Cervicothoracic

Feasibility of a 4-Week Manual Therapy and Exercise Intervention on Posture and Function in Community-Dwelling Older Adults: A Pilot Study

Author Names

Hughes, L., Galloway, R., Fisher, S.

Reviewer Name

Becca Seeger, SPT

Reviewer Affiliation(s)

Duke University, Division of Physical Therapy

Paper Abstract

Background and Purpose: Thoracic hyperkyphosis is a common condition that progresses with aging and has been associated with impaired functional performance, increased risk of falls, and even mortality. Previous studies to improve posture primarily used exercise for durations of 3 months or longer. The purpose of this pilot study was to examine the feasibility of a manual therapy intervention in community-dwelling older adults over a 4-week time frame that is comparable to the typical clinical setting, to test the appropriateness and procedures for the measurement of posture and function in the older population with hyperkyphosis, and to collect preliminary data to describe change in posture and function measures. Methods: Twenty-four participants with hyperkyphosis or forward head posture were recruited, and 22 participants completed this pilot study. Feasibility was measured based on attendance, tolerance, safety, and retention. Issues with measurement procedures were recorded. The intervention included manual therapy and exercise 3 times a week for 4 weeks to target spinal and peripheral joint stiffness, muscle lengthening, and muscle activation. Outcomes included height, kyphotic index (KI), Block Test, Acromion to Table (ATT), Timed Up and Go (TUG), 5 times sit-to-stand (5XSTS), Functional Reach (FR), 2-minute walk test (2MWT), and Patient-Specific Functional Scale (PSFS). Data collected at visits 1, 6, and 12 were analyzed using 1-way repeated-measures multivariate analysis of variance. Results and Discussion: Measurement and intervention protocols were found to be feasible. A significant effect for the aggregate dependent variables change over time was found. Univariate analysis of each dependent variable showed significance except for FR. All postural measures (height, KI, Block Test, and ATT) significantly improved statistically. The KI and ATT exceed the minimal detectable change for clinical significance. Function showed statistical improvements in the TUG, 5XSTS, 2MWT, and PSFS. Clinical significance was reached with the PSFS. Seven of 9 measures showed a statistically significant change in just 2 weeks. Conclusions: This pilot study suggests that manual therapy and exercise applied to older adults shows promise for improvement in measures of posture and functional performance in a clinically feasible 4-week time frame.

NIH Risk of Bias Tool

Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group

Was the study question or objective clearly stated?

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

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

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

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

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

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

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

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

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

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

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

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Manual therapy and exercise delivered three times per week for four weeks increased the height of participants and reduced the forward head, rounded shoulders posture associated with excessive thoracic kyphosis.

Key Finding #2

Manual therapy and exercise delivered three times per week for four weeks improved functional measures in older adults such as the Timed Up and Go test, the 5 times sit-to-stand test, the 2-minute walk test, and the Patient-Specific Functional Scale.

Key Finding #3

Over the twelve visits, feasibility benchmarks of adherence to the schedule, tolerance to the intervention, safety of the intervention, and retention of participants were met.

Please provide your summary of the paper

This article examined the effects of manual therapy interventions in addition to exercise on posture and functional performance in community-dwelling older adults with hyper kyphosis. Additionally, the study aimed to see if it was feasible for change to occur over a 4-week time frame that is comparable to a standard clinical setting. The study utilized manual therapy that included myofascial release techniques as well as joint mobilizations from grade II to grade V. Manual therapy for each participant was tailored to their individual needs and was most commonly performed in the thoracic spine and ribs but was also performed in the extremities for some. After the manual therapy was performed, weak musculature was targeted for activation and neuromotor re-education. The goal was not to increase strength due to the 4-week time period of the study but rather to increase muscular activation through new ranges of motion that were provided as a result of the manual therapy techniques. The intervention occurred over 4 weeks with 3 visits per week resulting in 12 total visits. At the end of the 12 visits, it was found that there was a significant change in the primary postural measures of height, thoracic curvature, rounded shoulders, and forward head that exceeded measurement error. Additionally, it was found that there was significant improvement in measures including the Timed Up and Go test, the 5 times sit-to-stand test, the 2-minute walk test, and the Patient-Specific Functional Scale. In terms of feasibility, 22 of 24 participants completed all 12 visits, no adverse events were reported, and only 2 participants withdrew from the study meaning all benchmarks were met.

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

Although the response to the intervention is promising, there are several limitations to this study. The group of participants for this study were a sample of convenience meaning they were already motivated to participate and were all relatively high functioning. Additionally, this group lacked many of the comorbidities seen in the older adult population today. So while these results are encouraging, it is unlikely that they can be generalized to the whole older adult population. Additionally, there was no control group and no post intervention follow up. This study provides great results to back up the use of this intervention to improve posture and function in older adults but progressing to a RCT and including a wider variety of older adults including those with additional comorbidities would be necessary to actually prove the effectiveness of this intervention for this specific population. Even though further research appears to be needed on this intervention, in this time frame, for the older adult population, the results allow clinicians to consider manual therapy as a potential intervention to improve posture in aging adults. Additionally, it is important to consider that by changing the posture of older adults, clinicians can impact their functional movement and work towards preventing falls and other injuries. The results of this study also suggest that a 4-week clinical period is a feasible time frame to make meaningful change through the use of manual therapy and exercise.

Spinal Manual Therapy for Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Author Names

Yan Sun , Yong Zhang, Haoning Ma, Mingsheng Tan, and Zhihai Zhang

Reviewer Name

Kelly Anne Faulk, SPT

Reviewer Affiliation(s)

Duke Doctor of Physical Therapy Program

Paper Abstract

Objective. We conducted this meta-analysis to provide better evidence of the efficacy of manual therapy (MT) on adolescent idiopathic scoliosis (AIS). Methods. All RCTs of MT for the management of patients with AIS were included in the present study. The treatment difference between the experimental and control group was mainly MT. The outcomes consisted of the total effective rate, the Cobb angle, and Scoliosis Research Society-22 (SRS-22) questionnaire score. Electronic database searches were conducted from database inception to July 2022, including the Cochrane Library, PubMed, Web of Science, Embase, Wanfang Data, CNKI, and VIP. The pooled data were analyzed using RevMan 5.4 software. Results. Four RCTs with 213 patients in the experimental group were finally included. There are 2 studies of standalone MT in the experimental group and 3 studies of MT with identical conservative treatments in the control group. Three trials reported total effective rate, and a statistically significant difference was found (P = 0:004). Three trials reported Cobb angle, and a statistical difference was found (P = 0:01). Then, sensitivity analysis showed that there was a significant difference in the additional MT subgroup (P < 0:00001) while not in the standalone MT subgroup (P = 0:41). Three trials reported SRS-22 scores (P = 0:55) without significant differences. Conclusion. There is insufficient data to determine the effectiveness of spinal manipulation limited by the very low quality of included studies. High-quality studies with appropriate design and follow-up periods are warranted to determine if MT may be beneficial as an adjunct therapy for AIS. Currently, there is no evidence to support spinal manipulation.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

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

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

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

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

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

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

Was publication bias assessed?

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

Key Finding #1

Since the 4 RCTs were of low quality with insufficient data, the effectiveness of treating adolescent idiopathic scoliosis with manual therapy could not be determined.

Key Finding #2

Currently there is no evidence to support spinal manipulation in regards to treating adolescent idiopathic scoliosis.

Please provide your summary of the paper

This meta-analysis aimed to provide better evidence to support the effectiveness of manual therapy for adolescent idiopathic scoliosis. After analysis, only 4 low quality RCT’s from China fit the criteria involving subjects age 10 to 19 with a Cobb angle of >10 degrees. Across these 4 studies the following outcomes were investigated: the total effective rate, the Cobb angle, and the Scoliosis Research Society-22 (SRS-22) questionnaire score. The effective rate and Cobb angle were found to have a statistically significant difference, while the SRS-22 did not. The primary limitations of this meta-analysis were insufficient long follow up periods, a lack of standard definition of manual therapy, and an exclusion of side effects from manual therapy treatment. Overall, this meta-analysis was unable to find evidence to support spinal manipulation for adolescent idiopathic scoliosis. In the future more high-quality RCT’s will help determine if manual therapy is beneficial as an adjunct therapy for adolescent idiopathic scoliosis.

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 did not provide evidence to support manipulation for adolescent idiopathic scoliosis, it can serve as encouragement for physical therapists to explore adjunct treatment options for their patients. Such as looking into manual therapy treatments targeted at pain relief as opposed to curve reduction for adolescent idiopathic scoliosis patients.

Effectiveness of Manual Therapy to the Cervical Spine with and without Manual Therapy to the Upper Thoracic Spine in the Management of Non-specific Neck Pain; A Randomized Controlled Trial

Author Names

Arsh, A

Reviewer Name

Tim Cho, SPT

Reviewer Affiliation(s)

Duke DPT Class of 2025

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

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

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

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

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

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

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

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

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

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

Key Finding #1

Both cervical and cervical with thoracic manual therapy can be used to treat neck pain.

Key Finding #2

Combined cervical and thoracic manual therapy results in greater reductions in neck pain and disability.

Please provide your summary of the paper

This paper aimed to see whether manual therapy in both the cervical and thoracic spine would help patients with neck pain more than just manual therapy to the cervical spine. 37 participants were split into each group, all receiving 6 treatments during 2 weeks. While both groups improved, the combined treatment group significant improved more in pain and disability than the cervical manual therapy alone 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 thoracic spine is close to the cervical spine. Working on both regions together can be beneficial for neck pain. The patients in this study were primarily male, possibly because all patients “were assessed and treated by male physiotherapists,” which does not reflect our current understanding that females report higher prevalence of neck pain. Nonetheless, it seems like treating the spine more holistically rather then segmentally may be beneficial for reducing pain and disability.

Hypoalgesic Effects of Three Different Manual Therapy Techniques on Cervical Spine and Psychological Interaction: A Randomized Clinical Trial

Author Names

Alonso-Perez, J., Lopez-Lopez, A., Touche, R., Lerma-Lara, S., Suarez, E., Rojas, J., Bishop, M., Villafane, J., Fernandez-Carnero, J.

