Four studies showed SMT had no effect on physiological parameters at rest or during exercise. There was no effect of SMT on scapular kinematics or transversus abdominus thickness. Three studies identified changes in muscle activation of the upper or lower limb, compared to two that did not. Five studies showed changes in range of motion (ROM). One study showed an increase lumbar proprioception and two identified changes in baropodometric variables after SMT. Sport-specific studies show no effect of SMT except for a small increase in basketball free-throw accuracy.
Conclusion: The preponderance of evidence suggests that SMT in comparison to sham or other interventions does not enhance performance-based outcomes in asymptomatic adult population. All studies are exploratory with immediate effects. In the few studies suggesting a positive immediate effect, the importance of such change is uncertain. Further high-quality performance specific studies are required to confirm these preliminary findings.
NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
1. Is the review based on a focused question that is adequately formulated and described?
Yes
2. Were eligibility criteria for included and excluded studies predefined and specified?
Yes
3. Did the literature search strategy use a comprehensive, systematic approach?
Yes
4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
Yes
5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
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.)
Cannot Determine, Not Reported, Not Applicable
Key Finding #1
Spinal manipulative therapy does not significantly impact performance-based outcomes when compared to other interventions in asymptomatic adults.
Key Finding #2
Bilateral cervicothoracic manipulative therapy significantly increased cervical range of motion compared to upper trapezius stretching.
Key Finding #3
Thoracic spinal manipulative therapy did not have significant immediate effects on scapular kinematics or scapulohumeral rhythm.
Key Finding #4
Studies found no adverse events other than a slight increase in pain after the intervention with any protocols including spinal manipulative therapy.
Please provide your summary of the paper
The purpose of this paper was to synthesize the current literature on the effect of spinal manipulative therapy on performance-related outcomes. Four databases were searched for randomized controlled trials, randomized crossover trials, and randomized controlled pilot trials that compared spinal manipulative therapy to other interventions or no intervention. Studies included in the review examined performance-related outcomes in asymptomatic adults and had a low risk of bias. Of the 1415 articles identified, 20 studies were selected and included in the review. In the studies, the effect of spinal manipulative therapy on muscle force, physiological outcomes, range of motion, gait parameters, biomechanical outcomes, performance-based outcomes, and adverse events were examined. It was identified that there were no significant effects from the respective manipulations on resting heart rate, heart rate variability, rate of perceived exertion, gait parameters, scapular kinematics, transverse abdominis thickness, or sports-specific parameters. In the studies, manipulations did improve muscle function of the plantar flexors for 30 minutes, lateral flexion bilaterally when conducted on the thoracic spine, and cervical ROM when conducted on the cervical spine. Additionally, several studies identified no adverse event associated with manipulations except for a slight potential increase in pain.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
The systematic review highlights the need for further research of the effects of spinal manipulative therapy on various performance outcome measures in asymptomatic adults. There is minimal evidence available to compare the outcome measures assessed in the aforementioned studies, making it hard to pull conclusive ideas from the research. Although several outcome variables were included in the systematic review, few studies examined the same ideas, thus making it difficult to establish overarching patterns from the results. It was concluded that there was no significant improvement of performance-based outcomes when employing spinal manipulative therapy in asymptomatic adults. However, the paper did identify several variables that were and were not impacted by manipulative treatments. As a physical therapist, understanding these variables can better help decipher optimal conditions for utilizing spinal manipulation on patients. Even though these manipulations may not have an impact on performance outcome measures in asymptomatic adults, the studies still noted benefits of utilizing this treatment. Using the ideas presented in this paper in conjunction with clinical reasoning, a clinician can make more informed decisions regarding the reactive or preventative care of patients, whether that includes spinal manipulations or not.
Author Names: John Krauss,Doug Creighton,Jonathan D. Ely &Joanna Podlewska-Ely
Reviewer Name: Patrick Kunkel
Reviewer Affiliation(s): Duke DPT
Paper Abstract:
This study examined the effect of translatoric spinal manipulation (TSM) on cervical pain and cervical active motion restriction when applied to upper thoracic (T1-T4) segments. Active cervical rotation range of motion was measured re- and post-intervention with a cervical inclinometer (CROM), and cervical pain status was monitored before and after manipulation with a Faces Pain Scale. Study participants included a sample of convenience that included 32 patients referred to physical therapy with complaints of pain in the mid-cervical region and restricted active cervical rotation. Twenty-two patients were randomly assigned to the experimental group and ten were assigned to the control group. Pre- and post-intervention cervical range of motion and pain scale measurements were taken by a physical therapist assistant who was blinded to group assignment. The experimental group received TSM to hypomobile upper thoracic segments. The control group received no intervention. Paired t-tests were used to analyze within-group changes in cervical rotation and pain, and a 2-way repeated-measure ANOVA was used to analyze between-group differences in cervical rotation and pain. Significance was accepted at p=0.05. Significant changes that exceeded the MDC95 were detected for cervical rotation both within group and between groups with the TSM group demonstrating increased mean (SD) in right rotation of 8.23° (7.41°) and le rotation of 7.09° (5.83°). Pain levels perceived during post-intervention cervical rotation showed significant improvement during right rotation for patients experiencing pain during bilateral rotation only (p=.05). This study supports the hypothesis that spinal manipulation applied to the upper thoracic spine (T1-T4 motion segments) significantly increases cervical rotation ROM and may reduce cervical pain at end range rotation for patients experiencing pain during bilateral cervical rotation.
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?
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? Stated that sample size was “limited in number, age, range, and gender”
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: High-velocity manipulation of the thoracic spine may increase
cervical spine rotation.
Key Finding #2: Treatment of the thoracic spine may improve the movement available in the cervical spine during rotation, but it may not necessarily reduce the reactivity of the cervical source of neck symptoms
Key Finding #3: There was a statistically significant improvement during right rotation for experiencing symptoms during bilateral rotation only
Please provide your summary of the paper
This randomized control trial sought to further explore the hypothesis that providing upper thoracic manipulation could aid in the treatment of cervical related pain and dysfunction. The ideology of treating thoracic deficits for the aid in relieving cervical symptoms can be found in numerous orthopedic manual physical therapy strategies, but this study aimed to evaluate the response of high velocity manipulations in the upper thoracic spine for treatment. Patient were admitted to three clinics with complaints of non-traumatic mid-cervical pain with insidious onset that was aggravated with cervical rotation. Physical therapists performed translatoric facet joint traction manipulation to the upper thoracic intervertebral segments of patients in the experimental group and the control group received no intervention to minimize nonspecific effects of sham treatment and remained seated on the treatment table for approximately the amount of time. Researchers found that 12 of the 22 subjects in the experimental group had increased cervical range of motion between 10-30 degrees. Further, patients has a statistically significant improvement in in pain levels during right rotation. This finding does support previous findings that treatment of the upper thoracic segments using translatoric spinal manipulation can have benefits toward treating cervical pain.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Although this study was limited in sample size, it does reinforce the notion that high-velocity manipulation of the thoracic spine can have benefits seen in the cervical spine. Many patients that had thoracic manipulation done saw an increase in cervical rotation range of motion as well as pain reduction. In my opinion the impact of this research will further reinforce treatment of cervical spine by addressing the thoracic spine through manipulation which has been suggested in numerous orthopedic manuals for treatment.
Author Names
N Nilsson, H W Christensen, J Hartvigsen
Reviewer Name
Emma Kurtz, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Purpose: To study whether the isolated intervention of high-speed, low-amplitude spinal manipulation in the cervical spine has any effect on cervicogenic headache.
Design: Prospective randomized controlled trial with a blinded observer.
Setting: Ambulatory outpatient facility in an independent research institution.
Participants: Fifty-three subjects suffering from frequent headaches who fulfilled the International Headache Society criteria for cervicogenic headache (excluding radiological criteria). These subjects were recruited from 450 headache sufferers who responded to newspaper advertisements.
Intervention: After randomization, 28 of the group received high-velocity, low-amplitude cervical manipulation twice a week for 3 wk. The remaining 25 received low-level laser in the upper cervical region and deep friction massage (including trigger points) in the lower cervical/upper thoracic region, also twice a week for 3 wk.
Main outcome measures: The change from week 1 to week 5 in analgesic use per day, in headache intensity per episode and in number of headache hours per day, as registered in a headache diary.
Results: The use of analgesics decreased by 36% in the manipulation group, but was unchanged in the soft-tissue group; this difference was statistically significant (p = .04, chi 2 for trend). The number of headache hours per day decreased by 69% in the manipulation group, compared with 37% in the soft-tissue group; this was significant at p = .03 (Mann-Whitney). Finally, headache intensity per episode decreased by 36% in the manipulation group, compared with 17% in the soft-tissue group; this was significant at p = .04 (Mann-Whitney).
Conclusion: Spinal manipulation has a significant positive effect in cases of cervicogenic headache.
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)?
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
There were noted improvements in number of headaches hours a day, headache intensity, and use of analgesics in individuals in the group receiving the manipulation.
Key Finding #2
Participants in the soft tissue group had noted improvements in number of headache hours a day.
Please provide your summary of the paper
The purpose of this study was to determine the effectiveness of spinal manipulation, specifically in the cervical region, in treating cervicogenic headaches, specifically when compared to soft tissue massage with laser light treatment. Treatment was assessed on number of headaches per day, headache intensity, and use of analgesics. Participants in the manipulation group received high-velocity thrusts to their upper, mid, and lower cervical regions. While participants in the soft tissue group did have reductions in the number of headache hours per day, participants in the manipulation group had decreases in all three variables.
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 demonstrates the effectiveness of spinal manipulations in managing symptoms of cervicogenic headaches. While soft tissue massage with light therapy was beneficial in reducing the amount of time patients experienced headaches each day, spinal manipulation provided relief in headache time, headache intensity, and use of analgesics. However, given that soft tissue massage did demonstrate some effectiveness in mitigating symptoms, a well-rounded approach may include the techniques of both soft tissue massage and spinal manipulation to provide patients experiencing cervicogenic headaches the most relief.
Author Names: Rana Alaa H. Youssef1, Nesreen Gharib El-Nahas2, Samir A. F. Elgazaar1,3, Alaa Mohamed EL Moatasem2
Reviewer Name: Victoria Leary
Reviewer Affiliation(s): Duke University DPT Student
Paper Abstract: SUMMARY
Background. Kyphosis is a prevalent condition in older women that can significantly impact their mobility. Various therapeutic approaches and modalities can be used to treat hyperkyphosis. Cervicothoracic fascia stretching reduces kyphotic angle, decreases cervical pain, and improves various dimensions of thoracic mobility.
Purpose of the study. The aim of this study is to evaluate the effect of the cervicothoracic fascia stretch on the thoracic mobility of older women.
Subjects and methods. Sixty older women with non-specific neck discomfort, whose ages ranged from 60 to 70, were recruited from the outpatient clinics at Heliopolis University. The recruited patients were randomly divided into two groups of equal numbers of subjects: Group A included 30 patients who underwent cervicothoracic fascia stretching, and 30 patients were included in Group B who underwent diaphragmatic breathing exercises three times a week for four weeks. The neck pain was assessed utilizing the Neck Pain and Disability Scale (NPAD), while thoracic kyphosis was assessed utilizing a flexion curve ruler. Moreover, thoracic circumference excursion was measured using tape, while transverse and latero-lateral dimensions of the thorax were assessed using a chest depth caliper.
Results. The comparison between pre- and post-study results showed a significant enhancement in all measured variables, including neck pain, thoracic circumference, chest width dimension, chest depth dimension, and kyphotic angle in both groups. Our findings indicated a statistically significant decrease in neck pain and kyphotic angle. Conversely, there was a statistically significant increase in thoracic circumference and chest width dimension for the cervicothoracic stretch group after treatment.
Conclusions. Both interventions, such as intrathoracic fascia stretch and diaphragmatic breathing exercises exhibited extraordinary effectiveness in the management of reduced thoracic mobility and neck pain in older women with better results in favor of cervicothoracic stretch. KEY WORDS Cervicothoracic fascia; elderly; chest dimensions; thoracic mobility; fascia properties.
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)?
NO / NOT APPLICABLE
Were study participants and providers blinded to treatment group assignment?
UNSURE
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?
UNDETERMINED
Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
UNDETERMINED
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)?
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:
There was a significant increase in thoracic circumference excursion, chest depth and width post treatment in both groups compared to pre-treatment.
Key Finding #2:
Both groups demonstrated statistically significant reduction in NPAD (Neck Pain and Disability Scale) and kyphotic angle following intervention.
Key Finding #3:
Patients in the group with intra-thoracic stretch technique demonstrated slightly better results compared to group B patients who performed diaphragmatic breathing.