Reviewer Name

Jennifer Burris, SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy Program APTA

Paper Abstract

Objective: The purpose of this study was to evaluate the extent to which psychological factors interact with a particular manual therapy (MT) technique to induce hypoalgesia in healthy subjects. Methods: Seventy-five healthy volunteers (36 female, 39 males), were recruited in this double-blind, controlled and parallel study. Subjects were randomly assigned to receive: High velocity low amplitude technique (HVLA), joint mobilization, or Cervical Lateral glide mobilization (CLGM). Pressure pain threshold (PPT) over C7 unilaterally, trapezius muscle and lateral epicondyle bilaterally, were measured prior to single technique MT was applied and immediately after to applied MT. Pain catastrophizing, depression, anxiety and kinesiophobia were evaluated before treatment. Results: The results indicate that hypoalgesia was observed in all groups after treatment in the neck and elbow region (P < 0.05), but mobilization induces more hypoalgesic effects. Catastrophizing interacted with change over time in PPT, for changes in C7 and in manipulation group. Conclusions: All the MT techniques studied produced local and segmental hypoalgesic effects, supporting the results of previous studies studying the individual interventions. Interaction between catastrophizing and HVLA technique suggest that whether catastrophizing level is low or medium, the chance of success is high, but high levels of catastrophizing may result in poor outcome after HVLA intervention.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

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

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

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

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

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

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

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

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

Cannot Determine, Not Reported, or Not Applicable

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

Key Finding #1

All three manual therapy techniques used including high velocity, low amplitude (HVLA), cervical lateral glide mobilization (CLGM), and unilateral posterior to anterior mobilization at the cervical spine provided hypoalgesic effects in healthy subjects.

Key Finding #2

Pain catastrophizing was the only psychological factor to influence the level of hypoalgesic effect using pressure pain threshold for any manual technique.

Key Finding #3

The high velocity, low amplitude technique applied in the cervical region proved to have hypoalgesic effects both locally and at the elbow in healthy subjects.

Please provide your summary of the paper

This paper set out to evaluate which psychological factors can interact with 3 different manual therapy techniques at the cervical spine to provide hypoalgesic effect. Psychological factors considered include anxiety castrophizing or kinesiophobia because they are often associated with poor prognosis and pain outcomes. The authors used healthy subjects from a university that had no prior history or neck pain, rheumatologic conditions, spinal surgery, dizziness, or neurologic signs/symptoms. They measured pain prior to the treatment and then shortly after. All the manual techniques produced local and segmental hypoalgesic effects. Catastrophizing and HVLA technique had the most significant relationship. If catastrophizing is low or medium then the HVLA will most likely be successful.

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

I think the biggest takeaway from this study is that manual therapy techniques alone may not provide the most relief or be appropriate for all populations. These patients were pain-free therefore, we have to take into account if our patients are present with neck pain at baseline and have pain catastrophizing factors then manipulation may not be appropriate even with the knowledge it can provide hypoalgesic effect. We need to look at factors outside of pain prior to movement.

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

Article: Kuligowski, T., Skrzek, A., & Cieślik, B. (2021). Manual Therapy in Cervical and Lumbar Radiculopathy: A Systematic Review of the Literature. International journal of environmental research and public health, 18(11), 6176.

Full Text

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

NIH Risk of Bias Score: 7/8 (Low Risk of Bias) Key Findings of the Study:

1. The authors followed study design and intent consistent with their PROSPERO research proposition and used an adequate PRISMA RCT search strategy.

2. The studies included in this SR had an averaged PEDRO score of 6.65, representing low to moderate overall quality, limiting confidence in findings.

3. Definitions, parameters, indications, and executions of manual therapy techniques for those with CR or LR were heterogenous, limiting ability to adequately study and make conclusions on descriptive accuracy and true effect in functional outcomes.

4. Many studies (in particular those studying LR) included diverse and multimodal strategies with limited descriptive characteristics, making it difficult to understand isolated effect of manual therapy on primary outcomes.

5. For those with LR, exercise programs included activation of “core muscles”, spinal mobilization, and traction may be best. Those with acute, moderate-severe impairments seemed to benefit most from an active trunk exercise program, and those with more chronic symptoms seemed to benefit from flexion-distraction oriented exercises. Groups who received a combination of exercise and manual therapy had superior outcomes compared to those who received manual therapy alone.

6. For those with CR, exercise programs included deep neck flexor stabilization, scapular retraction, stretching, active range of motion, and isometric exercises around the shoulder girdle. CR groups who received a combination of exercise and manual therapy had functional outcomes that were superior to those receiving manual therapy alone.

7. Comparison of exercise programs was not the intent of this study, and therefore is improper to draw conclusions on exercise program effectiveness for those with radiculopathic conditions.

8. The most common manual therapy techniques included appears to be mechanical traction but based on available literature and findings of this review, a multimodal treatment approach with traction, spinal mobilizations, and exercise appears to optimize patient reported outcomes.

Reviewer Summary: Due to a combination of multimodal interventions, poor descriptions of manual therapy performed, and limited consistent use of primary outcome measures for CR & LR, it is difficult to understand the true role of manual therapy for those with radiculopathic conditions. It appears including traction of some form with exercise, spinal mobilization, and avoiding passive modalities may be best for patients with radiculopathic presentations. There does not appear to be a superior form of manual therapy for those with CR or LR, as spinal mobilizations, manipulations, manual/mechanical traction, and neural mobilizations were included in this review with a seemingly positive impact on functional outcomes. It appears that manual therapy techniques, along with an exercise program, should be included for those with radiculopathic conditions to maximize functional outcomes. Future directions for manual therapy and radiculopathy research must include better descriptive characteristics on the indication, execution, and post-treatment response. Additionally, standardization of exercise programs is recommended to better understand effects of manual therapy on functional outcomes for those with CR and LR.

The Impact of Spinal Manipulation on Migraine Pain and Disability: A Systematic Review and Meta-Analysis

Article: Rist PM, Hernandez A, Bernstein C, Kowalski M, Osypiuk K, Vining R, Long CR, Goertz C, Song R, Wayne PM. The Impact of Spinal Manipulation on Migraine Pain and Disability: A Systematic Review and Meta-Analysis. Headache. 2019 Apr;59(4):532-542.

Full Text

Study Design: Systematic Review Abstract: Several small studies have suggested that spinal manipulation may be an effective treatment for reducing migraine pain and disability. We performed a systematic review and meta-analysis of published randomized clinical trials (RCTs) to evaluate the evidence regarding spinal manipulation as an alternative or integrative therapy in reducing migraine pain and disability. PubMed and the Cochrane Library databases were searched for clinical trials that evaluated spinal manipulation and migraine-related outcomes through April 2017. Search terms included: migraine, spinal manipulation, manual therapy, chiropractic, and osteopathic. Meta-analytic methods were employed to estimate the effect sizes (Hedges’ g) and heterogeneity (I2 ) for migraine days, pain, and disability. The methodological quality of retrieved studies was examined following the Cochrane Risk of Bias Tool. The search identified 6 RCTs (pooled n = 677; range of n = 42-218) eligible for meta-analysis. Intervention duration ranged from 2 to 6 months; outcomes included measures of migraine days (primary outcome), migraine pain/intensity, and migraine disability. Methodological quality varied across the studies. For example, some studies received high or unclear bias scores for methodological features such as compliance, blinding, and completeness of outcome data. Due to high levels of heterogeneity when all 6 studies were included in the meta-analysis, the 1 RCT performed only among chronic migraineurs was excluded. Heterogeneity across the remaining studies was low. We observed that spinal manipulation reduced migraine days with an overall small effect size (Hedges’ g = -0.35, 95% CI: -0.53, -0.16, P < .001) as well as migraine pain/intensity. Spinal manipulation may be an effective therapeutic technique to reduce migraine days and pain/intensity. However, given the limitations to studies included in this meta-analysis, we consider these results to be preliminary. Methodologically rigorous, large-scale RCTs are warranted to better inform the evidence base for spinal manipulation as a treatment for migraine..

NIH Risk of Bias Score: 5/8 (Moderate Risk of Bias) Key Findings of the Study:

1. This preliminary meta-analysis suggest that spinal manipulation may reduce migraine days and pain/intensity.

2. However, variation in study quality makes it difficult to determine the magnitude of this effect.

3. Methodologically rigorous, large-scale RCTs are warranted to better inform the evidence base for the role of spinal manipulation in integrative models of care.

Reviewer Summary: This is not the strongest systematic review. The use of GRADE would have assisted in determining publication bias. At this point, despite this being the third systematic review on spine manipulation and migraines, I’m still not sure we have an understanding of whether it is truly clinically meaningful.

Thoracic Spine Manipulation for the Management of Mechanical Neck Pain: A Systematic Review and Meta-Analysis

Article: Masaracchio M, Kirker K, States R, Hanney WJ, Liu X, Kolber M. Thoracic spine manipulation for the management of mechanical neck pain: A systematic review and meta-analysis. PLoS One. 2019;14(2):e0211877. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6373960/

Study Design: Systematic Review

Abstract: The study’s objective was to investigate the role of thoracic spine manipulation (TSM) on pain and disability in the management of mechanical neck pain (MNP). The study reviewed the electronic databases of: PubMed, CINAHL, Pedro, Embase, AMED, the Cochrane Library, and clinicaltrials.gov were searched in January 2018. Eligible studies were completed RCTs, written in English, had at least 2 groups with one group receiving TSM, had at least one measure of pain or disability, and included patients with MNP of any duration. The search identified 1717 potential articles, with 14 studies meeting inclusion criteria. Methodological quality was evaluated independently by two authors using the guidelines published by the Cochrane Collaboration. Pooled analyses were analyzed using a random-effects model with inverse variance methods to calculate mean differences (MD) and 95% confidence intervals for pain (VAS 0-100mm, NPRS 0-10pts; 0 = no pain) and disability (NDI and NPQ 0–100%; 0 = no disability). Across the included studies, there was increased risk of bias for inadequate provider and participant blinding. The GRADE approach demonstrated an overall level of evidence ranging from very low to moderate. Meta-analysis that compared TSM to thoracic or cervical mobilization revealed a significant effect favoring the TSM group for pain (MD -13.63; 95% CI: -21.79, -5.46) and disability (MD -9.93; 95% CI: -14.38, -5.48). Meta-analysis that compared TSM to standard care revealed a significant effect favoring the TSM group for pain (MD -13.21; 95% CI: -21.87, -4.55) and disability (MD -11.36; 95% CI: -18.93, -3.78) at short-term follow-up, and a significant effect for disability (MD -4.75; 95% CI: -6.54, -2.95) at long-term follow-up. Meta-analysis that compared TSM to cervical spine manipulation revealed a non-significant effect (MD 3.43; 95% CI: -7.26, 14.11) for pain without a distinction between immediate and short-term follow-up. The greatest limitation in this systematic review was the heterogeneity among the studies making it difficult to assess the true clinical benefit, as well as the overall level of quality of evidence. The authors conclude that TSM has been shown to be more beneficial than thoracic mobilization, cervical mobilization, and standard care in the short-term, but no better than cervical manipulation or placebo thoracic spine manipulation to improve pain and disability.