Please provide your summary of the paper
In this study, the efficacy of cervicothoracic fascia stretching was compared to the efficacy of diaphragmatic breathing in thoracic mobility of elderly women. The main outcome measures that were assessed included: chest depth Caliper, flexion curve ruler, neck pain disability scale and measurements of chest width and depth dimension, kyphosis curve, chest excursion and pain levels. Patients in group A received the cervicothoracic fascia stretch; the technique was used for the central and two lateral fascia chains. For all fascia chains, patients received some level of traction and performed deep breathing. Specifically with the lateral fascia chains, patients’ heads were positioned opposite of the lateral fascia and ipsilateral bending and rotation. Patients in group B were positioned in seated and were instructed through diaphragmatic breathing. Patients in both groups received treatment three times a week for four weeks. This study found that both groups demonstrated statistically significant reduction in NPAD (Neck Pain and Disability Scale) and kyphotic angle following intervention. Additionally, the incorporation of intrathoracic fascia stretching can help address thoracic mobility restriction, chest expansion and thoracic kyphotic angle in elderly female patients; the implementation of these techniques as a therapeutic option may be considered a safe and effective approach.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study shows that both diaphragmatic breathing and cervicothoracic fascia stretching can be beneficial in improving thoracic mobility in elderly women. Clinically, this can particularly be useful in helping patients who might be highly irritable in their pain in regards to limited thoracic mobility; they can incorporate diaphragmatic breathing into their sessions to help with mobility. Additionally, as the cervicothoracic fascia stretch technique incorporated aspects of traction, it can be something that can be helpful in treating patients’ limited mobility and pain.
Author Names
Samer Zehra, Muhammad Sarfraz, Hafsa Chandio, Iqra Waseem, Ayesha Naeem, Amjed Ali
Reviewer Name
Victoria Leary
Reviewer Affiliation(s)
Duke University Doctorate of Physical Therapy Program
Paper Abstract
B a c k g r o u n d : Non-specific neck pain is the type of neck pain which has no pathognomonic signs and symptoms or has no underlying condition. It is estimated that 70% of the population may suffer from non-specific neck pain at some point in their life.
O b j e c t i v e : To find out the effects of thoracic mobilization versus sling-based thoracic active exercises on pain, function and quality of life in patients with non-specific neck pain.
M e t h o d s : This randomized trial was conducted at the Physiotherapy Department of the University of Lahore Teaching Hospital. Participants aged 20 to 45 years, diagnosed patients of non-specific neck pain were included in the study. Patients with any neurological disease, previous surgical history, pregnancy, or cardiac disease were excluded. Group A performed cervical manual therapy for and sling-based active thoracic exercises. While Group B performed cervical manual therapy and thoracic mobilization. A numeric pain rating scale, neck disability index and short form-36 questionnaire were used to measure pain, function and quality of life respectively. Mann-Whitney U and Friedman tests were applied to identify within-group differences in both groups.
R e s u l t s : The mean rank for pain score in group A at the baseline was 31.42 and in group B 21.58 with a Z value of -2.437 and a p-value is 0.015. At the end of the treatment 4th week, the mean rank for pain in group A was 16.65 and in group B 36.35 with a Z-value of -4.851 and a p-value is 0.00. The mean rank for neck disability index score in group A at the baseline was 27.94 and in group B 25.06 with a Z-value of -1.158 and p-value is 0.247. At the end of the treatment 4th week, the mean rank for disability score in-group A was 22.5 and in-group B 30.5 with a Z-value of -3.045 and a p-value is 0.02. C o n c l u s i o n : Both groups showed significant improvements but Group A had more pronounced effects. Thoracic mobilization provides faster short-term relief but the active nature of sling-based exercises offers more sustainable benefits in long-term management of pain and patient wellbeing.
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)?
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?
Unsure
Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Unsure
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 – not reported
Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Unsure/unclear
Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Unsure/unclear
Key Finding #1
Group A (Group A performed cervical manual therapy for 20 minutes and sling-based active thoracic exercise for 20 minutes a day, 3 times a week, for 4 weeks) shows more significant improvements, in the week 4 treatment, functional abilities compared to Group B (Group B performed cervical manual therapy for 20 minutes and thoracic mobilization for the same duration).
Key Finding #2
Descriptive statistics of NPRS and NDI show that both groups experience a reduction in pain, measured by NPRS, from baseline treatment to week 2 and week 4 treatment.
Key Finding #3
Both groups demonstrate positive trends, but Group A shows more pronounced improvements in key variables and more significant improvements, in the week 2 and week 4 treatment
Please provide your summary of the paper
In this paper, researchers compared the effects of thoracic mobilization and sling based thoracic active exercises on patients who reported non-specific neck pain. The participants were divided into two groups – group A having had cervical manual therapy and sling based active thoracic exercises, each being performed for 20 min; group B having had cervical manual therapy and thoracic mobilizations, each being performed for 20 min as well. The study looked to determine outcomes relating to pain relief, functional improvements, and quality of life. Both intervention groups were effective in alleviating pain and improving function and QOL, but group A’s results yielded slightly more significant and sustainable benefits compared to group B’s.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Given group A’s slightly better outcomes, these interventions of cervical manual therapy with active sling based thoracic exercises can be utilized in clinic to help patients with non-specific neck pain. Additionally, while results weren’t as high, cervical manual therapy and thoracic mobilizations can also be used to help alleviate pain and improve function.
Authors Name: González-Iglesias, J., Fernández-de-las-Peñas, C., Cleland, J. A., & del Rosario Gutiérrez-Vega, M. (2009). Thoracic Spine Manipulation for the Management of Patients With Neck Pain: A Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy, 39(1), 20–27. https://doi.org/10.2519/jospt.2009.2914
Reviewer Name: Shelby Matheson, SPT
Reviewer Affiliations: Duke University School of Medicine, Doctor of Physical Therapy Division
Abstract:
Objectives: To investigate if patients with mechanical neck pain receiving thoracic spine thrust manipulation would experience superior outcomes compared to a group not receiving that manipulation.
Background: Evidence has begun to emerge in support of thoracic thrust manipulation as an intervention in the management of mechanical neck pain. However, to make a strong recommendation for a clinical technique it is necessary to have multiple studies with convergent findings.
Methods and Measures: Forty-five patients (21 females) were randomly assigned to 1 of 2 groups: a control group, which received electro/thermal therapy for 5 treatment sessions, and the experimental group, which received the same electro/thermal therapy program in addition to a thoracic spine thrust manipulation once a week for 3 consecutive weeks. Mixed-model analyses of variance (ANOVAs) were used to examine the effects of treatment on pain (100-mm visual analogue scale), disability (100-point disability scale), and cervical range of motion, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction for pain.
Results: The group-by-time interaction effects for the ANOVA models were statistically significant for pain, mobility, and disability (P<.05), indicating greater improvements in the manipulation group for all the outcome measures. Patients receiving thoracic thrust manipulation experienced greater improvements in pain at the fifth (final) treatment session and at the 2-week and 4-week follow-up periods (P<.001), with pain improvement scores in the manipulation group of 16.8 mm and 26.5 mm greater than those in the comparison group at the 2- and 4-week follow-up periods, respectively. The experimental group also experienced significantly greater improvements in disability with a between-group difference of 8.8 points (95% confidence interval [CI]: 7.5, 10.1; P<.001) at the fifth visit and 8.0 points (95% CI: 5.8, 10.2; P<.001) at the 2-week follow-up.
Conclusions: The results of our study suggest that thoracic spine thrust manipulation results in superior clinical benefits that persist beyond the 1-month follow-up period for patients with acute neck pain. Future studies should continue to investigate the effects of thoracic spine thrust manipulation, as compared to other physical therapy interventions, in a population with mechanical neck pain.
Level of Evidence: Therapy, level 1b.
Study Design: Randomized Clinical Trial
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, comorbid 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 Findings:
Patients who present with mechanical neck pain and are treated with a thoracic thrust manipulation in conjunction with an electro/thermal therapy program demonstrate better outcomes in pain, disability, and cervical range of motion than those treated with the electro/thermal therapy alone.
Improvements in pain for the thoracic manipulation group persist after the 4-week follow-up.
Thoracic spine thrust manipulation is supported for use in physical therapy treatment of patients with acute (<1 month) mechanical neck pain and no contraindications to manual therapy.
Reviewer Summary:
As physical therapy is frequently the first line of treatment for patients experiencing mechanical neck pain, it is important to determine the most appropriate treatments for these patients. Manual therapy, specifically thoracic spine thrust manipulation, has been growing in evidence and popularity for management of patients with neck pain. The authors of this study explore the outcomes of this manipulation versus electro/thermal therapy, focusing on pain, cervical range of motion, and disability, and investigate if these outcomes will persist after the treatment sessions have ended. In this randomized clinical trial, 45 patients were randomly assigned to a control group (electro/thermal therapy only) and an experimental group (electro/thermal therapy + thoracic spine thrust manipulation), all treated by the same physical therapist who provided the same treatments to each patient, depending on group assignments. The electro/thermal therapy modalities and parameters were the same for both groups, and all patients in the experimental group received the same thoracic “distraction” manipulation. Patients in both groups attended 5 treatment sessions over a 3-week period with the experimental group receiving the manipulation on the first, third, and fifth visits. Improvements in pain were measured using the 100 mm visual analog scale and were measured at baseline, immediately following the final treatment session, and at the 2- and 4-week follow-up visits. Cervical range of motion (flexion, extension, lateral flexion, and rotation) was assessed with a goniometer and the mean measurement of three trials was recorded at baseline, after the final treatment, and at the 2-week follow-up. Disability was measured via the Spanish version of the Northwick Neck Pain Questionnaire and measured at baseline, after the final treatment, and at the 2-week follow-up. The effectiveness of this treatment on pain was determined via a 2×4 mixed-model ANOVA, with group as the between-subjects variable and time as the within-subject variable, and group-by-time interaction being the hypothesis of interest. This analysis demonstrated a statistically significant interaction for pain as the dependent variable, indicating that patients receiving the thrust manipulation exhibited greater improvements in pain on the last physical therapy visit and these improvements persisted at the 2- and 4-week follow-ups. Separate 2×3 mixed-model ANOVAs were used to determine the efficacy of this treatment on cervical range of motion and disability, also focusing on the group-by-time interaction. These analyses showed statistically significant interactions for both dependent variables, indicating that the experimental group exhibited greater improvement in cervical range of motion and disability at the last treatment visit and at the 2-week follow-up. The improvements for pain surpassed the MCID for the VAS, indicating that clinicians should consider including thoracic spine thrust manipulation in their management of mechanical neck pain.
Clinical Interpretation:
Due to the prevalence of patients seeking physical therapy services for mechanical neck pain (~25% of all physical therapy visits), it is essential to determine the best treatment program for addressing this condition. This study highlights the benefits of adding manual therapy, specifically a thoracic spine thrust manipulation, to the treatment program for improving pain, range of motion, and disability outcomes for these patients. This approach is more effective than alternative treatment approaches in maintaining these outcomes beyond the end of physical therapy treatment. This study provides evidence supporting that physical therapists should consider including thoracic spine thrust manipulation in their treatment plan for patients with acute mechanical neck pain and no comorbidities for manual therapy.
Author Names
Cho, J., Lee, E., & Lee, S.
Reviewer Name
Breanna Nachazel
Reviewer Affiliation(s)
Duke DPT
Paper Abstract
Background: Although upper cervical and upper thoracic spine mobilization plus therapeutic exercises are common interventions for the management of forward head posture (FHP), no study has directly compared the effectiveness of cervical spine mobilization and stabilization exercise with that of thoracic spine mobilization and mobility exercise in individuals with FHP.
Methods: Thirty-two participants with FHP were randomized into the cervical group or the thoracic group. The treatment period was 4 weeks, with follow-up assessment at 4 and 6 weeks after the initial examination. Outcome measures including the craniovertebral angle (CVA), cervical range of motion, numeric pain rating scale (NPRS), pressure pain threshold, neck disability index (NDI), and global rating of change (GRC) were collected. Data were examined with a two-way repeated-measures analysis of variance (group × time).
Results: Participants in the thoracic group demonstrated significant improvements (p < .05) in CVA, cervical extension, NPRS, and NDI at the 6-week follow-up compared with those in the cervical group. In addition, 11 of 15 (68.8%) participants in the thoracic group compared with 8 of 16 participants (50%) in the cervical group showed a GRC score of +4 or higher at the 4-week follow-up.
Conclusions: The combination of upper thoracic spine mobilization and mobility exercise demonstrated better overall short-term outcomes in CVA (standing position), cervical extension, NPRS, NDI, and GRC compared with upper cervical spine mobilization and stabilization exercise in individuals with FHP.
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)?
Maybe/unsure
Was the treatment allocation concealed (so that assignments could not be predicted)?
Maybe/unsure
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?
Maybe/unsure
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)?
Maybe/unsure
Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Maybe/unsure
Key Finding #1
Upper thoracic spine mobilization and mobility exercises showed better short term outcomes in standing craniovertebral angle as compared to cervical spine mobilization and stabilization exercises in individuals with forward head posture.
Key Finding #2
Thoracic group showed better active cervical extension over time as compared to the cervical group, but there was no significance with cervical flexion, rotation and lateral flexion.
Key Finding #3
The numeric pain rating scale (NPRS) indicated improved pain reduction over time in the thoracic group as compared to the cervical group.
Please provide your summary of the paper
This study evaluated the differences between thoracic spine mobilization and mobility exercises compared to upper cervical spine mobilization and stabilization exercises in those with forward head posture. This study recruited 32 participants with neck pain from forward head posture (FHP). Participants met the criteria of having neck pain, being between the ages of 20-29, and having symptoms of FHP. Participants were evaluated before and after treatment, and interventions were performed 10 times over 4 weeks, followed by a re-evaluation after 2 weeks. The 32 participants were randomly assigned to either the cervical group or the thoracic group with 16 participants in both groups. The cervical group included mobilization of C1-C2 and cervical retraction exercises. The thoracic group included mobilization of T1-2 and thoracic extension exercises for mobility. The primary outcome measure was the cervicothoracic angle done using a photograph profile of the participant, with a measurement over 49 degrees qualifying as FHP. Other outcome measures included CROM, NPRS, PPT, NDI, and GRC. The results from the interventions were assessed through a two-way repeated measures ANOVA. Results showed greater improvements in CVA, cervical extension, and NPRS for the thoracic group when compared to the cervical group.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study is beneficial in showing a comparison between thoracic mobilization and exercise and cervical mobilization and exercises to treat neck pain from the forward head posture. Results showed significance in improvement for overall pain and CVA in the thoracic group. This study helps determine possible treatment approaches to neck pain resulting from FHP.
Author Names
Rungtawan Chaikla, Munlika Sremakaew , Suwit Saekho, Suchart Kothan, Sureeporn Uthaikhup
Reviewer Name
Neha Patel
Reviewer Affiliation(s)
Duke DPT
Paper Abstract
This trial aimed to investigate the effects of 10-week manual therapy combined with exercise compared to routine physical therapy on brain structure and clinical outcomes in patients with neck pain. Fifty-two participants with chronic nonspecific neck pain were randomized into either an intervention group or a control group (a 1:1 ratio). The intervention group received cervical mobilization and cervical and scapular exercises. The control group received routine physical therapy. The primary outcomes were cortical thickness and volume. Secondary outcomes were neck pain intensity, disability, psychological symptoms, cervical range of motion and cervical flexor muscle strength. Outcome measures were taken at baseline and post-treatment. There was no loss to follow-up. Compared to baseline, significant differences in cortical thickness were observed at post-treatment in both groups, including prefrontal cortex (PFC), anterior cingulate cortex (ACC), primary somatosensory cortex (S1), primary motor cortex (M1) and precuneus (p<0.05). The intervention group exhibited greater increases in cortical thickness in the ACC and M1 compared to controls (p<0.05). The secondary outcomes were improved in both groups (p<0.05). There were differences in brain structure (S1, PFC and insula) between participants who experienced ≥50% reduction in pain intensity and those with <50% reduction (p<0.05). Changes in brain structure were correlated with changes in pain intensity and neck disability (r =-0.31 to -0.44, p<0.05). The study suggests that patients with chronic nonspecific neck pain who experienced significant improvements in pain intensity exhibited greater changes in cortical structure following a 10-week intervention, particularly with a combination of manual therapy and exercise. PERSPECTIVE: A combination of manual therapy and exercise results in greater improvements in clinical outcomes and substantially alters cortical thickness compared to routine physical therapy in patients with chronic nonspecific neck pain. These findings highlight the potential impact of this intervention on both brain structure and clinical recovery.
Quality Assessment of Controlled Intervention Studies
Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
RCT
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)?
n/a
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?
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?
N/a
Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Yes
Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Key Finding #1
The intervention group, which received cervical mobilization and exercises, showed greater improvements in cortical thickness, particularly in brain areas associated with pain processing and motor control (e.g., ACC and M1), compared to the routine physical therapy group (control group).
Key Finding #2
Both experimental and control groups showed improvements in secondary outcomes like pain intensity, disability, and muscle strength, indicating that both manual therapy combined with exercise and routine physical therapy can be effective in managing chronic neck pain.
Key Finding #3
Patients who experienced significant reductions in pain (≥50%) also showed greater changes in brain structure, highlighting a connection between pain relief, neuroplasticity, and functional recovery in chronic neck pain patients.
Please provide your summary of the paper
This study is a RCT with the aim to investigate the effects of 10-week manual therapy combined with exercise in comparison to routine physical therapy on brain structure and clinical outcomes in individuals with neck pain.
The study included women and men aged 18-59 years with chronic nonspecific neck pain greater than or equal to 3 months and intensity greater or equal to 35/100mm on the VAS. Out of 52 participants that met eligibility criteria, 0 were lost to follow up. The intervention group received 20 sessions of manual therapy and therapeutic exercise.
Participants in the intervention group were given low velocity passive mobilization techniques and exercises in clinic and for at home for craniocervical and cervical flexors and extensors, axioscapular muscles and postural corrections. The control group was given a “routine physical therapy program” including physical modalities as well as range of motion and gentle stretching exercises.
The study used an ANCOVA model to perform statistical analysis. The outcomes of this study were that the intervention group showed greater changes in brain structure and increased cortical thickness than as compared to the control group. Furthermore, participants with greater reductions in pain also showed greater changes in brain structure.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Clinically, this study can be interpreted to prioritize pain management as well as a combination of manual therapy and therapeutic exercise to encourage neuroplasticity and improvements in clinical outcomes. This study may impact clinical practice because it highlights the importance of neuroplasticity in targeted interventions.
Author Names: Jacobo Rodríguez-Sanz , Miguel Malo-Urriés , María Orosia Lucha-López, Carlos López-de-Celis, Albert Pérez-Bellmunt, Jaime Corral-de-Toro, César Hidalgo-García
Reviewer Name: Ranffy Perez
Reviewer Affiliation(s): Duke DPT
Paper Abstract
Background: Cervical exercise has been shown to be an effective treatment for neck pain, but there is still a need for more clinical trials evaluating the effectiveness of adding manual therapy to the exercise approach. There is a lack of evidence on the effect of these techniques in patients with neck pain and upper cervical rotation restriction.
Purpose: To compare the effectiveness of adding manual therapy to a cervical exercise protocol for the treatment of patients with chronic neck pain and upper cervical rotation restriction.
Methods: Single-blind randomized clinical trial. Fifty-eight subjects: 29 for the Manual Therapy+Exercise (MT+Exercise) Group and 29 for the Exercise group. Neck disability index, pain intensity (0-10), pressure pain threshold (kPa), flexion-rotation test (°), and cervical range of motion (°) were measured at the beginning and at the end of the intervention, and at 3-and 6-month follow-ups. The MT+Exercise Group received one 20-min session of manual therapy and exercise once a week for 4 weeks and home exercise. The Exercise Group received one 20-min session of exercise once a week for 4 weeks and home exercise.
Results: The MT+Exercise Group showed significant better values post-intervention in all variables: neck disability index: 0% patient with moderate, severe, or complete disability compared to 31% in the Exercise Group (p = 0.000) at 6-months; flexion-rotation test (p = 0.000) and pain intensity (p = 0.000) from the first follow-up to the end of the study; cervical flexion (p = 0.002), extension (p = 0.002), right lateral-flexion (p = 0.000), left lateral-flexion (p = 0.001), right rotation (p = 0.000) and left rotation (p = 0.005) at 6-months of the study, except for flexion, with significative changes from 3-months of follow up; pressure pain threshold from the first follow-up to the end of the study (pvalues range: 0.003-0.000).
Conclusion: Four 20-min sessions of manual therapy and exercise, along with a home-exercise program, was found to be more effective than an exercise protocol and a home-exercise program in improving the neck disability index, flexion-rotation test, pain intensity, and pressure pain threshold, in the short, medium, and medium-long term in patients with chronic neck pain and upper rotation restriction. Cervical range of motion improved with the addition of manual therapy in the medium and medium-long term. The high dropout rate may have compromised the external validity of the study.
Quality Assessment of Controlled Intervention Studies
Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes, RCT
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?
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, the interventions had similar treatments with the exception that one group had manual therapy.
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
There were statistically significant effects in the flexion-rotation test. The results highlighted that the Exercise Group did not change over the follow-ups, whereas the MT+Exercise Group increased ROM over time(p = 0.000) and compared to the Exercise Group in the three moments of the study
Key Finding #2:
The MT+ Exercise group had superior results post- intervention on the neck disability index with 0% patient with moderate, severe, or complete disability compared to 31% in the Exercise Group (p = 0.000) at 6-months.
Key Finding #3
The MT+ Exercise group showed more significant improvement when compared to the exercise group in all ROM of the neck over the 6 months of the study.
Please provide your summary of the paper
The study “Comparison of an Exercise Program With and Without Manual Therapy for Patients With Chronic Neck Pain and Upper Cervical Rotation Restriction: A Randomized Controlled Trial” by Rodriguez-Sanz et al. investigates the effectiveness of integrating manual therapy into a physical therapy exercise program for patients experiencing chronic neck pain and restrictions in upper cervical rotation. The research assesses pain levels, disability, and cervical range of motion at three different intervals: immediately after the intervention, three months later, and six months later. The study involved fifty-eight participants: 29 in the Manual Therapy Plus Exercise (MT+E) group and 29 in the Exercise (E) group. The subjects included 17 men and 41 women with a mean age of 49.2 ± 15.9 years who met all eligibility criteria and consented to participate. At the end of the experiment, five subjects (one MT+E group and four E group) dropped out for unspecified reasons. The groups received interventions over a total duration of 4 weeks. During this period, the MT+E group participated in 20-minute sessions of manual therapy and exercise once a week, followed by home exercises. Similarly, the E group attended 20-minute exercise sessions once a week in addition to their home exercises. Both groups followed the same exercise routine, which comprised two sets of 10 repetitions. Each exercise was held for 10 seconds, with a 40-second rest between repetitions and a 2-minute rest between sets. The exercises provided targeted cervical stabilization, deep neck flexors/ extensors, and cranial cervical flexors/extensors. The experiment employed four outcome measures to assess progress during the three intervals: The Neck disability index, pain intensity (0–10), pressure pain threshold (kPa), flexion-rotation test (°), and cervical range of motion (°). The authors concluded that the MT+exercise group demonstrated superior results compared to the E group across all metrics. Specifically, the MT+exercise group showed more significant improvement over time in the neck disability index, flexion-rotation test, pain intensity, pressure pain threshold, and cervical ROM compared to the E group.
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 conducted by Rodriguez-Sanz et al. suggests that manual therapy can be an effective and low-risk addition to the treatment plans for patients suffering from chronic neck pain and limitations in upper cervical rotation. However, I believe the study’s findings may not be fully generalizable to all patients with cervical impairments due to its specific inclusion and exclusion criteria. Out of the 81 applicants for the study, only 58 participants met the necessary criteria to participate, which may limit the applicability of the results. The relatively small sample size could reduce the study’s generalizability, introduce potential bias, and negatively impact the statistical power and significance of the findings. Additionally, the authors acknowledged that the external validity of the results may have been compromised by a high dropout rate. This is concerning because participant losses can lead to skewed data, further affecting the reliability of the study’s conclusions. Despite these limitations, the study does demonstrate the potential of manual therapy as a valuable component of a physical therapy plan. However, for these findings to be more broadly applicable, I suggest further research involving larger, more diverse populations is needed. This will help confirm the treatment’s effectiveness and safety, especially for patients with cervical and thoracic issues. When implementing these findings in a clinical setting, it is crucial to acknowledge that the study’s results may not apply to patients who do not fulfill the specific criteria outlined in the study. Therefore, if manual therapy is incorporated into a treatment plan alongside exercise, it is crucial to proceed with caution. I believe clinicians should take the time to ensure the treatment is effective by monitoring for any potential side effects and closely evaluating if it leads to any meaningful improvements in patients’ functional outcomes.
Author Names: Andoni Carrasco-Uribarren, Pilar Pardos-Aguilella, Silvia Pérez-Guillén, Carlos López-de-Celis, Jacobo Rodríguez-Sanz, Sara Cabanillas-Barea.
Reviewer Name: Ke-Vin Chang
Reviewer Affiliation(s): Ranffy Perez
Paper Abstract:
Cervicogenic dizziness is clinically associated with upper cervical spine dysfunctions. It seems that manual therapy decreases the intensity of dizziness in these subjects, but what happens to pain measured by pressure pain threshold (PPT) has not been studied. Purpose: analyze the short-term effects of combination two manipulation techniques protocol in worst dizziness intensity (wVAS), dizziness and cervical disability, upper cervical spine mobility and mechanosensivity of cervical tissue. Methods: Assessor-blinded randomized controlled trial was developed. A total of 40 patients with cervicogenic dizziness were randomly divided into two groups. The experimental group received three treatments consisting of a functional massage and a manipulation technique, and compared with a control group. The wVAS, dizziness handicap inventory (DHI), neck disability index (NDI), UCS mobility, and PPTs were measured. Measurements were made at the baseline, first follow-up 48 h after intervention and second follow-up 1 month after the intervention. Results: at second follow-up wVAS (p < 0.001), NDI (p < 0.001), DHI (p< 0.001), and upper right trapezius (p < 0.022) and right suboccipital (p< 0.043) PPTs showed a difference between groups in favor of the experimental group. Conclusions: apparently, the proposed intervention protocol decreases the intensity of dizziness and the mechanosensitivity of the cervical tissue and improves the feeling of disability due to neck pain and dizziness.
Quality Assessment of Controlled Intervention Studies
Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes, RCT
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?
Not clear. Says participant where blinded but a Physical therapist knew the group assignments.
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?
Not reported.
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?
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?
Not specified.
Key Finding #1
In the experimental group, the visual analogue scale demonstrated that worst intensity of dizziness was significantly lower after the intervention at T1 (p < 0.001, d = 2.43), and at T2 follow-up (p < 0.001, d = 1.64).
Key Finding #2
On the Dizziness Handicap inventory (DHI), the experimental group subjects who perceived severe dizziness handicap decreased from 3 to 1 at T1 and T2 follow ups, moderate dizziness handicap decreased from 12 to 3 between T0 to T1 follow ups, and only 1 felt moderate disability. The data between groups showed difference in favor of the experimental group at T1 follow up (p < 0.005, V = 0.503) and at T2 follow-up (p < 0.001, V = 0.571).