NIH Risk of Bias Score: 8/8 (Low Risk of Bias)

Key Findings of the Study:

Thoracic spine manipulation (TSM) provided short-term pain, disability, and self-perceived rating of change in function in the majority of studies.

The technique should theoretically reduce the risk of adverse events that are present with spinal manipulation of the neck

Clinicians should interpret these findings carefully with an overall quality of evidence ranging from very low to moderate

Reviewer Summary: There does seem to be a short-term effect with thoracic manipulation for neck pain and function. The quality of the many studies is generally low and the effect does not seem to last much longer than 1 week (although some found differences between groups at longer periods. TSM appears to be a useful approach for selected individuals with neck pain in which a clinician may have concerns about applying direct manual therapy at the neck.

Pragmatic Application of Manipulation versus Mobilization to the Upper Segments of the Cervical Spine Plus Exercise for Treatment of Cervicogenic Headache: A Randomized Clinical Trial

https://doi.org/10.1080/10669817.2020.1834322

Effects of Cervical Spine Manual Therapy on Range of Motion, Head Repositioning, and Balance in Participants With Cervicogenic Dizziness: A Randomized Controlled Trial

Author Names

Reaid, S.A., Callister, R., Katekar, M.G., Rivett, D.A.

Reviewer Name

Paula Stonehouse Salinas

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: To evaluate and compare the effects of 2 manual therapy interventions on cervical spine range of motion (ROM), head repositioning accuracy, and balance in patients with chronic cervicogenic dizziness.

Design: Randomized controlled trial with 12-week follow-up using blinded outcome assessment.

Setting: University School of Health Sciences.

Participants: Participants (NZ86; mean age SD, 62.0 12.7y; 50% women) with chronic cervicogenic dizziness.

Interventions: Participants were randomly assigned to 1 of 3 groups: sustained natural apophyseal glides (SNAGs) with self-SNAG exercises, passive joint mobilization (PJM) with ROM exercises, or a placebo. Participants each received 2 to 6 treatments over 6 weeks.

Main Outcome Measures: Cervical ROM, head repositioning accuracy, and balance.

Results: SNAG therapy resulted in improved (P.05) cervical spine ROM in all 6 physiological cervical spine movement directions immediately posttreatment and at 12 weeks. Treatment with PJM resulted in improvement in 1 of the 6 cervical movement directions posttreatment and 1 movement direction at 12 weeks. There was a greater improvement (P<.01) after SNAGs than PJM in extension (mean difference, -7.5º; 95% confidence interval [CI], -13º to -2.0º) and right rotation (mean difference, -6.8º; 95% CI, -11.5º to -2.1º) posttreatment. Manual therapy had no effect on balance or head repositioning accuracy

Conclusions: SNAG treatment improved cervical ROM, and the effects were maintained for 12 weeks after treatment. PJM had very limited impact on cervical ROM. There was no conclusive effect of SNAGs or PJMs on joint repositioning accuracy or balance in people with cervicogenic dizziness.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

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

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

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

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

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

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

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

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

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

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

Key Finding #1

Among patients with chronic cervicogenic dizziness, SNAG exercises resulted in significant improvement in cervical spine ROM in all directions.

Key Finding #2

Comparing SNAG and PJM, the SNAG group had significantly greater changes in extension and right rotation posttreatment, but no differences at 12 weeks.

Key Finding #3

Manual therapy had no conclusive effect on head repositioning accuracy or balance.

Please provide your summary of the paper

This article studied the effects of 2 manual therapy interventions, passive joint mobilization (PJM) and sustained natural apophyseal glide (SNAG), on cervical ROM, head repositioning accuracy, and balance in people with cervicogenic dizziness. The participants in the SNAGs group received an anterior glide to the C1 or C2 vertebra and sustained the glide through head movement in the direction that produced dizziness. The participants were advised on how to self-SNAG using a strap placed on the cervical spine, as a home exercise to be performed as 6 repetitions once daily. The PJM group received mobilization to hypomobile or painful joints in the upper cervical spine. The participants were advised to perform cervical ROM exercises once a day. The placebo group received an intervention consisting of a deactivated laser. The study lasted 12 weeks. The outcome measures were cervical ROM, head repositioning accuracy, and balance. The SNAG group had greater ROM in all 6 cervical spine movement directions both after treatments and at 12 weeks (when participants performed self-SNAG at home). The PJM group had significant difference from placebo in left cervical rotation after treatment and right cervical rotation at 12 weeks. Comparing SNAG and PJM, the SNAG group had significantly greater changes in extension and right rotation posttreatment, but no differences at 12 weeks. There were no conclusive effect for SNAGs and PJMs on head repositioning accuracy nor balance in people with cervicogenic dizziness.

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

Based on the results, it can be concluded that treatment with SNAGs resulted in a greater improvement in cervical ROM than treatment with PJM. The article concludes that it is recommended to treat with SNAGs and ongoing self-SNAG exercises to improve cervical spine ROM in people with cervicogenic dizziness. Self-SNAGs is a simple technique that can be used outside the clinical setting to create significant changes in everyday activity and quality of life of people with cervicogenic dizziness. Clinicians can consider implementing this into their manual therapy techniques and home exercise programs as a functional approach to treatment.

Effectiveness of Pediatric Integrative Manual Therapy in Cervical Movement Limitation in Infants with Positional Plagiocephaly: A Randomized Controlled Trial

Author Names

Pastor-Pons, I and Garcia, C, and Lopez, M, and Lalmolda, M, and Pastor, I, and Fernandez, A, and Moreno, J

Reviewer Name

Annemarie Jacob

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

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.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

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

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

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

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

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

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

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

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

Key Finding #1

After the intervention, the group that received manual therapy showed a much higher increase in R cervical rotation actively and total cervical ROM overall. There weren’t many significant differences noted on the left.

Key Finding #2

Coupling pediatric integrative manual therapy with the caregiver education program leads to better results in cervical ROM and congenital muscular torticollis than just receiving the caregiver education program.

Please provide your summary of the paper

Positional plagiocephaly is very common amongst the pediatric population and it is frequently seen with congenital muscular torticollis. This article looks at the relationship between pediatric integrative manual therapy (PIMT) and AROM. 34 children were assessed and randomly placed in two groups. One receiving PIMT and caregiver education while the control group only exclusively received caregiver education. After results were analyzed, the intervention group showed a significantly higher increase in rotation than the control group. From this study, it can be concluded that adding PIMT to a caregiver educational program can lead to better outcomes overall in neck movement in children with positional plagiocephaly.

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

I think that there were a lot of limiting factors involved in this study. The relationship between active and passive ROM in the pediatric population was not looked at. There also weren’t any studies analyzed that looked at long-term outcomes to assess the true relevance of the data found. However, even though there were a good amount of limitations, in babies with cervical restrictions in mobility, PIMT can be considered an efficient intervention. At the moment, it’s considered the most effective and least dangerous form of manual therapy that can be provided to this population.

Using Functional Magnetic Resonance Imaging to Determine if Cerebral Hemodynamic Responses to Pain Change Following Thoracic Spine Thrust Manipulation in Healthy Individuals

Author Names

Sparks, C., Cleland, J., Elliott, J., Zagardo, M., Liu, W.C.

Reviewer Name

Sara Yuen, student physical therapist

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study Design: Case series. Objectives: To use blood oxygenation level-dependent functional magnetic resonance imaging (fMRI) to determine if supraspinal activation in response to noxious mechanical stimuli varies pre-and post-thrust manipulation to the thoracic spine. Background: Recent studies have demonstrated the effectiveness of thoracic thrust manipulation in reducing pain and improving function in some individuals with neck and shoulder pain. However, the mechanisms by which manipulation exerts such effects remain largely unexplained. The use of fMRI in the animal model has revealed a decrease in cortical activity in response to noxious stimuli following manual joint mobilization. Supraspinal mediation contributing to hypoalgesia in humans may be triggered following spinal manipulation. Methods: Ten healthy volunteers (5 women, 5 men) between the ages of 23 and 48 years (mean, 31.2 years) were recruited. Subjects underwent fMRI scanning while receiving noxious stimuli applied to the cuticle of the index finger at a rate of 1 Hz for periods of 15 seconds, alternating with periods of 15 seconds without stimuli, for a total duration of 5 minutes. Subjects then received a supine thrust manipulation directed to the mid-thoracic spine and were immediately returned to the scanner for reimaging with a second delivery of noxious stimuli. An 11-point numeric pain rating scale was administered immediately after the application of noxious stimuli, premanipulation and postmanipulation. Blood oxygenation level-dependent fMRI recorded the cerebral hemodynamic response to the painful stimuli premanipulation and postmanipulation. Results: The data indicated a significant reduction in subjects’ perception of pain (P<.01), as well as a reduction in cerebral blood flow as measured by the blood oxygenation level-dependent response following manipulation to areas associated with the pain matrix (P<.05). There was a significant relationship between reduced activation in the insular cortex and decreased subjective pain ratings on the numeric pain rating scale (r = 0.59, P<.05). Conclusion: This study provides preliminary evidence that suggests that supraspinal mechanisms may be associated with thoracic thrust manipulation and hypoalgesia. However, because the study lacked a control group, the results do not allow for the discernment of the causative effects of manipulation, which may also be related to changes in levels of subjects’ fear, anxiety, or expectation of successful outcomes with manipulation. Future investigations should strive to elicit more conclusive findings in the form of randomized clinical trials.