Key Finding #3
On the Neck Disability Index (NDI), the experimental group disability perceived by the patients were significantly lower after the intervention at T1 follow-up (p < 0.001, d = 0.53). At T2 follow-up, the reduction was of 4.5 point (p < 0.002, d = 0.73). In the control group the decrease was lower in both follow ups. Between groups, significant differences were found at T2 follow-up in favor of the experimental group (p < 0.012, d = 0.94)
Key Finding #4
During the Pressure Pain Threshold (PPT) there was statistical significance in favor of the experimental group in the right upper trapezius (p < 0.022, d = 0.46) and left upper trapezius (p < 0.035, d = 0.26) for T1 follow-up. For the T2 follow-up, there were observed statistically significant results in the right upper trapezius (p < 0.016, d = 0.43), left upper trapezius (p < 0.009, d = 0.37) and right suboccipital (p < 0.018, d = 0.46). However, the control group also showed significant improvement from baseline.
Please provide your summary of the paper
The study “Combination of Two Manipulative Techniques for the Treatment of Cervicogenic Dizziness” by Carrasco-Uribarren et al. aimed to observe the short-term effects of combining two manipulation techniques on dizziness intensity, cervical passive mobility, and cervical pain. The authors recruited 40 participants who met the inclusion and exclusion criteria, consisting of 32 females and 8 males, with an average age of 54 years (±14.09 years). The participants were randomly assigned to two groups of twenty: an experimental group, which received the two cervical manipulative techniques, and a control group. The intervention protocol consisted of three sections: pre-manipulative, manipulative, and post-manipulative. Each group underwent three interventions on alternate days, each lasting 11 minutes. The data for each patient were collected at three time points: the initial evaluation (T0), 48 hours post-intervention (T1), and one month after the final intervention (T2). The primary outcome measures utilized in this study were the wVAS and the DHI which were used to assess the level of dizziness. The secondary outcome measures included the Flexion Rotation Test (FRT) and NDI, which helped evaluate the cervical range of motion (ROM), as well as PPT, which was used to assess cervical pain and sensitivity. Moreover, at T0, fear of movement was recorded with the Tampa Kinesiophobia Scale (TSK-11). In their conclusion, the authors explained that the combination of the two manipulative techniques in the experimental group led to reduced dizziness and pain, as well as improved ROM, as highlighted by the significant between-group differences across all outcome measures.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
After carefully analyzing the paper by Carrasco-Uribarren et al., I believe it demonstrates that manual therapy can be a valuable addition to a treatment plan for cervicogenic dizziness and may even serve as a standalone intervention. However, I believe more data is necessary to confirm the true impact of manipulative techniques on the broad population. In this experiment, the small sample size and strict inclusion criteria may have introduced selection bias, potentially impacting the validity of the results. Additionally, the predominance of female participants raises concerns about gender bias, as the low number of male participants limits the study’s generalizability. Moreover, hormonal fluctuations and ligamentous laxity variations in women throughout the month could have been another confounding factor, further influencing the outcomes. Thus, to implement this intervention in clinical practice, therapists must exercise caution and conduct thorough patient history assessments to ensure the intervention is suitable. Additionally, continuous outcome measurement throughout the treatment plan can help establish whether the intervention is effective and provide therapists with insights into whether a shift in protocol is necessary.
Author Names: Lopez-Lopez, A; Alonso Perez, J; Gonzalez Gutierez, J; La Touche, R; Lerma Lara, S; Izquierdo, H; Fernandez-Carnero, J
Reviewer Name: Elena Renke
Reviewer Affiliation(s): Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract:
Background: Three different types of manual therapy techniques for patients with neck pain and relationship with psychological factors has not been evaluated.
Aim: To compare the effectiveness high velocity and low amplitude (HVLA) manipulation vs. posteroanterior mobilization (PA mob) vs. sustain appophyseal natural glide (SNAG) in the management of patients with neck pain and to evaluate the interaction with psychological factors.
Study design: Randomized clinical trial.
Setting: Primary Health Care Center.
Population: Patients with history of chronic neck pain over the last 3 months were recruited.
Methods: Patients were randomly assigned to receive treatment with HVLA (N.=15), with PA mob (N.=16) or with SNAG (N.=17). One session was applied. Pain intensity of neck pain, pressure pain threshold over processus spinosus of C2 (PPT_C2) and cervical range of motion (CROM) were measured pre- and post-intervention. Pain catastrophizing, depression, anxiety and kinesiophobia were assessed in baseline. ANOVAs were performed, with main effects, two-way (treatment x time) and three-way interactions (treatment x psychological variable x time) were examined.
Results: Fourthy-eight patients (mean±SD age, 36.5±8.7 years; 87.5% female). A significant interaction treatment x time was observed for VAS-rest in HVLA and AP mob groups (P<0.05). With more pain relief to HVLA and AP mob groups than SNAG groups but all groups improve the same in CROM. Also, a significant three-way treatment x anxiety x time interaction for VAS in Flexion/Extension was identified (P<0.01), and a trend toward significance was observed for the three way treatment x anxiety x time interaction, with respect to CROM in Lateral-Flexion movement (P<0.05).
Conclusion: The results suggest that an HVLA and PA mob groups relieved pain at rest more than SNAG in patients with Neck pain. Among psychological factors, only trait anxiety seems interact with Manual therapy, mainly high anxiety conditions interact with the Mobilization and SNAG effects but under low anxiety conditions interact with the HVLA effects. Significant mean differences can be observed both in VAS in Flexion/Extension and in CROM in lateral-flexion movement when using mobilization under high anxiety conditions
Clinical rehabilitation impact: The findings provide preliminary evidence to support that three different techniques have similar immediate effects over neck pain and while under high anxiety levels a better outcome is expected after mobilization intervention, under low anxiety levels a better prognosis is expected after manipulation and SNAG intervention.
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)?
Not reported
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: All three interventions provided resulted in similar improvements in cervical range of motion, but the high velocity low amplitude (HVLA) manipulation and the posteroanterior (PA) mobilization groups experienced a significantly greater reduction in pain than the sustained apophyseal natural glide (SNAG) group.
Key Finding #2: With patients who experience higher levels of anxiety, better outcomes were observed in the PA mobilization group.
Key Finding #3: With patients who experience lower levels of anxiety, better outcomes were observed in the HVLA manipulation and SNAG intervention groups.
Please provide your summary of the paper
This randomized controlled trial aimed to determine the effectiveness of high velocity and low amplitude (HVLA) manipulation compared to posteroanterior (PA) mobilization compared to sustained apophyseal natural glide (SNAG) interventions in reducing pain and increasing range of motion (ROM) in patients with chronic neck pain. Additionally, this study identified how psychological factors such as pain catastrophizing, depression, anxiety, and kinesiophobia may affect the outcomes associated with each form of treatment. Participants were eligible for this study if they reported neck pain in the posterior region of the cervical spine lasting at least 12 weeks without radiating symptoms. Of the 48 adult patients selected for this study, 42 were female. The primary outcome of this study which was measured pre- and post-intervention was neck pain intensity as measured by the visual analogue scale (VAS). A pain intensity rating was measured during active flexion, extension, rotation, and lateral flexion movements. Secondary outcomes included cervical ROM measured by a CROM device and pressure pain thresholds (PPT) which were measured at the spinous process of C2. Participants were randomly assigned to one of the three intervention groups (HVLA manipulation, PA mobilization, or SNAG) and received one session of the respective treatment. It was found that all three manual therapy techniques resulted in significant improvements in pain, hyperalgesia, and ROM with no significant differences between the groups. When the findings were analyzed with relation to the psychological factors being studied, it was found that better outcomes were achieved following the HVLA and SNAG interventions for patients with low anxiety, but the PA mobilizations were more effective for patients with higher anxiety levels.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
For patients with chronic neck pain, manual therapy techniques of HVLA manipulation, PA mobilizations, and SNAGs may be equally effective for reducing pain and mechanical hyperalgesia and increasing cervical ROM. It should be noted, however, that patient anxiety levels may play a role in identifying which technique would be most appropriate. PA mobilizations may produce better outcomes in patients with higher levels of anxiety while SNAGs and HVLA manipulations may produce better outcomes in less anxious patients. Another clinically significant finding was that while all three interventions resulted in decreased pain levels during active cervical motion, only the manipulation and mobilization groups experienced decreased pain at rest. One limitation of this study that should be considered is that the subject population was mostly female potentially limiting the clinical relevance of these findings in the male patient population.
Author Names: César Fernández-de-las-Peñas , Luis Palomeque-del-Cerro, Cleofás Rodríguez-Blanco, Antonia Gómez-Conesa, Juan C Miangolarra-Page
Reviewer Name: Haylee Rice
Reviewer Affiliation(s): Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Objective: Our aim was to report changes in neck pain at rest, active cervical range of motion, and neck pain at end-range of cervical motion after a single thoracic spine manipulation in a case series of patients with mechanical neck pain.
Methods: Seven patients with mechanical neck pain (2 men, 5 women), 20 to 33 years old, were included. All patients received a single thoracic manipulation by an experienced manipulative therapist. The outcome measures of these cases series were neck pain at rest, as measured by a numerical pain rating scale; active cervical range of motion; and neck pain at the end of each neck motion (eg, flexion or extension). These outcomes were assessed pre treatment, 5 minutes post manipulation, and 48 hours after the intervention. A repeated-measures analysis was made with parametric tests. Within-group effect sizes were calculated using Cohen d coefficients.
Results: A significant (P < .001) decrease, with large within-group effect sizes (d > 1), in neck pain at rest were found after the thoracic spinal manipulation. A trend toward an increase in all cervical motions (flexion, extension, right or left lateral flexion, and right or left rotation) and a trend toward a decrease in neck pain at the end of each cervical motion were also found, although differences did not reach the significance (P > .05). Nevertheless, medium to large within-group effect sizes (0.5 < d < 1) were found between preintervention data and both postintervention assessments in both active range of motion and neck pain at the end of each neck motion.
Conclusions: The present results demonstrated a clinically significant reduction in pain at rest in subjects with mechanical neck pain immediately and 48 hours following a thoracic manipulation. Although increases in all tested ranges of motion were obtained, none of them reached statistical significance at either posttreatment point. The same was found for pain at the end of range of motion for all tested ranges, with the exception of pain at the end of forward flexion at 48 hours. More than one mechanism likely explains the effects of thoracic spinal manipulation. Future controlled studies comparing spinal manipulation vs spinal mobilization of the thoracic spine are required.
Quality Assessment Tool for Case Series Studies
Was the study question or objective clearly stated? Yes
Was the study population clearly and fully described, including a case definition? Yes
Were the cases consecutive? Yes
Were the subjects comparable? Yes
Was the intervention clearly described? Yes
Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants? Yes
Was the length of follow-up adequate? No
Were the statistical methods well-described? Yes
Were the results well-described? Yes
Key Finding #1
- A single thoracic manipulation was helpful in improving pain at rest immediately and 48 hours after manipulation.
Key Finding #2
- The results of this study are important in that they prove that thoracic manipulation can improve cervical ROM and pain. This is important because thoracic procedures are free of risk of injury to the vertebral artery unlike cervical manipulative procedures.
Please provide your summary of the paper
- The purpose of this study was to observe changes in neck pain at rest, neck pain at end ROM, and active cervical ROM after a single thoracic spinal manipulation. Seven patients with mechanical neck pain were selected for this study. Each patient received a single supine thoracic manipulation. If a cracking or popping did not occur during the first manipulation a second was attempted. There was a max of two attempts. Outcome measures were taken prior to, immediately following the manipulation, and then 48 hours after. Outcome measures included the 11- point numerical pain rate scale (NPRS) to measure neck pain at rest and end ROM and a cervical goniometric device was used to measure cervical active ROM. Results of a 1-way ANOVA of repeated measures showed a significant decrease in neck paint at rest after manipulation. Neck pain at end ROM and cervical ROM also improved but not a statistically significant amount. Future studies with a larger sample size and longer follow up period are required to better determine the effects of thoracic spinal manipulation on the cervical spine.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
- The findings in this study are helpful in that they show that thoracic manipulations can reduce neck pain at rest. Cervical manipulations have a higher risk of injury to the vertebral artery, but thoracic manipulations do not, therefore, thoracic mobilizations in patients with neck pain can be a helpful alternative if patients are fearful of or have contraindications to cervical manipulations.
Author Names: Bracht, M., Buogo Coan, A., Yahya, A., Jose Dos Santos, M.
Reviewer Name: Chloee Richey
Reviewer Affiliation(s): Duke University School of Medicine, Department of Physical Therapy
Paper Abstract:
Objectives
Individuals with neck pain experience disrupted grip force control when performing manipulative tasks. Manipulative physical therapy might decrease pain and change the activity of surrounding muscles; however, its effect on upper limb motor control remains undetermined. This study aims to analyze the effects of cervical manipulation on pressure pain threshold (PPT), upper extremity muscle activity along with grip force control in individuals with neck pain.
Methods
Thirty subjects with neck pain were instructed to grasp and lift an object before and after cervical (n = 15) or sham (n = 15) manipulation. The patients’ PPT, electromyographic (EMG) activity of the upper extremity/scapular muscles, and grip force control were analyzed before and after one session of manipulation.
Results
No significant differences were found in the grip force control, PPT and EMG activity variables between groups.
Discussion
These results suggest that a single session of cervical manipulation may not modify upper limb motor control, more specifically grip force control and EMG activity, in patients with cervical pain. Future studies should investigate potential changes in grip force control in patients with different features of neck pain and/or by applying long-term treatment.
Level of Evidence
1b.
Keywords: Grasping, lifting, neck pain, thrust, grip force control, EMG
Key Finding #1: No patient was excluded from the study due to lack of cavitation phenomenon
caused by the cervical spine manipulation or because of intolerance to the maneuver.
Key Finding #2: The results of the present study indicate that one single session of cervical
manipulation in subjects with cervical pain might not immediately change the PPT, muscle
activity of upper extremity and grip force control.
Key Finding #3: the results of the present study combined with the findings of the previous
studies does not invalidate the use of cervical manipulation for patients with neck pain in clinical
sites.
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)? Y
3. Was the treatment allocation concealed (so that assignments could not be predicted)? Y
4. Were study participants and providers blinded to treatment group assignment? Y
5. Were the people assessing the outcomes blinded to the participants’ group assignments? N
6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, comorbid conditions)? Y
7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? Y
8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? Y
9. Was there high adherence to the intervention protocols for each treatment group? Y
10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)? Y
11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? Y
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? Y
13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? Y
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? Y
(ALL YES, but #5)
Please provide your summary of the paper:
This study looked at the effects of manual therapy of the cervical spine on pain, grip force control, and upper extremity muscle activity in people with neck pain. It also looked at the effects of cervical manipulation on pain pressure threshold (PPT). 30 individuals were chosen, aged 18-50, with 27 being female, and 3 male. Those selected were chosen based on having a history of three or more episodes of cervical pain in the last three months, with or without pain radiating to the upper extremities. PPT was measured using a digital pressure algometer, and muscle activity was measured using EMG. The study consisted of the individuals grasping and lifting a cup before and after receiving cervical manipulations. The subjects in the experimental group received high-velocity, low-amplitude (HVLA) cervical manipulation technique, also known as a thrust or grade V manipulation. Those in the control group had a manipulation technique mimicked on them, without the proper tissue tension required for a cavitation. The results of the study showed that one single session of cervical manipulation in those with cervical pain might not immediately change the PPT, muscle activity of upper extremity and grip force control.
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 show that physical therapy interventions cannot soely rely on manual theapy for treatment of cervical pain. Other interventions such as exercise and motor control training are needed to greatly impact the grip strength and muscle activity. Providing short-term pain relief can allow someone to complete the needed exercises and interventions needed to achieve long term relief. Although manual therapy should not be depended on, it can provide needed pain relief. This study also used tools such as a digital pressure algometer, and EMG technology, which likley would not be accessible for most clinics.
Author Names
Matthew Fernandez, et. al
Reviewer Name
Megan Ringo, Student Physical Therapist
Reviewer Affiliation(s)
Duke DPT, Class of 2026
Paper Abstract:
Background: Spinal manipulative therapy (SMT) is frequently used to manage cervicogenic headache (CGHA). No meta-analysis has investigated the effectiveness of SMT exclusively for CGHA.
Objective: To evaluate the effectiveness of SMT for CGHA.
Databases and Data Treatment: Five databases identified randomized controlled trials comparing SMT with other manual therapies. The PEDro scale assessed the risk-of-bias. Pain and disability data were extracted and converted to a common scale. A random effects model was used for several follow-up periods. GRADE described the quality of evidence.
Results: Seven trials were eligible. At short-term follow-up, there was a significant, small effect favouring SMT for pain intensity (mean difference [MD] −10.88 [95% CI, −17.94, −3.82]) and small effects for pain frequency (standardized mean difference [SMD] −0.35 [95% CI, −0.66, −0.04]). There was no effect for pain duration (SMD − 0.08 [95% CI, −0.47, 0.32]). There was a significant, small effect favouring SMT for disability (MD − 13.31 [95% CI, −18.07, −8.56]). At intermediate followup, there was no significant effects for pain intensity (MD − 9.77 [−24.21 to 4.68]) and a significant, small effect favouring SMT for pain frequency (SMD − 0.32 [−0.63 to − 0.00]). At long-term follow-up, there was no significant effects for pain intensity (MD − 0.76 [−5.89 to 4.37]) and for pain frequency (SMD − 0.37 [−0.84 to 0.10]).
Conclusion: For CGHA, SMT provides small, superior short-term benefits for pain intensity, frequency and disability, but not pain duration, however, high-quality evidence in this field is lacking. The long-term impact is not significant.
Significance: CGHA are a common headache disorder. SMT can be considered an effective treatment modality, with this review suggesting it providing superior, small, short-term effects for pain intensity, frequency and disability when compared with other manual therapies. These findings may help clinicians in practice better understand the treatment effects of SMT alone for CGHA.
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?
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
Spinal Manipulative Therapy provides significant short term benefits for individuals with cervicogenic headache by decreasing pain intensity, frequency and disability.
Key Finding #2
Spinal Manipulative Therapy does not provide significant short term benefits for pain duration in individuals with cervicogenic headache.
Key Finding #3
Spinal Manipulative Therapy does not provide significant long term benefits for pain intensity and pain frequency in individuals with cervicogenic headache.
Please provide your summary of the paper
The aim of this study was to investigate the impact of spinal manipulative therapy in isolation on the treatment of individuals with cervicogenic headache (CGHA). Previous studies had investigated spinal manipulative therapy in tandem with other treatment strategies, but research lacked a clear consensus as to whether spinal manipulative therapy was superior to other manual therapy treatment approaches. Four researchers conducted the literature review and followed study selection criteria involving adults diagnosed with CGHA, primary treatment was SMT, comparison group utilized other forms of manual therapy, and study designs were RCTs. Outcome data was compiled into three groups of time intervals: short term (> 2 weeks, < 3 months) , intermediate term (> 3 months, < 12 months), and long term (> 12 months). A total of 7 RCTs were utilized in this systematic review following inclusion and exclusion criteria. Overall, there was low to moderate quality evidence among all three time intervals, with only a small significant effect of manual therapy on CGHA in the short term follow up for pain intensity, frequency, and disability. However, due to discourse on measuring MCID for CGHA, the study was unable to quantify its findings in a clinically significant way. More studies will need to be conducted in the future to investigate this further.
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 impact spinal manipulation can have on patients with cervicogenic headache in the short term in isolation to other treatments. However, due to the findings of the study showing only short term benefits, it is clear that other treatment efforts such as strengthening and stretching are necessary in addition to manual therapy alone. This is a good first way to build rapport and patient buy-in to therapy, but without adequate intervention progression spinal manipulation alone will not fully treat cervicogenic headache.
Author Names: Kara, S., Olson Hunt, M.J., Temes, B., Thiel, M., Swoverland, T., & Windsor, B.
Reviewer Name: Alex Roque, MA, SPT
Reviewer Affiliation(s): Duke Doctor of Physical Therapy
Paper Abstract:
Objectives: To determine the difference on neck outcomes with directional manipulation to the thoracic spine. There is evidence that thoracic spine manipulation is effective in treating patients with neck pain. However, there is no research that determines if the assessment of directional hypomobility and the selection of thrust direction offer improved outcomes. Methods: A total of 69 patients with cervical spine pain were randomly assigned to receive either a manipulation that was consistent with their thoracic spine motion loss (matched) or opposite their motion loss (unmatched). The patient was given care consistent with the orthopedic section guidelines for neck pain and the physical therapist’s clinical reasoning. Baseline outcome measures (NPRS, NDI, GROC) were taken and reassessed two days and two weeks after treatment. Results: Both groups had positive results when pain, neck disability index, and global rating of change were assessed. There was no difference between the matched and unmatched groups. Discussion: Directional manipulation of hypomobile thoracic spine segments may not be required to improved outcomes in patients with neck pain. Future studies should assess a variety of factors when determining the best available treatment, including manual therapy procedures, exercise, and patient selection. Level of Evidence: 1b.
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, only participants.
Were the people assessing the outcomes blinded to the participants’ group assignments?
Not mentioned.
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
NIH Risk of Bias Score: 11/14
Key Finding #1
Improvements in numeric pain rating scale, neck disability index, and global rating of change scale scores were found two days and two weeks following initial treatment in subjects who received manipulation in supine to the thoracic spine that corresponded to their motion limitation at the restricted segment.
Key Finding #2
Manipulation in supine to the thoracic spine that did not correspond to a patient’s motion limitation at the hypomobile segment resulted in short-term (two days) and medium term (two weeks) improvements in numeric pain rating scale, neck disability index, and global rating of change scale two days and two weeks.
Key Finding #3
There were no differences in short term (two days) and medium term (two weeks) improvements between manipulation in supine to the thoracic spine that corresponded to the motion limitation at the restricted segment and manipulation that did not correspond to the motion limitation.
Please provide your summary of the paper
The purpose of this study was to determine if there were short-term and medium-term (two weeks) differences in cervical spine outcomes when a manipulation was performed in the direction of the limitation at an identified hypomobile joint in patients with neck pain. Subjects were randomly assigned to receive thoracic spine manipulation in the supine position that either matched the movement limitation at the restricted segment (matched) or was opposite of their motion limitation (unmatched). Posterior to anterior passive accessory intervertebral motions were used to determine the most hypomobile vertebral segment. The patients either received a flexion or extension manipulation to the thoracic spine. The patients received treatment and were instructed to maintain motion with a home exercise program. Primary outcomes were numeric pain rating scale, neck disability index, and global rating of change scale, which were measured at baseline, two days after initial treatment, and two weeks following initial treatment. Both groups showed improvements in all cervical spine outcomes two days and two weeks following treatment. Additionally, there were no differences in the amount of improvement between groups. Applying manipulation in the direction of the motion restriction did not influence the outcomes measured throughout the study period.
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 support that manipulation to the thoracic spine can improve cervical spine outcomes in patients with neck pain. The direction of the manipulation appears to not have an effect on short term and medium-term improvements. These findings indicate that movement of the hypomobile segment is beneficial for these patients and may elicit physiological mechanisms that produces lasting effects. Additionally, this study shows that physical therapists do not have to apply a thoracic spine manipulation technique in the direction of a neck pain patient’s motion limitation. Instead, they can choose the technique that the patient prefers, which can further improve a patient’s physical therapy experience. Lastly, this study implies the importance of maintaining mobility gained with manipulations with a home exercise program.
Author Names
Mustafa Corum, Tugba Aydin, Cansin Medin Ceylan, and Fatma Nur Kesiktas
Reviewer Name
Dillan Rowley, SPT
Reviewer Affiliation(s)
Duke University Doctor of Physical department
Paper Abstract
Objectives
To evaluate the effects of two manual treatment methods on pain, disability, and pressure pain threshold (PPT) in tension-type headache (TTH) patients with and neck pain.
Methods
Forty-five patients with TTH were randomly assigned to one of three groups and received eight sessions treatment: manipulation plus exercise (manipulation), suboccipital inhibition plus exercise (myofascial release), and exercise only (control). Headache frequency, pain severity (VAS-headache, VAS-neck pain) and headache and neck disability (HIT-6 and NDI, respectively) were measured at baseline, posttreatment, and at the third month follow-up. PPT was also evaluated on the temporalis muscle.
Results
Manipulation group was statistically better than myofascial release group in terms of headache frequency, headache severity, and PPT scores. Also, manipulation group showed statistically significant improvements in all outcome criteria when compared control group.
Conclusions
Manipulation and exercise, in addition to pharmacologic treatment in TTH patients with cervical dysfunction appear to be a promising approach.
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)?
Similar
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?
Unsure
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
Cervical manipulation has a positive impact on tension type headaches when compared to myofascial release and exercise alone.
Key Finding #2
Myofascial release is more beneficial than exercise alone in relieving neck pain in those with tension type headaches.
Please provide your summary of the paper
This randomized controlled trial (RCT) included two intervention groups and one control group. All three groups performed exercise sessions three times per week, incorporating range of motion (ROM) and strengthening exercises. The two intervention groups received additional treatment twice a week for four weeks, totaling eight sessions. All treatments were administered by the same physician, ensuring consistency, and all participants followed the same exercise regimen. Exercise intensity was adjusted based on participants’ responsiveness to ensure safety and minimize irritation. Assessments were conducted before treatment, immediately after the eight sessions, and again three months later to evaluate progress. Results showed that at both post-treatment and the three-month follow-up, cervical manipulation combined with exercise was more effective in reducing headache frequency and intensity compared to myofascial release with exercise or exercise alone. However, further research with a larger sample size is needed to strengthen these findings.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Cervical manipulation, when combined with exercise, may be an effective treatment for patients with tension-type headaches. However, as only one specific manipulation technique was used in this study, it remains uncertain whether other techniques would yield similar benefits. Further research is needed to explore the effectiveness of different cervical manipulation methods.
Author Names: Iñaki Pastor-Pons, César Hidalgo-García, María Orosia Lucha-López, Marta Barrau-Lalmolda, Iñaki Rodes-Pastor, Ángel Luis Rodríguez-Fernández and José Miguel Tricás-Moreno
Reviewer Name: Emily Ryan, SPT
Reviewer Affiliation(s): Duke University School of Medicine Doctorate of Physical Therapy Program ‘26
Paper Abstract:
Background: Positional plagiocephaly (PP) is a cranial deformation frequent amongst children and consisting in a flattened and asymmetrical head shape. PP is associated with excessive time in supine and with congenital muscular torticollis (CMT). Few studies have evaluated the efficiency of a manual therapy approach in PP. The purpose of this parallel randomized controlled trial is to compare the effectiveness of adding a manual therapy approach to a caregiver education program focusing on active rotation range of motion (AROM) and neuromotor development in a PP pediatric sample.