NIH Risk of Bias Tool

Was the study question or objective clearly stated?

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

Were the cases consecutive?

Were the subjects comparable?

Was the intervention clearly described?

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

Was the length of follow-up adequate?

Cannot Determine, Not Recorded, Not Applicable

Were the statistical methods well-described?

Were the results well-described?

Key Finding #1

The study explores the potential of fMRI to help identify supraspinal structures associated with pain reduction following spinal manipulation.

Key Finding #2

The insular cortex was the only area analyzed that showed a significant relationship with the reduction in subjective pain reports using the verbal 11- point numeric pain rating scale.

Key Finding #3

This study offers insight into mechanisms that might underlie manual therapy’s contribution to pain management via the insular cortex. The insular cortex is part of the limbic system and is theorized to be involved in modulating how much attention the patient should allot to the nociceptive stimulus based on memory and the selective transmission of sensory information based on context. It is possible that high velocity end-range thrust manipulations to the spine affect that neural process.

Please provide your summary of the paper

It is a classic question: By what mechanism(s) does spinal manipulation affect a patient’s pain reduction? This study uses hemodynamic displacement as a theorized correlate of neural activity to measure levels of activation to noxious stimuli pre and post thrust manipulation. Although the real-world processing of pain is complicated by other psychosocial and physiological stimuli, the authors of this paper state that previous literature notes the “somatosensory cortices, insula, anterior cingulate cortex, the premotor and supplementary motor areas, and subcortical structures, including the thalami and amygdala” are the cortical and subcortical structures that are most commonly activated in correlation with nociception. A comparison of pre and post manipulation imaging revealed a significant decrease in activation in those brain structures following thrust manipulation to the thoracic spine.

This thoracic thrust manipulation technique was described as “a high velocity, end-range, anterior/ posterior force applied through the elbows and directed to the midthoracic spine on the lower thoracic spine in cervical thoracic flexion…. performed with the patient positioned in supine….[T]he therapist used her manipulative hand to stabilize the inferior vertebra of the targeted motion segment and used her body to push down through the patient’s arms, performing a high velocity, low amplitude thrust.”

The authors single out the insular cortex as the only area analyzed that showed a significant relationship with the reduction in subjective pain reports using the verbal 11- point numeric pain rating scale. The authors also discuss that belief in the effectiveness of thrust manipulation and habituation may also modulate participant’s expectations and the excitability or inhibition of their dorsal horn structures to fire and report sensory information up the chain. The authors suggest pain reduction following high velocity, end-range manipulation to the thoracic spine may be influenced by cortical and subcortical interactions within the human brain.

A limitation of fMRI studies is their ecological validity–a real patient’s pain experienced during activity out in the community is not likely well simulated by monofilaments applied to the finger, and no one lives in an fMRI. Another limitation is that the participants were recruited from a “physical therapist education program.” They may have had prior beliefs about manual therapy. The sample size of the study is small and performed on healthy, pain-free adults– different from the patient population to which the treatment technique would be applied. This study also lacked a control group and does not follow the participants’ change over time. The authors write that this was purposeful, as their objective was to create a testing protocol to apply noxious stimuli and fMRI pre and post manipulation to a human population.

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

Clinicians should keep in mind that while fMRI studies can be useful, an fMRI measures changes in levels of deoxygenated hemoglobin; it measures a correlate of neural activity, not neural activity itself. As these authors put it, images allow, “inferences to be made regarding neural activity within the brain.” For these reasons, clinicians should not throw out fMRI studies altogether, but approach them with a healthy perspective. It is helpful to remember that firing a specific neuron does not repeatedly lead to the same physiological action or experience, it is not a one-to-one relationship that can be applied across all patients. The nervous system is a network of firings continuously adapting its wirings based on an individual’s experiences.

Comparison of Manual Therapy and Exercise Therapy for Postural Hyperkyphosis: A Randomized Clinical Trial

Author Names

Kamali, Fahimeh; Shirazi,Sara; Ebrahimi, Samaneh; Mirshamsi, Maryam; Ghanbari, Ali.

Reviewer Name

Jessika Barnes, LPTA, SPT

Reviewer Affiliation(s)

Duke DPT Program

Paper Abstract

Abstract: Objective: To compare the efficacy of a manual therapy and an exercise therapy program in improving postural hyperkyphosis among young adults. Methods: Forty-six women between the ages of 18 to 30 years with thoracic kyphosis diagnosed by flexicurve ruler were randomly assigned to either an exercise therapy or a manual therapy group. The exercise therapy program focused on stretching and strengthening exercises in 15 sessions over 5 weeks. The manual therapy group received 15 sessions of manual techniques including massage, mobilization, muscle energy and myofascial release. Kyphosis angle and back extensor muscle strength were measured with a motion analysis system and a dynamometer at the baseline and after treatment. The data were analyzed with paired and independent t-tests. Results: After treatment, the angle of thoracic kyphosis was smaller and back extensor muscle strength was significantly greater in both the exercise and manual therapy groups (p < 0.001). We found no significant differences between groups in the changes in kyphosis angle or muscle strength after treatment (p > 0.05). Conclusion: Manual therapy was as effective as exercise therapy in reducing kyphosis angle and increasing back extensor muscle strength in young women with postural hyperkyphosis.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

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

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

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

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

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

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

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

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

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

Key Finding #1

Hyperkyphosis defined as excessive thoracic curvature of the thoracic spine (>40 degrees) is one of the spinal abnormalities that may develop during adolescence. Increasing the thoracic curvature may lead to pain, breathing difficulties or damage to internal organs, in addition to cosmetic deformities.

Key Finding #2

After the treatments, the thoracic kyphosis angle in both sitting positions was reduced and back extensor muscle strength was significantly increased in both the exercise and manual therapy groups.

Key Finding #3

In this study, both exercise and manual therapy were effective in reducing thoracic kyphosis angle and increasing back extensor muscle strength in women with postural hyperkyphosis.

Please provide your summary of the paper

This study looked at the effects of both exercise and manual therapy and whether they effectively reduced thoracic kyphosis angle and increased back extensor muscle strength in women with postural hyperkyphosis. The patients in the exercise therapy group performed 15 sessions of stretching and strengthening exercises for five weeks. The exercises included stretching the pectoralis major, extensor muscles, and latissimus dorsi muscle. Strengthening of the anterior neck flexors and back extensor muscles. The manual therapy group received 15 sessions of manual techniques by a trained and certified manual therapist over five weeks. The techniques included massage, mobilization, muscle energy, and myofascial release. After the treatments, the thoracic kyphosis angle in both sitting positions was reduced, and back extensor muscle strength was significantly increased in both the exercise and manual therapy groups. This study concluded that exercise and manual therapy effectively reduced thoracic kyphosis angle and increased back extensor muscle strength in women with postural hyperkyphosis.

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 made me realize that exercise and manual therapy can both be effective equally. I would be interested to see the results if both manual therapy and exercise was provided to one group. I plan utilize both manual therapy and exercise when I treat my future patients.

Does the Addition of Manual Therapy Approach to a Cervical Exercise Program Improve Clinical Outcomes for Patients with Chronic Neck Pain in Short-term and Mid-term? A Randomized Controlled Trial

Author Names

Rodriguez-Sanz, J. et al

Reviewer Name

Megan Benzie, SPT, B.S.

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Chronic neck pain is one of today’s most prevalent pathologies. The International Classification of Diseases categorizes four subgroups based on patients’ associated symptoms. However, this classification does not encompass upper cervical spine dysfunction. The aim is to compare the short- and mid-term effectiveness of adding a manual therapy approach to a cervical exercise protocol in patients with chronic neck pain and upper cervical spine dysfunction. Fifty-eight subjects with chronic neck pain and upper cervical spine dysfunction were recruited (29 = Manual therapy + Exercise; 29 = Exercise). Each group received four 20-min sessions, one per week during four consecutive weeks, and a home exercise regime. Upper flexion and flexion-rotation test range of motion, neck disability index, craniocervical flexion test, visual analogue scale, pressure pain threshold, global rating of change scale, and adherence to self-treatment were assessed at the beginning, end of the intervention and at 3- and 6-month follow-ups. The Manual therapy + Exercise group statistically improved short- and medium-term in all variables compared to the Exercise group. Four 20-min sessions of Manual therapy + Exercise along with a home-exercise program is more effective in the short- to mid-term than an exercise protocol and a home-exercise program for patients with chronic neck pain and upper cervical dysfunction.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

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

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

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

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

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

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

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

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

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

Cannot Determine, Not Reported, or Not Applicable

Key Finding #1

The participants who received manual therapy and exercise had statically significant better outcomes than the exercise only group.

Key Finding #2

Three participants in the exercise only group had mild neck pain at the six month follow up, which the exercise and manual therapy group had no reported long term symptoms.

Key Finding #3

The sample size was 29 participants total. A small sample size can cause the findings to not be as transferable to similar population groups than if there were a larger sample size.

Key Finding #4

This study did not discuss or look into which manual therapy technique is most effective for this patient population.

Please provide your summary of the paper

This randomized, longitudinal controlled trial looked at the effect of utilizing manual therapy with exercise versus only exercise for the treatment of upper cervical neck pain. This study used four 20-minute sessions, once a week for four weeks. It looked at upper flexion, flexion-rotation test range of motion, neck disability index, craniocervical flexion test, the visual analogue pain threshold, etc. The manual therapy performed was individualized to the specific participant and aimed to improve the range of motion at a specific joint, which was measured by the flexion rotation test. These patients also showed decreased ratings of pain and an increased pressure pain threshold. For both groups, the exercises used were standardized and performed. The group with exercise and manual therapy showed more improvement than the exercise only group at both short and midterm follow ups in neck disability index, patients’ perfection of improvement, range of motion, pain intensity, and pressure pain thresholds. This study shows the potential importance of utilizing manual therapy for upper cervical neck pain, in addition to an individualized exercise program. This study did not look into which exercises result in the greatest ECG activation or which manual therapy technique is most effective. Therefore, individualized care and continued research is needed.