Methods: Thirty-four children with PP and less than 28 week-old were randomly distributed into two groups. AROM and neuromotor development with Alberta Infant Motor Scale (AIMS) were measured. The evaluation was performed by an examiner, blinded to the randomization of the subjects. A pediatric integrative manual therapy (PIMT) group received 10-sessions involving manual therapy and a caregiver education program. Manual therapy was addressed to the upper cervical spine to mobilize the occiput, atlas and axis. The caregiver educational program consisted in exercises to reduce the positional preference and to stimulate motor development. The control group received the caregiver education program exclusively. To compare intervention effectiveness across the groups, improvement indexes of AROM and AIMS were calculated using the difference of the final measurement values minus the baseline measurement values. If the distribution was normal, the improvement indexes were compared using the Student t-test for independent samples; if not, the Mann-Whitney U test was used. The effect size of the interventions was calculated using Cohen’s d.
Results: All randomized subjects were analysed. After the intervention, the PIMT group showed a significantly higher increase in rotation (29.68 ± 18.41°) than the control group (6.13 ± 17.69°) (p = 0.001). Both groups improved the neuromotor development but no statistically significant differences were found. No harm was reported during the study.
Conclusion: The PIMT intervention program was more effective in increasing AROM than using only a caregiver education program. The study has been retrospectively registered at clinicaltrials.gov, with identification number
NCT03659032.
Registration date: September 1, 2018.
Keywords: Positional plagiocephaly, Deformational plagiocephaly, Manual therapy, Physical therapy, Congenital muscular torticollis
Quality Assessment of Controlled Intervention Studies
1. Was the study described as randomized, a randomized trial, a randomized clinical
trial, or an RCT – yes. Randomized controlled trial
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? No
9. Was there high adherence to the intervention protocols for each treatment group?
N/A
10. Were other interventions avoided or similar in the groups (e.g., similar background
treatments)? N/A
11. Were outcomes assessed using valid and reliable measures, implemented consistently
across all study participants? Yes, AIMS and AROM
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? Not sure
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: The restriction of cervical mobility and plagiocephaly did not affect the
neuromotor development in the sample
Key Finding #2: PIMT is considered an efficient and safe therapeutic alternative treatment of
restrictions of the cervical mobility in babies with plagiocephaly
Please provide your summary of the paper
Positional plagiocephaly (PP) is a condition in which a baby’s head, and sometimes face, becomes deformed due to pre-birth external molding forces (such as how the baby settles in the mother’s pelvis) and/or post-birth external molding forces (such as excessive time spent lying in a supine position) acting on a malleable and growing cranium. PP is generally characterized by an abnormally flattened and asymmetrical shape of the skull. Children with PP are more likely to develop conditions such as postural compensations, muscle flexibility and balance alterations, visual dysfunction, temporomandibular dysfunctions, mandibular and occlusal asymmetries, neurodevelopmental alterations, lower cognitive and academic performance, and language acquisition deficits. Although various developmental conditions are associated with plagiocephaly, congenital torticollis is most frequently linked to it, as restricted cervical spine rotation to one side can result from a head preference when lying in a supine position. This study examined the effects of manual therapy on active cervical rotation and neuromotor development in a sample of 34 children younger than 28 weeks who were diagnosed with non-synostotic moderate-to-severe positional plagiocephaly. The study was conducted as a randomized controlled trial (RCT), in which participants were randomly assigned to two intervention groups using a computer application. The control group received an evidence-based educational physical therapy program for caregivers, which consisted of exercises aimed at reducing positional preference and stimulating motor development. The intervention group received the same educational approach as the control group, along with a specific manual therapy protocol tailored for pediatric patients. This technique targeted the upper cervical spine to aid in remodeling cranial deformation. The dependent variables in this study were active cervical spine rotation and neuromotor development. Active range of motion (AROM) of the cervical spine was measured in each direction, with the center of the neck serving as the axis of rotation. To ensure inter-rater reliability, a cloth halo strap was used, connecting the most anterior part of the head (aligned with the nose) to the most posterior part. Measurements were taken in an upright position to assess head control in the sagittal plane. The examiner stood in front of the child and used a sound toy, moving it in a semicircle around the child to elicit end-range rotation in each direction. Three valid repetitions to each side were performed to ensure maximal rotation, and cervical AROM was recorded using photographic images. Two photographs were taken before the intervention—one on the first day and another 25 hours later—while the third photograph was taken after the intervention. Neuromotor development was assessed using the Alberta Infant Motor Scale (AIMS), which evaluates motor performance in infants based on milestones throughout early development. The AIMS consists of 58 items divided into four subcategories: prone position (21 items), supine position (9 items), sitting (12 items), and standing (16 items). To calculate a child’s AIMS score, one point was awarded for each observed motor performance item, with the total score determined by summing these points. To analyze the results, a one-way ANCOVA was performed, with a confidence interval of 95% and statistical significance set at p < 0.05. The study followed the principles of an intention-to-treat analysis. The results showed that the increase in right cervical rotation AROM was significantly greater in the pediatric manual therapy (PIMT) group compared to the control group. However, the increase in left cervical rotation AROM in the PIMT group was not significantly different from that in the control group. Total cervical rotation AROM increased in both groups, with significantly greater improvements observed in the PIMT group. Regarding neuromotor development, there was no significant difference in improvement between the groups based on AIMS scores.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
For pediatric patients with moderate to severe PP, it may be beneficial to incorporate PIMT into
their plan of care, alongside the evidence-based education that parents or guardians received in
both the control and PIMT groups. This study suggests that PIMT may be an effective manual
therapy technique for improving AROM of cervical rotation in both the left and right directions,
which could help reduce potential developmental complications as these children continue to
grow.
Author Names: Ferhat Simsek, Baha Naci, Meltem Bozaci Kilicoglu, Zeynep Alkan, Osman Melih Topcuoglu, Aysegul Gormez, Gunter Hafiz, Ali Fethi Okyar
Reviewer Name: Brian Santos
Reviewer Affiliation(s): Duke University School of Medicine, Doctor of Physical Therapy Program
Paper Abstract
Objective: Shoulder and neck dysfunctions resulting from spinal accessory nerve injury impair quality of life. This study aims to investigate the effects of manual therapy in combination with standard physiotherapy on the mechanical properties of muscle, neck and shoulder function, pain, and quality of life in head and neck cancer patients.
Study Design: Prospective, randomized, controlled, double-blind clinical trial.
Setting: Department of Otorhinolaryngology–Head and Neck Surgery of a university hospital.
Methods: A total of 26 participants were randomized into two groups. The control group (n = 11) received standard physiotherapy including therapeutic exercises, scar tissue massage, and education. The intervention group (n = 10) received manual therapy consisting of soft tissue, myofascial release, and mobilization techniques in combination with standard physiotherapy. Outcome measures were mechanical properties of muscle, neck and shoulder active range of motion, shoulder pain and disability, and quality of life.
Results: Upper trapezius and sternocleidomastoid muscle stiffness increased significantly in the control group (P < .01), whereas a significant reduction was observed in the intervention group compared to the control group (P = .001). A reduction in muscle thickness was observed bilaterally in both groups (P < .01). Moreover, all participants showed improvements in neck and shoulder active range of motion, shoulder pain, and quality of life (P < .01).
Conclusion: Manual therapy in addition to standard physiotherapy was more effective in improving neck and shoulder function, quality of life, and reducing muscle stiffness compared to standard physiotherapy alone. Therefore, clinicians should consider incorporating manual therapy into their treatment protocols to optimize patient outcomes.
Keywords: head and neck cancer; manual therapy; mechanical properties of muscle; muscle stiffness; physiotherapy; shear wave elastography; spinal accessory nerve
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? — 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 Findings
1. There was a notable increase in the shear modulus of the sternocleidomastoid and upper trapezius muscles on both the affected and the unaffected sides in the control group, whereas there was a statistically significant reduction on both the affected and unaffected sides in the intervention group.
2. There were notable and statistically significant improvements in cervical range of motion in both the control group and intervention group, but a larger and significant improvement was noted in the intervention group.
3. There were statistically significant improvements on the involved sides for shoulder active range of motion in abduction, flexion, and external rotation for both the control and intervention groups.
4. Both the control group and intervention group saw significant reductions in pain severity.
Summary of the Paper
Spinal accessory nerve injury is a potential complication associated with neck dissection in head and neck cancer. Spinal accessory nerve injuries are well understood to impair range of motion, quality of life, and muscle stiffness. The goal of this study was to investigate the role of physical therapy and manual therapy in comparison to just physical therapy on these measures. The study randomly allocated participants to one of these groups. The manual therapy group received all of the same interventions as the control group but also received myofascial release and mobilization techniques. The study found statistically significant improvements in muscle function and stiffness, active range of motion of both shoulders and the neck, and pain severity.
Clinical Interpretation
The findings suggest that a conventional physical therapy course centered around progressive resistance training was effective at improving muscle function and stiffness, active range of motion of both shoulders and the neck, and pain severity. Yet, there was a significant added benefit of including manual therapy, which included scapular mobilization and trapezius release. Greater observed improvements in all of the aforementioned measures suggest a larger clinical impact when manual therapy is included. Clinicians should consider incorporating manual therapy to optimize patient outcomes, especially in individuals recovering from spinal accessory nerve injury following head and neck cancer treatment.
Author Names: Ferhat Simsek, Baha Naci, Meltem Bozaci Kilicoglu, Zeynep Alkan, Osman Melih Topcuoglu, Aysegul Gormez, Gunter Hafiz, Ali Fethi Okyar
Reviewer Name: Brian Santos
Reviewer Affiliation(s): Duke University School of Medicine, Doctor of Physical Therapy Program
Paper Abstract:
Objective: Shoulder and neck dysfunctions resulting from spinal accessory nerve injury impair quality of life. This study aims to investigate the effects of manual therapy in combination with standard physiotherapy on the mechanical properties of muscle, neck and shoulder function, pain, and quality of life in head and neck cancer patients.
Study design: Prospective, randomized, controlled, double-blind clinical trial.
Setting: Department of Otorhinolaryngology Head and Neck Surgery of a university hospital.
Methods: A total of 26 participants were randomized into two groups. The control group (n = 11) received standard physiotherapy including therapeutic exercises, scar tissue massage, and education. The intervention group (n = 10) received manual therapy consisting of soft tissue, myofascial release, and mobilization techniques in combination with standard physiotherapy. Outcome measures were mechanical properties of muscle, neck and shoulder active range of motion, shoulder pain and disability, and quality of life.
Results: Upper trapezius and sternocleidomastoid muscle stiffness increased significantly in the control group (P < .01), whereas a significant reduction was observed in the intervention group compared to the control group (P = .001). A reduction in muscle thickness was observed bilaterally in both groups (P < .01). Moreover, all
participants showed improvements in neck and shoulder active range of motion, shoulder pain, and quality of life (P < .01).
Conclusion: Manual therapy in addition to standard physiotherapy was more effective in improving neck and shoulder function, quality of life, and reducing muscle stiffness compared to standard physiotherapy alone. Therefore, clinicians should consider incorporating manual therapy into their treatment protocols to optimize patient outcomes.
Keywords: head and neck cancer; manual therapy; mechanical properties of muscle; muscle stiffness; physiotherapy; shear wave elastography; spinal accessory nerve.
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 di6erential 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: There was a notable increase in the shear modulus of the sternocleidomastoid and upper trapezius muscles on both the a4ected and the unaffected sides in the control group, whereas there was a statistically significant reduction on both the affected and unaffected side in the intervention group.
Key Finding #2: There were notable and statistically significant improvements in cervical range of motion in both the control group and intervention group, but a larger and significant improvement were noted in the intervention group
Key Finding #3: There were statistically significant improvements on the involved sides for shoulder active range of motion in abduction, flexion, and external rotation for both the control group and intervention group.
Key Finding #4: Both the control group and intervention group saw significant reductions in pain severity.
Please provide your summary of the paper
Spinal accessory nerve injury is a potential complication associated with neck dissection in head and neck cancer. Spinal accessory nerve injuries are well understood to impair range of motion, quality of life, and muscle sti4ness. The goal of this study was to investigate the role of physical therapy and manual therapy in comparison to just physical therapy on these measures. The study randomly allocated participants to one of these groups. The manual therapy group received all of the same interventions as the control group but also received myofascial release and mobilization techniques. The study found statistically significant improvements in muscle function and sti4ness, active range of motion of both shoulders and the neck, and pain severity.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented. The findings suggest that conventional physical therapy course centered around progressive resistance training was effective at improving muscle function and stiffness, active range of motion of both shoulders and the neck, and pain severity. Yet, there was a significant added benefit of including manual therapy, which included scapular mobilization and trapezius release, with greater observed improvements in all of the
aforementioned measures to make a larger impact in your patient’s outcome.
Author Names: James Dunning, Raymond Butts, Noah Zacharko, Keith Fandry, Ian Young, Kenneth Wheeler, Jennell Day, César Fernández-de-Las-Peñas
Reviewer Name: Brian Santos
Reviewer Affiliation(s): Duke University School of Medicine, Doctor of Physical Therapy Program
Paper Abstract
Background context: Spinal manipulation, spinal mobilization, and exercise are commonly used in individuals with cervicogenic headache (CH). Dry needling is being increasingly used in the management of CH. However, questions remain about the effectiveness of these therapies and how they compare to each other.
Purpose: The present study aims to compare the combined effects of spinal manipulation and dry needling with spinal mobilization and exercise on pain and disability in individuals with CH.
Study design/setting: Randomized, multicenter, parallel-group trial.
Patient sample: One hundred forty-two patients (n = 142) with CH from 13 outpatient clinics in 10 different states were recruited over a 36-month period.
Outcome measures: The primary outcome was headache intensity as measured by the Numeric Pain Rating Scale. Secondary outcomes included headache frequency and duration, disability (Neck Disability Index), medication intake, and the Global Rating of Change (GROC). Follow-up assessments were taken at 1 week, 4 weeks, and 3 months.
Methods: Patients were randomized to receive upper cervical and upper thoracic spinal manipulation plus electrical dry needling (n = 74) or upper cervical and upper thoracic spinal mobilization and exercise (n = 68). In addition, the mobilization group also received a program of craniocervical and peri-scapular resistance exercises, whereas, the spinal manipulation group also received up to eight sessions of perineural electrical dry needling. The treatment period for both groups was 4 weeks. The trial was prospectively registered at ClinicalTrials.gov (NCT02373605). Drs Dunning, Butts and Young are faculty within the AAMT Fellowship and teach postgraduate courses in spinal manipulation, spinal mobilization, dry needling, exercise and differential diagnosis. The other authors declare no conflicts of interest. None of the authors received any funding for this study.
Results: The 2 × 4 analysis of covariance revealed that individuals with CH who received thrust spinal manipulation and electrical dry needling experienced significantly greater reductions in headache intensity (F = 23.464; p < .001), headache frequency (F = 13.407; p < .001), and disability (F = 10.702; p < .001) than those who received nonthrust mobilization and exercise at a 3-month follow-up. Individuals in the spinal manipulation and electrical dry needling group also experienced shorter duration of headaches (p < .001) at 3 months. Based on the cutoff score of ≥ +5 on the GROC, significantly (X² = 54.840; p < .001) more patients (n = 57, 77%) within the spinal manipulation and electrical dry needling group achieved a successful outcome compared to the mobilization and exercise group (n = 10, 15%) at 3-month follow-up. Between-groups effect sizes were large (0.94 < standardized mean score difference < 1.25) in all outcomes in favor of the spinal manipulation and electrical dry needling group at 3 months. In addition, significantly (X² = 29.889; p < .001) more patients in the spinal manipulation and electrical dry needling group (n = 49, 66%) completely stopped taking medication for their pain compared to the spinal mobilization and exercise group (n = 14, 21%) at 3 months.
Conclusion: Upper cervical and upper thoracic high-velocity low-amplitude thrust spinal manipulation and electrical dry needling were shown to be more effective than nonthrust mobilization and exercise in patients with CH, and the effects were maintained at 3 months.
Keywords: Acupuncture; Cervicogenic headache; Dry needling; Exercise; Spinal manipulation.
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? — 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 Findings
Key Finding #1: The findings of the study found that 7 sessions of spinal thrust manipulation primarily focused on atlanto-axial joints and a semi-standardized intramuscular and perineural electrical dry needling protocol resulted in greater improvements in headache intensity, disability, headache frequency, headache duration, and medication intake than non-thrust spinal mobilization and low-load cervical exercises.
Key Finding #2: Both groups, spinal thrust manipulation and dry-needling group and nonthrust manipulation and exercise, saw improvements in headache intensity at each time point of follow-up including 1 week after, 4 weeks after, and 3 months after. Statistically significant improvements between groups were noted at 4 weeks after, and 3 months after for the thrust manipulation and dry needling group.
Key Finding #3: Both groups, spinal thrust manipulation and dry-needling group and nonthrust manipulation and exercise, saw improvements in headache frequency at each time point of follow-up including 1 week after, 4 weeks after, and 3 months after. Statistically significant improvements between groups were noted at 4 weeks after, and 3 months after for the thrust manipulation and dry needling group.
Key Finding #4: Both groups, spinal thrust manipulation and dry-needling group and nonthrust manipulation and exercise, saw improvements in neck disability index at each time point of follow-up including 1 week after, 4 weeks after, and 3 months after. Statistically significant improvements between groups were noted at 1 week after, 4 weeks after, and 3 months after for the thrust manipulation and dry needling group.
Summary of the Paper
This randomized clinical trial investigated the combined effects of spinal thrust manipulation and dry needling compared to the combined effects of spinal mobilization and exercise on headache intensity, headache frequency, and neck disability. The participants received up to 8 treatment sessions with a frequency of 1–2 visits per week. Patients reported average intensity of headache pain from 0–10, headache frequency as the number of days in the last week, medication intake, and neck disability index at baseline, 1 week, 4 weeks, and 3 months following the initial treatment session. The findings of the study found that 7 sessions of spinal thrust manipulation primarily focused on atlanto-axial joints and a semi-standardized intramuscular and perineural electrical dry needling protocol resulted in greater improvements in headache intensity, disability, headache frequency, headache duration, and medication intake than non-thrust spinal mobilization and low-load cervical exercises.
Clinical Interpretation
This study provides valuable clinical insights into the various management strategies for working with individuals experiencing cervicogenic headaches. This study highlights that the best approach may include thrust manipulations and dry needling, but the more traditional improvements also showed improvements. Thus, when tailoring a plan towards a patient, it may be prudent, if indicated, to incorporate thrust manipulation and dry needling, but if not indicated or patient declines these interventions, then pursuing the more traditional approach will also be beneficial to the patient.
Author Names
Dario Calafiore, Nicola Marotta, Umile Giuseppe Longo, Michele Vecchio, Roberta Zito, Lorenzo Lippi, Francesco Ferraro, Marco Invernizzi, Antonio Ammendolia, Alessandro de Sire
Reviewer Name
Rachel Scott
Reviewer Affiliation(s)
Duke University DPT Student
Paper Abstract
Background: Chronic non-specific neck pain (CNSNP) is a highly prevalent musculoskeletal disorder associated with significant disability, resulting in growing recourse to healthcare providers, huge cost for society and a great number of workdays lost.
Objective: By this systematic review and metanalysis we aimed to assess the effects of different physical therapy techniques in patients with CNSNP.
Methods: PubMed, Scopus, and Web of Science databases were regularly used to search for articles published from 1st January 2010 until 31st January 2024. All RCTs were assessed for eligibility, including studies on: patients with diagnosis of CNSNP; physical therapy approaches such as manual therapy (MT) and therapeutic exercise (TE); waiting list, sham treatments, as comparison; Visual Analogue Scale, Numerical Rating Scale, Numerical Pain Rating Scale, and Numerical Pain Scale, as outcomes.
Results: At the end of the search, 14025 studies were identified. After the removal of duplicates, 10,852 were considered eligible according to title and abstract screening, while 10,557 papers were excluded after this process. Therefore; a total of 11 RCTs were included in this systematic review. A decrease of pain intensity was observed in all groups, albeit in patients being treated with TE and MT. Besides this, the combination of TE and MT demonstrated a 91% of probability to be the best choice in patients with CNSNP at the first visit. Only the combination of TE plus MT/cognitive behavioral therapy and MT as a single treatment showed a reduction in pain score. Overall, 3 studies (27.2%) showed a low risk of bias, 6 (54.5%) showed some concerns in bias assessment, and 2 (19%) a high risk of bias.
Conclusion: Collectively, the findings of this systematic review showed that MT and TE might be considered as effective rehabilitation approaches for treatment of pain in patients with CNSNP.
Keywords: chronic non-specific neck pain; cognitive behavioral therapy; manual therapy; physical therapy; therapeutic exercise.
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
Therapeutic exercise in combination with manual therapy produced better pain reduction than therapeutic exercise alone in four out of five studies which compared these two groups.
Key Finding #2
Therapeutic exercise was more effective than no treatment at reducing pain in patients with chronic nonspecific neck pain.
Key Finding #3
Two out of three studies showed no difference between therapeutic exercise combined with cognitive behavioral therapy as compared to therapeutic exercise alone.
Please provide your summary of the paper
This is a systematic review and meta-analysis to review the current literature on the effects of different physical therapy techniques on chronic non-specific neck pain (CNSNP). The search of the literature yielded 14025 RCTs and after screening, 11 RCTs were included in the review. The results of the review show a decrease of pain intensity in all groups. Therapeutic exercise in combination with manual therapy was shown to have the highest probability of being the best choice for patients with CNSNP at the first visit.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Therapeutic exercise, manual therapy, and cognitive behavioral therapy may be effective at reducing pain in patients with CNSNP. The best front-line approach in the first visit is manual therapy combined with therapeutic exercise. Cognitive behavioral therapy may be used to impart lasting changes and provide a comprehensive approach to psychologically informed practice in the treatment of CNSNP. Clinically, all approaches of therapy showed reduction of pain intensity versus no intervention, so any approach may be effective in improving symptoms in this patient population.
Author Names: Mark Wilhelm, Joshua Cleland, Anthony Carroll, Mark Marchinch, Margaret Imhoff, Nicholas Severini
Reviewer Name: Anna Smith, SPT
Reviewer Affiliation(s): Duke University
Paper Abstract
Background: Neck pain is among the most prevalent and costly musculoskeletal disorders. Manual therapy and exercise are two standard treatment approaches to manage neck pain. In addition, clinical practice guidelines recommend a multi-modal approach, including both manual therapy and exercise for the treatment of neck pain; however, the specific effects of these combined interventions have not recently been reported in the literature. Objective: To perform a systematic review and meta-analysis to determine the effect of manual therapy combined with exercise on pain, disability, and quality of life in individuals with nonspecific neck pain.
Design: Systematic Review and Meta-Analysis Methods: Electronic database searches were completed in PubMed, CINAHL, Cochrane, EMBASE, Ovid, and SportDiscus, with publication dates of January 2000 to December 2022. The risk of bias in the included articles was completed using the Revised Cochrane Risk of Bias Tool (RoB 2). Raw data were pooled using standardized mean differences and mean differences for pain, disability, and quality of life outcomes, and forest plots were computed in the metaanalysis.
Results: Twenty-two studies were included in the final review. With moderate certainty of evidence, three studies demonstrated no significant difference between manual therapy plus exercise and manual therapy alone in pain (SMD of −0.25 (95% CI: −0.52, 0.02)) or disability (−0.37 (95% CI: −0.92, 0.18)). With a low certainty of evidence, 16 studies demonstrated that manual therapy plus exercise is significantly better than exercise alone for reducing pain (−0.95 (95%CI: −1.38, −0.51)). Similarly, with low certainty of evidence, 13 studies demonstrated that manual therapy plus exercise is significantly better than exercise alone for reducing disability (−0.59 (95% CI: −0.90, −0.28)). Four studies demonstrated that manual therapy plus exercise is significantly better than a control intervention for reducing pain (moderate certainty) (−2.15 (95%CI: −3.58, −0.73)) and disability (low certainty) (−2.39 (95% CI: −3.80, −0.98)). With a high certainty of evidence, four studies demonstrated no significant difference between manual therapy plus exercise and exercise alone in quality of life (SMD of −0.02 (95% CI: −0.21, 0.18)). Conclusion: Based on this systematic review and meta-analysis, a multi-modal treatment approach including exercise and manual therapy appears to provide similar effects as manual therapy alone, but is more effective than exercise alone or other interventions (control, placebo, ‘conventional physical therapy’, etc.) for the treatment of nonspecific neck pain and related disability. Some caution needs to be taken when interpreting these results given the general low to moderate certainty of the quality of the evidence
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
Findings were consistent with the clinical practice guidelines for treating neck pain
Key Finding #2
Multi-modal (exercise and manual therapy) demonstrated better pain outcomes than exercise alone.
Key Finding #3
Multi-modal (exercise and manual therapy) demonstrated no statistically significant difference in pain outcomes than exercise alone.
Please provide your summary of the paper
Meta-analysis of research on interventions of exercise, manual therapy, and the combination of exercise and manual therapy to treat neck pain from 2000 to 12/2022. The primary outcome evaluated was neck pain; however, the paper also evaluated quality of life and disability as secondary outcomes. While some differences were found between the groups, the level of evidence for all results was low to moderate. Overall, research on non-specific neck pain continues to support a multi-modal approach utilizing manual therapy and exercise to treat 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.
Manual therapy is a key intervention for non-specific neck pain. Exercise does not demonstrate a significant influence on neck pain. However, this research does not investigate the evidence on the reoccurrence of neck pain. Clinicians should look for research on exercises’ role in prevention of neck pain before excluding the intervention before treating neck pain with solely manual therapy. This research further strengthens the current multi-modal recommendation of the clinical practice guidelines for treating neck pain.