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 for upper cervical pain, manual therapy in conjunction with exercise is an effect treatment. These participants were also only treated once a week, for four weeks. This shows that manual therapy may be able to take effect in a short time period. However, the study only had 29 participants total. Further studies would need to be done with much larger sample sizes for this to be applicable to a large population group. In addition, the most effective type of manual therapy for this population was not studied, but would be helpful for clinicians.

Upper Cervical and Upper Thoracic Manipulation versus Mobilization and Exercise in Patients with Cervicogenic Headache: A Multi-center Randomized Clinical Trial

Author Names

Dunning, J., Butts, R., Mourad, F., Young, I., Penas, C., Hagins, M., Stanislawski, T., Donley, J., Buck, D., Hooks, T., Cleland, J.

Reviewer Name

Ericka Boeger, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Although commonly utilized interventions, no studies have directly compared the effectiveness of cervical and thoracic manipulation to mobilization and exercise in individuals with cervicogenic headache (CH). The purpose of this study was to compare the effects of manipulation to mobilization and exercise in individuals with CH.

Methods: One hundred and ten participants (n = 110) with CH were randomized to receive both cervical and thoracic manipulation (n = 58) or mobilization and exercise (n = 52). The primary outcome was headache intensity as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included headache frequency, headache duration, disability as measured by the Neck Disability Index (NDI), medication intake, and the Global Rating of Change (GRC). The treatment period was 4 weeks with follow-up assessment at 1 week, 4 weeks, and 3 months after initial treatment session. The primary aim was examined with a 2-way mixed-model analysis of variance (ANOVA), with treatment group (manipulation versus mobilization and exercise) as the between subjects variable and time (baseline, 1 week, 4 weeks and 3 months) as the within subjects variable.

Results: The 2X4 ANOVA demonstrated that individuals with CH who received both cervical and thoracic manipulation experienced significantly greater reductions in headache intensity (p < 0.001) and disability (p < 0.001) than those who received mobilization and exercise at a 3-month follow-up. Individuals in the upper cervical and upper thoracic manipulation group also experienced less frequent headaches and shorter duration of headaches at each follow-up period (p <0.001 for all). Additionally, patient perceived improvement was significantly greater at 1 and 4-week follow-up periods in favor of the manipulation group (p < 0.001).

Conclusions: Six to eight sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with CH, and the effects were maintained at 3 months.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

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

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

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

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

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

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

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

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

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

Key Finding #1

Primary outcome: The manipulation group had statistically significant greater improvements in Numeric Pain Rating Scale (NPRS) at the 1-week and 3-month follow-up appointments.

Key Finding #2

Secondary outcomes: The manipulation group had greater reductions in the disability index at all follow-up periods. This group also experienced greater perceived improvement at all follow-up periods (measured by the GRC). The frequency and duration of headaches were significantly lower in the manipulation group, and they also experienced a greater reduction in medication intake.

Key Finding #3

The results listed above suggest that 6-8 therapy sessions (over a 4-week time period) with manipulation of the upper cervical and upper thoracic spines have greater improvements and benefits than mobilization combined with exercise for patients diagnosed with cervicogenic headache.

Please provide your summary of the paper

This summary is a multi-center randomized clinical trial that compared the use of cervical and thoracic manipulation vs mobilization and exercise on headache intensity, frequency, duration, disability index, medication intake, and global rate of change in patients with cervicogenic headaches.

There were 110 participants involved who were diagnosed with cervicogenic headache. They were randomized to the cervical and thoracic manipulation group or the mobilization and exercise group. The main outcome was headache intensity. However, they also measured headache frequency, duration, disability index, medication intake, and global rate of change. They received treatment for 4 weeks (total of 6-8 treatment sessions) and were re-assessed with the above outcome measures at 1 week, 4 weeks, and 3 months. The manipulation group received manipulations targeting the right and left C1-2 articulation and bilateral T1-2 articulations during at least one session and other sessions could include repeating the C1-2 and/or T1-2 manipulations or targeted other spinal manipulations (C0-1, C2-3, C3-7, T2-9, ribs 1-9). The mobilization and exercise group received mobilizations targeting the right and left C1-2 articulation and bilateral T1-2 articulations during at least one session and other sessions could include repeating the C1-2 and/or T1-2 mobilizations or targeted other spinal mobilizations (C0-1, C2-3, C3-7, T2-9, ribs 1-9). The also performed cranio-cervical flexion and shoulder girdle progressive resistance exercises, specifically targeting the lower trapezius and serratus anterior.

The results demonstrated that the manipulation group experienced better outcomes overall, such as statistically significant improvements in NPRS, greater reductions in the disability index, and experienced less frequent headaches at the follow-up appointments. A decrease in medication intake was also greater for the manipulation group. The authors discussed that although the manipulation group demonstrated more significant improvements, the mobilization and exercise group also demonstrated improvements. They also mentioned that the techniques used may not be generalizable to other manual therapy techniques. They pondered why the manipulation group had better outcomes and mentioned that more research should be conducted. However, the current thought is that high-velocity manipulation with impulse duration of <200ms can, “alter afferent discharge rates by stimulating mechanoreceptors and proprioceptors.” It is also thought that manipulation stimulates deep paraspinal musculature receptors, where mobilization is likely more superficial. The decrease in pain following manipulation is thought to be due to biomechanical, spinal or segmental, and central descending inhibitory pain pathways. However, further research needs to be conducted.

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 can impact clinical practice by giving therapists an idea of whether manipulation or mobilization and exercise are more effective for patients with cervicogenic headache. This study demonstrated that therapists should consider using spinal manipulations in patients with cervicogenic headache due to the positive outcomes noted at each follow-up appointment and the longer-lasting impact at the 3-month follow-up appointment. However, both groups did make clinical improvements. This is important to consider because all patients respond differently to different treatments. Therefore, the clinician should try different techniques and use the one(s) that the patient responds best to and that offers the best results for each individual.

Manual therapy, Exercise Therapy or Combined Treatment in the Management of Adult Neck Pain – A Systematic Review and Meta-Analysis

Author Names

Fredin, K., & Lorås, H

Reviewer Name

Meera V. Bucklin, SPT

Reviewer Affiliation(s)

Duke DPT

Paper Abstract

This study looks at the musculoskeletal condition of neck pain and its two main therapies- manual therapy, exercise therapy, and a combination of the two. The study assesses whether or not the combined treatment of manual therapy (MT) and exercise therapy (ET) are more effective than either in isolation in relieving pain and improving function in adults with neck pain graded I-II through a systematic review and meta-analysis. The studies included were found on EMBASE, MEDLINE, AMED, CENTRAL, and PEDro through the dates of July 2017 and if they rated pain intensity or disability on a numeric scale. A secondary outcome assessed was quality of life. The studies were assessed using the PEDro scale, and the quality of evidence was assessed as being low, citing the lack of blinding of patients and therapists for 4 of the studies. The meta-analysis found 1169 articles and was narrowed down to 7 studies that were used that investigated the addition of ET to MT. Small and non-significant differences were found in pain at rest, neck disability, and QOL at immediate post-treatment, 6 months, and 12-month follow-ups. The quality of evidence was moderate for pain-at-rest outcomes and moderate to low for neck disability and QOL outcomes. The combined treatment of MT and ET for neck pain does not seem to be more effective in reducing neck pain at rest or neck disability or improving QOL in adult patients with grade I-II neck pain than ET alone.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

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

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

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

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

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

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

Was publication bias assessed?

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

Key Finding #1

There were non-significant differences in pain at rest, neck disability, and QOL for patients with just ET alone and MT with ET.

Key Finding #2

Long-term outcomes of combined therapy were considered to be low-quality evidence as there was a loss of follow-up and presented with little to insignificant differences in outcomes.

Key Finding #3

The study finds a gap in research for the effects of solely MT compared to ET as opposed to the combined therapy comparisons.

Key Finding #4

The study results indicated that if manual therapy has effects it ad little to the overall treatment outcomes when in supplement to exercise therapy for patients with neck pain.

Please provide your summary of the paper

This study found that there were no significant short or long-term effects of the addition of manual therapy to exercise therapy in the outcomes of patients with grade I-II neck pain but listed several limitations to their study. They had less than 1000 total participants over 7 included studies and noted only including studies written in English listed as limitations to their study. As a strength of this study, the inclusion criteria were strict in its inclusion of what manual therapy was. # articles were not included as their intervention of manual therapy was hot pack and heat therapy as well so it can be determined this meta-analysis looked at true manual therapy interventions. Secondly, it acknowledges the heterogeneity of neck pain and the benefits of a multi-mechanism approach to treatment.

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

This study’s overall rating of finding moderate to low-quality evidence to support the treatment of neck pain with MT and ET was used to support the need for further research on the sole and combined effects of both treatments at varying points in time. Although this study does not point towards or away from manual therapy it does offer insight into the level of research available to justify it as an intervention.

Effect of Post-isometric Relaxation versus Myofascial Release Therapy on Pain, Functional Disability, ROM and QOL in the Management of Non-specific Neck Pain: A Randomized Controlled Trial

Author Names

Zainab Khalid Khan, Syed Imran Ahmed, Aftab Ahmed Mirza Baig, and Waqas Ahmed Farooqui

Reviewer Name

Jordan Burnett, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Non-specific neck pain is the most prevailing musculoskeletal disorder which has a large socioeconomic burden worldwide. It is associated with poor posture and neck strain which may lead to pain and restricted mobility. Physical therapists treat such patients through several means. Post isometric relaxation and myofascial release therapy are used in clinical practice with little evidence to be firmed appropriately. So, this study was conducted to explore the effect of Post-isometric relaxation in comparison to myofascial release therapy for patients having non-specific neck pain. Methodology: Sixty patients were randomly allocated to Post isometric group and the Myofascial group. The treatment period was of 2 weeks. All the patients were evaluated using the Visual analogue scale (VAS), Neck disability index (NDI), Universal Goniometer, and WHO BREF Quality of life-100 in the 1st and 6th sessions. Recorded data was entered on SPSS 21. Data were examined using two-way repeated ANOVA to measure the variance of analysis (group x time). Results: Analysis of the baseline characteristics revealed that both groups were homogenous in terms of age and gender i.e. a total of 60 participants were included in this research study 30 in each group. Out of 60 patients, there were 20(33.3%) males and 40(66.7%) females with a mean age of 32.4(5.0) years. Participants in the Post Isometric group demonstrated significant improvements (p<0.025) in VAS, NDI, Cervical Extension, left side rotation ranges, and QoL (Social Domain) at the 2-week follow-up compared with those in the myofascial group. In addition, the myofascial group indicated significantly better improvement in the mean score of CROM (flexion and right and left side bending). Conclusion: The study demonstrated patients with nonspecifc neck pain can benefit from the post isometric relaxation with significant improvement in pain, disability, cervical ROM, and Quality of life compared with myofascial release therapy.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

Cannot Determine, Not Reported, or Not Applicable

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

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

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

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

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

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

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

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

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

Key Finding #1

Post isometric relaxation (PIR) and myofascial release (MFR) are both helpful in decreasing pain, increasing cervical ROM, decreasing neck-related disability, and increasing quality of life (QOL) in patients with non-specific neck pain.