Author Names
Francisco Gómez, Pablo Escribá, Jesús Oliva-Pascual-Vaca, Roberto Méndez-Sánchez, Ana Silvia Puente-González
Reviewer Name
Sierra Tosten, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
This study aimed to determine the immediate and short-term effects of a single upper cervical high-velocity, low-amplitude (HVLA) manipulation on standing postural control and cervical mobility in chronic nonspecific neck pain (CNSNP). A double-blinded, randomized placebo-controlled trial was performed. Forty-four patients with CNSNP were allocated to the experimental group (n = 22) or control group (n = 22). All participants were assessed before and immediately after the intervention, with a follow-up on the 7th and 15th days. In each evaluation, we assessed global and specific stabilometric parameters to analyze standing postural balance and performed the cervical flexion-rotation test (CFRT) to analyze upper cervical mobility. We obtained statistically significant differences, with a large effect size, in the limited cervical rotation and global stabilometric parameters. Upper cervical HVLA manipulation produced an improvement in the global stabilometric parameters, significantly decreasing the mean values of velocity, surface, path length, and pressure in all assessments (p < 0.001; ƞ 2 p = 0.323–0.856), as well as significantly decreasing the surface length ratio (L/S) on the 7th (−0.219 1/mm; p = 0.008; 95% confidence interval (CI): 0.042–0.395) and 15th days (−0.447 1/mm; p < 0.001; 95% CI: 0.265–0.629). Limited cervical rotation values increased significantly immediately after manipulation (7.409°; p < 0.001; 95% CI: 6.131–8.687) and were maintained during follow-up (p < 0.001). These results show that a single upper cervical HVLA manipulation produces an improvement in standing postural control and increases the rotational range of motion (ROM) in the upper cervical spine in patients with CNSNP.
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, participants were blinded. No, providers were not.
Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
Was there high adherence to the intervention protocols for each treatment group?
Yes
Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes
Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
Yes
Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Yes
Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Key Finding #1
Upper cervical high-velocity, low-amplitude (HVLA) manipulations demonstrated statistically significant improvement in global stabilometric parameters analyzing standing postural control, measured by surface-length ratio (L/S), in individuals with chronic nonspecific neck pain (CNSNP).
Key Finding #2
Upper cervical HVLA manipulations demonstrated statistically significant improvement in limited upper cervical rotation values, measured using the Cervical Flexion Rotation Test, in individuals with CNSNP.
Key Finding #3
The statistically significant effect of upper cervical HVLA manipulations on global stabilometric parameters analyzing standing postural control was achieved on day 7 and 15 post intervention, suggesting short-term benefits for those with CNSNP.
Key Finding #4
The statistically significant effect of upper cervical HVLA manipulations on upper cervical mobility was achieved immediately post intervention and sustained on day 7 and 15 post intervention, suggesting both immediate and short-term benefits for those with CNSNP.
Please provide your summary of the paper
The study by Gomez et el. evaluated the immediate and short-term effects of upper cervical high-velocity, low-amplitude (HVLA) manipulation on standing postural control and cervical mobility in individuals with chronic nonspecific neck pain (CNSNP) through a randomized controlled trial. CNSNP is associated with an unclear underlying cause or pathology lasting 12 weeks or more and is the leading presentation of neck pain. CNSNP is linked to high economic costs, disability, muscle alterations, decreased cervical mobility, increased pain sensitivity, and altered postural stability and proprioception. Cervical HVLA manipulations have been recommended for management of neck pain, guided by impairment and functional assessments. This study included 44 participants, with half assigned to an intervention group, which received a single upper cervical HVLA manipulation, and the other half assigned to the control group, which received a sham intervention. Both the participants and the assessors were blinded to the treatment groups; however, the physiotherapist performing the intervention was not blinded. Participants were assessed before and immediately following the intervention, and both 7- and 15-days post-intervention. Key outcomes included stabilometric parameters of standing postural control (specifically the surface-length ratio: S/L) and upper cervical range of motion obtained via the Cervical Flexion Rotation Test. A statistically significant difference was obtained in global stabilometric parameters (significantly decreased S/L ratio) at day 7 and 15, indicating short-term improvement in standing postural control following an upper cervical HVLA manipulation in individuals with CNSNP. Upper cervical rotation values also had a statistically significant increase both immediately after the intervention and on days 7 and 15, indicating both immediate and short-term improvements in upper cervical mobility following upper cervical HVLA manipulation in individuals with CNSNP.
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 by Gomez et al. provides insight into the clinical application of upper cervical HVLA manipulations in patients with CNSNP to improve immediate and short term upper cervical range of motion and standing postural stability. Key strengths of the study that minimize bias include its RCT design, with both the assessors and participants blinded to treatment groups. Other strengths include no participant dropout, a sufficiently large sample size, a highly experienced physiotherapist performing the upper cervical HVLA manipulation, and the use of validated measures such as stabilometric parameters and the Cervical Flexion Rotation Test to collect the key outcomes. The study’s findings of significant improvements in short-term postural control and immediate and short-term upper cervical mobility suggests benefits with clinical implementation of upper cervical HVLA manipulations for short term functional results in CNSNP patients. Limitations of the study include the lack of blinding of the physiotherapist to treatment allocation, a limited follow-up window ending at 15 days, and participant selection criteria which excluded individuals over 60 years old and those with pain in regions other than the head or neck. These factors limit the generalizability of the study to a broader, more representative clinical population, as many CNSNP patients may be older than 60 and/or have pain in other locations, therefore limiting the clinical applicability of this study. Additionally, the lack of long-term follow-up limits the ability to assess sustained clinical benefits in upper cervical mobility and postural control. Overall, the findings suggest upper cervical HVLA manipulations could be beneficial in clinical practice for improving short-term cervical mobility and postural control in younger to middle aged patients with CNSNP who lack other pain regions. These immediate and short-term postural and mobility improvements are likely to provide short-term functional gains with the clinical implementation of upper cervical HVLA mobilizations for CNSNP. However, the long-term effects of the intervention and the combined impacts of upper cervical HVLA mobilizations in a multimodal treatment approach should be explored.
Author Names
Emily Sandow
Reviewer Name
Katey Wang
Reviewer Affiliation(s)
Duke University
Paper Abstract
It has been reported that manual therapy directed at the thoracic spine followed by exercise may improve outcomes in patients with mechanical neck pain. At this point, there is little available data on dancers with neck pain, and it is unclear whether this type of treatment is appropriate for restoring the rigorous level of activity required of the dancer. The purpose of this study was to review the evaluation, clinical decision-making process, and treatment of two dancers-one with acute and the other with chronic neck pain-who fell into the classification of patients who might benefit from an intervention to the thoracic spine. The two participants were a musical theater dancer with an acute onset of neck pain and a retired dancer who was an active dance company director with an 11-year history of chronic neck pain. Both participants went through a standard examination and were treated with mobilizations to the upper thoracic spine followed by therapeutic exercises. In both cases, successful outcomes were achieved immediately after treatment and up to six months after discharge from physical therapy.
Quality Assessment Tool for Case Series Studies
Was the study question or objective clearly stated?
Yes
Was the study population clearly and fully described, including a case definition?
Yes
Were the cases consecutive?
N/A
Were the subjects comparable?
Yes
Was the intervention clearly described?
Yes
Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?
Yes
Was the length of follow-up adequate?
Yes
Were the statistical methods well-described?
No
Were the results well-described?
Yes
Key Finding #1
Thoracic mobilization before exercise is an effective treatment for mechanical neck pain in dancers with acute and chronic neck pain. This was true for both immediately after treatment and 6 months after discharge from physical therapy.
Key Finding #2
Upper thoracic mobilizations lead to immediate improvements in neck pain, muscle spasm, range of motion, and neural tension. Soft tissue manual therapy and thoracic spine mobilization demonstrated reduced muscle spasm, increased left rotation, neck range of motion, and decreased pain for one of the cases. The other dancer demonstrated improved cervical spine rotation, decreased pain on thoracic spring tests, and increased median nerve mobility after thoracic mobilization.
Key Finding #3
The clinical prediction rule for thoracic spine mobilization was applicable to both patients, demonstrating a high probability of success with thoracic mobilization, which is demonstrated in the positive results.
Key Finding #4
Hypomobility in the thoracic spine is likely contributing to neck pain in dancers. Stiffness and restrictions was revealed in both dancers thoracic spin, and immediate relief of symptoms was experienced post-mobilization.
Please provide your summary of the paper
The case studies reviewed thoracic spine manual techniques effect on mechanical neck pain. Two participants were described in the cases, one being a 28-year-old male musical theater dancer with acute onset neck pain, and the other being a 47-year-old female modern dancer with a history of 11 years of chronic neck pain. Both participants underwent a standard evaluation and the Numeric Pain Rating Scale, Neck Disability Index, Neck and Upper Limb Index, and Fear Avoidance Belief Questionnaire were the outcome measures used. The acute case used muscle energy technique at T4 to extend, left rotate, and left side bend, while the chronic case addressed T4 flexion restriction. Both dancers were provided active ROM exe rises for the neck, while the chronic case also received cervical stabilization and neural glide mobilizations. The mobilizations of the thoracic spine in combination with exercise was an effective treatment for mechanical neck pain in both cases, as they demonstrated immediate improvements in neck pain, muscle spasms, cervical ROM, and neural tension. Potential limitations addressed are the small sample size and descriptive nature, making it difficult to apply to broader populations.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
In clinical practice, consideration of the thoracic spine while treating the neck for athletes will be important. Regional interdependence was a highlight of the article, demonstrating the significance of addressing the thoracic spine, although the primary complaint is in the neck. This can be beneficial in cases where the cervical spine is tender and not tolerated as well as manipulating the thoracic spine. However, given that this study only reviewed two dancers, generalizations cannot be drawn to the entire dancer population with neck pain and this should be kept in mind while treating.
Author Names:
Natalie Pankrath, MS, Svenja Nilsson, BS, and Nikolaus Ballenberger, PhD
Reviewer Name:
John Wellers
Reviewer Affiliation(s)
Duke University Doctorate of Physical Therapy
Paper Abstract
Background: Cervical manipulations are widely used by physiotherapists, chiropractors, osteopaths, and medical doctors for musculoskeletal dysfunctions like neck pain and cervicogenic headache. The use of cervical manipulation remains controversial, since it is often considered to pose a risk for not only benign adverse events (AEs), such as aggravation of pain or muscle soreness, but also severe AEs such as strokes in the vertebrobasilar or carotid artery following dissections. Studies finding an association between cervical manipulation and serious AEs such as artery dissections are mainly case control studies or case reports. These study designs are not appropriate for investigating incidences and therefore do not imply causal relationships. Randomized controlled trials (RCTs) are considered the gold standard study designs for assessing the unconfounded effects of benefits and harms, such as AEs, associated with therapies.
Objective: Due to the unclear risk level of AEs associated with high-velocity, low-amplitude (HVLA) cervical manipulation, the aim of this study was to extract available information from RCTs and thereby synthesize the comparative risk of AEs following cervical manipulation to that of various control interventions.
Study Design: Systematic review and meta-analysis.
Methods: A systematic literature search was conducted in the PubMed and Cochrane databases. This search included RCTs in which cervical HVLA manipulations were applied and AEs were reported. Two independent reviewers performed the study selection, the methodological quality assessment, and the GRADE approach. Incidence rate ratios (IRR) were calculated. The study quality was assessed by using the risk of bias 2 (RoB-2) tool, and the certainty of evidence was determined by using the GRADE approach.
Results: Fourteen articles were included in the systematic review and meta-analysis. The pooled IRR indicates no statistically significant differences between the manipulation and control groups. All the reported AEs were classified as mild, and none of the AEs reported were serious or moderate.
Limitations: The search strategy was limited to literature in English or German. Furthermore, selection bias may have occurred, since only PubMed and Cochrane were used as databases, and searching was done by hand. RCTs had to be excluded if the results did not indicate the group in which the AEs occurred. A mandatory criterion for inclusion in the meta-analysis was a quantitative reproduction of the frequencies of AEs that could be attributed to specific interventions.
Conclusion: In summary, HVLA manipulation does not impose an increased risk of mild or moderate AEs compared to various control interventions. However, these results must be interpreted with caution, since RCTs are not appropriate for detecting the rare serious AEs. In addition, future RCTs should follow a standardized protocol for reporting AEs in clinical trials.
Key words: Cervical manipulation, adverse events, randomized controlled trial, systematic review, meta-analysis
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
In the manipulation group, 187 AEs occurred during 31,691 person-days, corresponding to an IR of 0.0059. In the control group, 251 AEs were observed during 30,623 person-days, giving an IR of 0.0082. None of the AEs that occurred were serious or moderate.
Key Finding #2
This paper self-identified as having a high risk of bias, because investigators were not blinded.
Please provide your summary of the paper
This was a meta-analysis of RCTs looking at adverse events associated with cervical HVLA manipulation techniques. After 5,711 potential studies were identified, 14 were included in this analysis after inclusion/exclusion criteria were applied. The paper found no significant difference in the rate of AE in groups that perceived HVLA cervical manipulation and those who did not. In the manipulation group, 187 AEs occurred during 31,691 person-days, corresponding to an IR of 0.0059. In the control group, 251 AEs were observed during 30,623 person-days, giving an IR of 0.0082. None of the AEs that occurred were serious or moderate. The risk of bias for this paper is high, as investigators were not blinded, however the inclusion/exclusion criteria were well-described, robust, and transparent.
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 should give clinician confidence to perform HVLA cervical manipulations. The risks of these maneuvers are low, and the adverse events that do occur are virtually never serious events. As more research comes out that demonstrates the contexts in which manipulations are beneficial to patient outcomes, clinicians should feel empowered to perform these techniques knowing that they are adequately safe.