Key Finding #2

PIR showed more statistically significant effects than MFR in decreasing pain scores, improving cervical extension and bilateral rotation, and in increasing patients’ QOL in the social domain.

Key Finding #3

The findings in this article generally align with positive effects noted in prior studies investigating effectiveness of PIR, though others did not compare the effects of PIR on non-specific neck pain to the effects of MFR.

Please provide your summary of the paper

Authors investigated the effect of post isometric relaxation (PIR) and myofascial release (MFR) on pain, cervical range of motion (CROM), neck disability, and quality of life (QOL) in patients with non-specific neck pain (NSNP). PIR is a type of muscle energy technique that activates muscles and joint mechanoreceptors through isometric contraction of a muscle, stimulating Golgi tendon organs and leading to an inhibitory reflex allowing the muscle to relax. MFR is a technique directed at soft tissue through application of low load and long duration tension to restricted fascia, often with therapists’ hands or elbows. Participants were blinded to the intervention they received three times per week for two weeks, though both interventions included cryotherapy and isometric cervical strengthening in addition to either the PIR or MFR. The authors found that while both PIR and MFR improved CROM, decreased pain and disability, and increased quality of life (QOL) for patients with NSNP, PIR demonstrated greater and statistically significant effects. The study is limited in that the follow up was only two weeks so there was no analysis of long-term effects.

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

This paper demonstrates a comparison of two types of manual techniques that direct change through different mechanisms, which can be beneficial for identification of an optimal technique. When deciding between manual therapy techniques for patients with non-specific neck pain, this study reports that muscle energy techniques, specifically post isometric relaxation (PIR), can help decrease pain, increase range of motion, and increase quality of life. The effects were only measured after two weeks of treatment with six sessions total, so it is unclear what the long-term effects would be and if PIR would still be helpful with lower frequency; these data can be used to guide initial treatment and alongside clinical reasoning rather than as a long-term plan to follow to treat patients with non-specific neck pain.

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

Author Names

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

Reviewer Name

Alyssa Bush, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

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

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

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

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

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

Cannot Determine, Not Reported, or Not Applicable

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

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

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

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

Key Finding #1

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

Key Finding #2

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

Key Finding #3

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

Please provide your summary of the paper

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

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

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

Effectiveness of Manual Therapy and Acupuncture in Tension-Type Headache: A Systematic Review

Author Names

Turkistani A, Shah A, Jose AM, et al.

Reviewer Name

Kyra Callens, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Tension-type headache is one of the most prevalent types of headache. The common presentation is a mild-to-moderate dull aching pain around the temporal region, like a tight band around the forehead, neck, shoulder, and sometimes behind eyes. It can occur at any age but most commonly in the adult female population. The exact underlying mechanism is not clear but muscle tension is one of the main causes, which can be due to stress and anxiety. There are several non-pharmacologic treatment options suggested for tension-type headaches, such as cognitive behavioral therapy, relaxation, biofeedback, acupuncture, exercise, manual therapy, and even some home remedies. This systematic review was performed to evaluate the effectiveness of acupuncture and manual therapy in tension-type headaches. The literature search was primarily done on PubMed. Eight articles involving 3846 participants showed evidence that acupuncture and manual therapy can be valuable non-pharmacological treatment options for tension-type headaches. Acupuncture was compared to routine care or sham intervention. Acupuncture was not found to be superior to physiotherapy, exercise, and massage therapy. Randomized controlled trials done in various countries showed manual therapy also significantly decreased headache intensity. Manual therapy has an efficacy that equals prophylactic medication and tricyclic antidepressants in treating tension-type headaches. The available data suggests that both acupuncture and manual therapy have beneficial effects on treating symptoms of tension-type headache. However, further clinical trials looking at long-term benefits and risks are needed.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

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

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

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

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

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

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

Was publication bias assessed?

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

Key Finding #1

The implementation of acupuncture shows a 50% decrease in headache frequency in patients with tension type headaches.

Key Finding #2

Manual therapy appears to be the most common form of non-pharmacological treatment for tension type headaches and indicates a decrease in headache symptoms, frequency, and intensity.

Please provide your summary of the paper

Tension type headaches are the most common type of primary headaches, as well as the second most common chronic condition. This systematic review determines the effectiveness of manual therapy and acupuncture on tension type headaches. Majority of the articles used in this review came from PubMed and were screened by two independent authors. Two random control trials indicated that acupuncture shows a 50% decrease in headache frequency, however, short term effects can only be observed as participants were given this treatment for 3 months. Another study showed correlation between acupuncture treatment and improvement in overall quality of life. Manual therapy appears to be the most common form of non-pharmacological treatment for tension type headaches. The effects of manual therapies on the relief of headache symptoms ranged from 17.0% to 82.0%. Head and neck massage showed a reduction in headache intensity, and with the incorporation of relaxation and stretching twice a week, headache days were statistically significantly reduced. Mobilizations of cervical and thoracic spines along with exercise and postural correction indicated a significant reduction in headache frequency.

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

This systematic review indicated the effectiveness of acupuncture and manual therapy on the symptoms and frequency of tension type headaches, as well as overall quality of life. Therefore, these treatments may be beneficial for patients presenting with tension headaches. While common acupuncture points were presented, a standard effective prescription needs to be established in order to better determine the effectiveness of acupuncture. Accordingly, to determine the true short and long term benefits of manual therapy more research needs to be done implementing a standardized protocol.

Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review

Author Names

Boyes, R; Toy, P; Mellon Jr., J; Hayes, M; Hammer, B

Reviewer Name

Andres Carro

Reviewer Affiliation(s)

Duke University School of Medicine: Doctor of Physical Therapy

Paper Abstract

Abstract Study design Systematic review of randomized clinical trials. Objective Review of current literature regarding the effectiveness of manual therapy in the treatment of cervical radiculopathy. Background Cervical radiculopathy (CR) is a clinical condition frequently encountered in the physical therapy clinic. Cervical radiculopathy is a result of space occupying lesions in the cervical spine: either cervical disc herniations, spondylosis, or osteophytosis. These affect the pain generators of bony and ligamentous tissues, producing radicular symptoms (i.e. pain, numbness, weakness, paresthesia) observed in the upper extremity of patients with cervical nerve root pathology. Cervical radiculopathy has a reported annual incidence of 83·2 per 100 000 and an increased prevalence in the fifth decade of life among the general population. Results Medline and CINAHL via EBSCO, Cochrane Library, and Google Scholar were used to retrieve the randomized clinical trial studies for this review between the years of 1995 and February of 2011. Four studies met inclusion criteria and were considered to be high quality (PEDro scores of ⩾5). Manual therapy techniques included muscle energy techniques, non-thrust/thrust manipulation/mobilization of the cervical and/or thoracic spine, soft-tissue mobilization, and neural mobilization. In each study, manual therapy was either a stand-alone intervention or part of a multimodal approach which included therapeutic exercise and often some form of cervical traction. Although no clear cause and effect relationship can be established between improvement in radicular symptoms and manual therapy, results are generally promising. Conclusion Although a definitive treatment progression for treating CR has not been developed a general consensus exists within the literature that using manual therapy techniques in conjunction with therapeutic exercise is effective in regard to increasing function, as well as AROM, while decreasing levels of pain and disability. High quality RCTs featuring control groups are necessary to establish clear and effective protocols in the treatment of CR. Keywords: Cervical radiculopathy, Conservative treatment, Manual therapy, Manipulation, Mobilization, Non-operative, Physiotherapy, Physical therapy

NIH Risk of Bias Tool

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

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

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

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

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

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

Was publication bias assessed?

Cannot Determine, Not Reported, Not Applicable

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

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Rangonese found that those with cervical radiculopathy who received a combination of manual therapy and exercise interventions showed a significant improvement measures of pain when compared to only manual therapy and only therapeutic exercise groups, yet all three groups demonstrated statistically significant improvements.

Key Finding #2

Cleland et al. found that 66.7% of the patients within the study that were treated with thoracic spine thrust mobilization as part of their treatment had a successful outcome that met the minimally clinically important change (MCIC) for the NDI, PSFS, NPRS, and GROC at re-examination

Key Finding #3

In the Cleland et al’s article, 57% of patients who received non-thrust manipulation to the cervical spine as part of their treatment protocol for CR had successful outcomes

Key Finding #4

In the Rangonese article, 56.5% of patients who received neural dynamic techniques or neural mobilizations had a successful outcome.

Please provide your summary of the paper

This systematic review of the literature on the effectiveness of manual therapy as a treatment for cervical radiculopathy (CR) found that the general consensus within the literature is that manual therapy can be used as an effective adjunct to exercise therapy in the treatment of cervical radiculopathy. Four articles were used in this systematic based on the authors’ inclusion criteria. All four articles found a reduction in pain with some form of manual therapy treatment. Rangonese found that pain improved more with manual therapy and exercise combination groups than each treatment group alone. While three of the four articles did not specify exactly what manual therapy techniques were performed the articles in review reach a general consensus that thrust mobilizations, non-thrust mobilizations, neural dynamic techniques, and muscle energy techniques all have some evidence as successful forms of treatment for CR meeting the minimal clinically important changes (MCIC) in multiple pain and function 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.

This paper summarizes the literature that was available from 1995-2011 for manual therapy’s effectiveness as a treatment for cervical radiculopathy (CR), and really shows the potential that manual therapy has as a treatment for these patients but also demonstrates the dearth of quality RCTs that have been conducted to find a cause and effect relationship. The largest issue with the majority of the articles utilized is that they do not specify the manual therapy techniques utilized for many of these patients and only specify the category of manual therapy (i.e. muscle energy, non-thrust mobilization, etc.) used as part of a treatment protocol for patients with CR. The Rangonese article takes a step in the right direction by separating out treatment groups and specifying the type of manual therapy performed on the patients involved in the study. Clinically, these results can be used in a limited manner, but do at least show the therapist that there are no harms in utilizing manual therapy and that the literature is trending towards showing that manual therapy is an effective treatment as an adjunct to exercise for patients with CR.

Effects of the Manual Therapy Approach of Segments C0-1 and C2-3 in the Flexion-Rotation Test in Patients with Chronic Neck Pain: A Randomized Controlled Trial

Author Names

Rodríguez-Sanz, J., Malo-Urriés, M., Lucha-López, MO., Pérez-Bellmunt, A., Carrasco-Uribarren, A., Fanlo-Mazas, P., Corral-de-Toro, J., Hidalgo-García, C.

Reviewer Name

Casie Coffman SPT, NBC-HWC

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

BACKGROUND: Flexion-rotation test predominantly measures rotation in C1-2 segment. Restriction in flexion-rotation may be due to direct limitation in C1-2, but also to a premature tightening of the alar ligament as a result of lack of movement in C0-1 or C2-3. The aim of this study was to compare the effect of a 20-min single cervical exercise session, with or without manual therapy of C0-1 and C2-3 segment in flexion-rotation test, in patients with chronic neck pain and positive flexion-rotation test. METHODS: Randomized controlled clinical trial in 48 subjects (24 manual therapy+exercise/24 exercise). Range of motion and pain during flexion-rotation test, neck pain intensity and active cervical range of motion were measured before and after the intervention. RESULTS: Significant differences were found in favour of the manual therapy group in the flexion-rotation test: right (p < 0.001) and left rotation (p < 0.001); pain during the flexion-rotation test: right (p < 0.001) and left rotation (p < 0.001); neck pain intensity: (p < 0.001); cervical flexion (p < 0.038), extension (p < 0.010), right side-bending (p < 0.035), left side-bending (p < 0.002), right rotation (p < 0.001), and left rotation (p < 0.006). CONCLUSIONS: Addition of one C0-C1 and C2-C3 manual therapy session to cervical exercise can immediately improve flexion-rotation test and cervical range of motion and reduce pain intensity.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

Cannot Determine, Not Reported, or Not Applicable

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

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

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

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

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

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

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

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

Cannot Determine, Not Reported, or Not Applicable

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

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

Key Finding #1

Combined manual therapy and exercise resulted in a statistically significant reduction in pain intensity measured via NPRS.

Key Finding #2

Exercise alone did not result in statistically significant changes in pain intensity measured via NPRS.

Key Finding #3

Combined manual therapy and exercise resulted in a greater increase in ROM assessed during the flexion-rotation test.

Please provide your summary of the paper

This RCT compared the effects of cervical exercise with or without the addition of manual therapy in individuals with chronic neck pain and a positive flexion-rotation test. 48 participants who met the inclusion criteria of chronic neck pain (greater than 3 months), a positive flexion-rotation test, and loss of C1-0 and/or C2-3 motion were randomly assigned groups. The primary outcome was ROM available during the flexion-rotation test. Current pain intensity and pain intensity during the flexion-rotation test were assessed via the numeric pain rating scale (NPRS). Active cervical ROM was measured with a cervical ROM (CROM) device. Each group underwent a 20-minute session. In the exercise (control) group, participants performed 2 sets of 10 reps of a deep neck flexor exercise, held for 10 seconds with 40 seconds of rest between reps and 2 minutes of rest between sets. The combined manual therapy and exercise (experimental) group underwent manipulation and/or mobilization of C0-1 and C2-3 spinal segments prior to exercise. Within 3 minutes and with the participant’s head in a near neutral position, up to 2 trials of thrusts could be performed at each indicated level. Mobilization was performed for 45 seconds with 15 seconds of rest between cycles. Participants then performed the same exercise intervention, with the minor difference of a 30-second rest between reps to keep total session durations consistent. Within-group and between-group outcomes favored combined manual therapy and exercise across all domains. After intervention, the combined manual therapy and exercise group demonstrated a statistically significant difference in the improvement of ROM (bilateral rotation) and pain intensity during the flexion-rotation test compared to the exercise-only group. There were also significantly better outcomes in current pain intensity. Lastly, while active cervical ROM decreased in some measures of the exercise group, the combined manual therapy and exercise group demonstrated improved left side-bending. Furthermore, between-group differences for cervical AROM showed statistically significant differences in all directions.

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

Neck pain is a prevalent condition that people across older and younger ages experience, particularly with desk work. Pain can become disabling and costly, which makes physical therapy a valuable intervention to attempt. This study showed that combining C0-1 and C2-3 manual therapy with exercise can immediately improve pain intensity and ROM in individuals with chronic neck pain and a positive flexion-rotation test. While this can be easily adopted to clinical practice, it should be noted that the long-term efficacy of this treatment is unknown, and requires further research.

Effectiveness of pediatric integrative manual therapy in cervical movement limitation in infants with positional plagiocephaly: a randomized controlled trial

Author Names

Pastor-Pons I., Hidalgo-García C., Lucha-López M.O., Barrau-Lalmolda M., Rodes-Pastor I., Rodríguez-Fernández A.L., Tricás-Moreno J.M.

Reviewer Name

Abby Davis, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

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

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

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

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

Cannot Determine, Not Reported, or Not Applicable

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

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

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

Cannot Determine, Not Reported, or Not Applicable

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

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

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

Cannot Determine, Not Reported, or Not Applicable

Key Finding #1

Infants in the pediatric integrative manual therapy (PIMT) group had a statistically significant increase in right cervical rotation active range of motion compared to the control group.

Key Finding #2

There was no statistical difference in AIMS scores between the PIMT group and the control group.

Key Finding #3

Manual therapy focusing on mobilization of the occiput, C1, and C2 via traction and assistance in all head movements can be utilized along with strengthening exercises and caregiver education to treat infants with positional plagiocephaly.

Please provide your summary of the paper

This study sought to compare the effectiveness of pediatric integrative manual therapy (PIMT) to the cervical spine and caregiver education (including exercise therapy) on infants with moderate to severe positional plagiocephaly. PIMT included mobilization of the occiput, C1, and C2, utilizing some gentle distraction and moving the infant’s head into flexion, extension, side bending, and rotation once the infant moves into one of these directions. Physical therapists avoided end-range extension and rotation. For 10 weeks, the patients in the PIMT group had manual therapy once a week for 20 minutes. The control group received a program consisting of exercises that alter positional preference and augment development. This group met once more during the 10 weeks. The PIMT group also received the same program as the control group. Outcomes used to measure changes were AROM and the Alberta Infant Motor Scale. The results showed a statistically significant increase in right cervical AROM in the PIMT group compared to the control, although the baseline of the PIMT group’s right cervical AROM was lower than the control group. Additionally, there was no significant difference in AIMS score improvement over the 10 weeks between the groups.

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

Based on the results of this study, cervical manual therapy appears effective in increasing active range of motion in infants with positional plagiocephaly. It may be beneficial for clinicians to include this in the treatment of these patients, alongside strengthening exercises and caregiver education, but is not necessarily crucial to treatment. There were no differences in the AIMS between the two groups, showing neither is more effective than the other in fostering neurodevelopment. Ideally, further studies should be completed with PIMT and long-term outcome to assess any neurodevelopment changes over time. Most important to note is for physical therapists to not move the infant into end range cervical extension and rotation during this therapy. Altogether, PIMT is an effective therapy that can assist physical therapists in treating restrictions of the cervical spine in infants with positional plagiocephaly.

Manipulative Therapies for Infant Torticollis

Author Names

Brurberg KG, Dahm KT, Kirkehei I

Reviewer Name

Abby Davis, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctorate of Physical Therapy Division

Paper Abstract

Background: Professionals in fields including chiropractic, physiotherapy, manual therapy and osteopathy recommend manipulation techniques for the treatment of infant torticollis. This article summarises the research evaluating such treatment. Material and method: The article is based on a search in MEDLINE, EMBASE, CINAHL, Cochrane CENTRAL, AMED, PEDro, and the Index to Chiropractic Literature in August 2017. Controlled studies were included to assess efficacy, and observational studies to reveal the risk of harm. Results: We reviewed 3 418 unique hits from the literature search. We included three randomised controlled studies on the efficacy of manual therapy or osteopathy and three observational studies on possible adverse effects. Two studies on manual therapy suggested that manipulation techniques do not have any greater effect on symmetry and motor outcomes than parental guidance, physiotherapy and home exercises. One study suggested that osteopathy may contribute to increased symmetry compared to placebo, but the clinical significance of this change is uncertain. Neither the three randomised studies nor a large patient series involving 695 infants found manipulation techniques to be associated with a risk of serious adverse events, but three patient histories demonstrated that manipulation techniques may cause harm if the observed asymmetry has serious underlying causes. Interpretation: Manipulation techniques have not been shown to be efficacious in the treatment of infant torticollis, but the available evidence must be considered uncertain.

NIH Risk of Bias Tool

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

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

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

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

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

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

Was publication bias assessed?

Cannot Determine, Not Reported, Not Applicable

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

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

There is not enough evidence to recommend manipulative therapy for infants with torticollis at this time.

Key Finding #2

There is some anecdotal evidence that manipulations could cause adverse events if the patient has underlying medical conditions.

Key Finding #3

Conventional physical therapy, inlcuding gentle mobilizations, is the most proven and efficacious method of treating infants with torticollis.

Please provide your summary of the paper

This study sought to understand the evidence on manipulation techniques used for infantile torticollis or cervical asymmetries. There were six studies included in this review- three were randomized controlled trials and three were observational studies. The observational studies were to obtain information on possible adverse events that have occurred after manipulations. The result of this systematic review shows that manipulations are not more effective than traditional physical therapy with home exercises and caregiver education. There were no reported adverse effects in any of the randomized controlled trials, however the observational studies showed there could be adverse events as a result of manipulations in patients that have underlying medical conditions.

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

Based on the results of this systematic review, manipulations are not recommended to be performed on infants with torticollis. There is not enough evidence to show that it is beneficial for this patient population. Anecdotally, there are reports of discomfort from infants as a result of manipulations. There is some data that have shown apnea and bradycardia immediately post manipulation in infants. Overall, the evidence on manipulations for infant torticollis is not certain and therefore beliefs on this should not be firm until higher level evidence is published. However, manual therapy (mobilization) as a whole is recommended for these patients and should be utilized in clinic.

Effectiveness of a manual therapy protocol based on articulatory techniques in migraine patients. A randomized controlled trial

Author Names

Mun ̃oz-Go ́mez, E. et al

Reviewer Name

Paige Dewalt

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Physiotherapy is used as a non-pharmacological treatment for migraine. However, controversy exists over whether articulatory manual techniques are effective in some aspects related to migraine. Objectives: To assess the effectiveness of a manual therapy protocol based on articulatory techniques in pain intensity, frequency of episodes, migraine disability, quality of life, medication intake, and self-reported perceived change after treatment in migraine patients. Design: Randomized controlled trial. Methods: Fifty individuals with migraine were randomized into the experimental group, which received manual therapy based on articulatory techniques (n = 25), or the placebo group (n = 25). The intervention lasted 4 weeks and included 4 sessions. Patients were assessed before (T1), after (T2) and at a one-month follow-up following the intervention (T3). The instruments used were the Migraine Disability Assessment (MIDAS) questionnaire, the Short Form-36 Health Survey (SF-36), the medication intake, and The Patients’ Global Impression of Change scale. Results: In comparison with placebo group, manual therapy patients reported significant effects on pain intensity at T2 (p < 0.001; d = 1.15) and at T3 (p < 0.001; d = 1.13), migraine disability at T3 (p < 0.05; d = 0.69), physical quality of life at T2 (p < 0.05; d = 0.72), overall quality of life at T2 (p < 0.05; d = 0.60), decrease in medication intake at T2 (p < 0.001; d = 1.11) and at T3 (p < 0.05; d = 0.77) and self-reported perceived change after treatment at T2 and T3 (p < 0.001). No serious adverse events were reported. Conclusions: The application of a manual therapy protocol based on articulatory techniques reduced pain intensity, migraine disability, and medication intake, while improving quality of life in patients with migraine.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

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

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

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

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

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

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

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

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

Cannot Determine, Not Reported, or Not Applicable

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

Key Finding #1

The present protocol based on articulatory techniques was effective in reducing pain intensity, migraine disability and medication intake, while improving physical QoL and self-reported perceived change after treatment; these changes were maintained after one month.

Key Finding #2

Significant differences were observed in terms of the frequency of episodes and mental QoL at T2 and T3 compared to the placebo intervention.

Key Finding #3

The decrease in pain intensity for the experimental group (AG) may be due to joint mobilization techniques, which target several regions of the spinal column, triggering systemic neurophysiological responses in the peripheral and central nervous system that lead to pain inhibition.

Please provide your summary of the paper

This study shows that a manual therapy protocol based on articulatory techniques reduces pain intensity, frequency of migraine, migraine disability, and medication intake, while improving QoL in patients with migraine. Low velocity and moderate to high amplitude movements were conducted on the neck and upper trunk joints and the SIJ joints to force their full ROM. The following techniques were applied bilaterally: occiput-atlas-axis articulatory manipulation, upper cervical spine (C0–C1) mobilization, middle cervical spine (C2–C7) mobilization in supine, middle cervical spine (C2–C7) mobilization in prone, cervicothoracic junction articulatory manipulation, upper thoracic spine (T2-T6) articulatory manipulation and global sacroiliac joint articulatory manipulation. Results from the short-term treatment provided in this study were maintained after one month, although longer interventions may be more effective in reducing frequency. The decrease seen in pain intensity for the AG group may be due to mobilization techniques triggering systemic neurophysiological responses in the PNS and CNS that lead to pain inhibition. The results from this study, along with additional research, suggest that combining cervicothoracic and lumbosacral techniques could be more effective in reducing medication intake. Primary headaches have a negative impact on QoL and manual therapy is considered an effective approach to improve QoL in patients with migraine, likely due to the decrease in pain intensity and frequency. However, the study does have limitations as most participants were women. Also given the variety of techniques used, improvement can’t be attributed to one technique alone.

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 low velocity and moderate to high amplitude articulatory techniques can be used on the neck/upper-trunk joints along with the SIJ to reduce pain intensity, frequency of migraine, migraine disability, and medication intake in individuals seen in the clinic for migraines. This is also a beneficial intervention for improving physical, mental, and overall QoL in this population. It’s important to review the clinical history and perform pre-manipulative testing of the cervical spine to rule out any possible cervical artery dissection before performing the intervention. Further research is needed to examine the appropriate dosage for each technique and whether or not multiple techniques are required in order to see improvements.

Effects of thoracic spine manipulation on pressure pain sensitivity of rhomboid muscle active trigger points: A randomized controlled trial

Author Names

Haleema B, Riaz H

Reviewer Name

Paige Dewalt

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: To determine the effects of thoracic spine manipulation on pain pressure sensitivity of rhomboid muscles and thoracic spine mobility. Method: The randomized controlled trial was conducted at the Women Institute of Rehabilitation Sciences, Abbottabad, Pakistan, from July to December 2019, and comprised subjects aged 18-30 years having active trigger points in the rhomboid muscle. The subjects were randomized into experimental group A and control group B. The experimental group received thoracic manipulation along with conventional physical therapy, while the control group only received conventional physical therapy. The intervention lasted 2 sessions per week for 3 weeks. Pre- and post-intervention assessment was done with the numeric pain rating scale, algometry, inclinometer, and the neck disability index. Data was analyzed using SPSS 20. Results: Of the 60 subjects, there were 30(50%) in each of the two groups. There were 21(70%) females and 9(30%) males in group A with an overall mean age of 23.86±4.56 years. In group B, there were 18(60%) females and 12(40%) males, with an overall mean age of 23.93±3.96. There was a significant improvement in terms of pain (p<0.01) and pain pressure sensitivity (p<0.05). All outcome measures showed significant intra-group differences (p<0.000). Conclusion: Upper thoracic spine manipulation was found to be more effective in treating interscapular pain and pain pressure threshold of trigger points in rhomboid muscles.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

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

Cannot Determine, Not Reported, or Not Applicable

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

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

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

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

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

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

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

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

Key Finding #1

A significant difference was found in pain (p=0.004) and PPT (p=0.048) post-treatment between the groups (p<0.05), while the difference was non-significant for thoracic flexion, thoracic extension, and NDI.

Key Finding #2

Intra-group analysis showed significant differences for pain, PPT, thoracic flexion, thoracic extension, and NDI in both the control and experimental group, with better results shown in the experimental group.

Key Finding #3

Further analysis showed there was a significant change (p<0.05) from baseline values in all variables except NDI (p>0.05).

Please provide your summary of the paper

This study shows that upper thoracic spine manipulation is more effective in treating interscapular pain and pain pressure sensitivity of myofascial trigger points (MTrPs) in the rhomboid muscle. Compared to manual pressure release (MPR) and general exercises (GEx) alone, the screw manipulation technique combined with MPR and GEx showed greater improvements in thoracic flexion/extension, pain pressure threshold (PPT), and the numeric pain rating scale (NPRS). MRPS and GEx included pressure applied over the identified Trp in the rhomboid until the release of tissue barrier; stretching of pectoral muscles, levator scapula, and upper trapezius; and strengthening of rotator cuff muscles and rhomboids. The screw manipulation technique used required a low amplitude, high-velocity thrust directed at the target joint to correct joint dysfunctions in the thoracic spine. It is suggested that neurophysiologic mechanisms are mainly responsible for the observed pain-modulatory effects of spinal manipulation. However, the study is not without limitations. This study was single-blind, single-center, and only the most active Trp of the rhomboid muscle was treated.

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 upper thoracic spine manipulation may be beneficial in treating interscapular pain and pain pressure sensitivity MTrPs of the rhomboid muscle. In individuals with upper back pain, a little less than half Trp are found in the rhomboids. Individuals with abnormal/poor posture, altered body biomechanics, or joint dysfunction have higher odds of myofascial pain. The above populations could show improvements in pain rating, thoracic flexion/extension, and PPT through the implementation of upper spine manipulation. Further research is needed as this was a small-scale study and may lack the external validity required to support widespread changes in practice.

Effectiveness of Manual Therapy and Acupuncture in Tension-Type Headache: A Systematic Review

Author Names

Turkistani, A., Shah, A., Jose, A.M., Melo, J.P., Luenam, K., Ananias, P., Yaqub, S., & Mohammed, L.

Reviewer Name

Shelby Dobratz, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

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

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

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

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

Cannot Determine, Not Reported, Not Applicable

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

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

Was publication bias assessed?

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

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Manual therapy is the most common non-pharmacological treatment for tension-type headaches (TTH) and significant effects of manual therapy on relieving TTH were significant.

Key Finding #2

Manual therapies focused on massage intervention for TTH showed significant decreases in headache frequency as well as intensity.

Key Finding #3

Combined results across professionals administering manual therapy showed significant positive effects on relieving TTH from self-reported surveys.

Key Finding #4

There was a decrease in headache frequency, decrease in headache severity, and increased cervical range of motion of individuals receiving manual therapy after 8 weeks.

Please provide your summary of the paper

This study summarized findings from eight different research studies that investigated the effectiveness of either manual therapy or acupuncture on tension-type headaches (TTH). Typical treatment options for TTH included pharmacological methods such as analgesics, anticonvulsants, antidepressants, NSAIDs, and triptans. Non-pharmalogical treatment options included cognitive-behavioral therapy, biofeedback, mindfulness training, acupuncture, nutritional supplementation (magnesium, vitamin B12, vitamin B6, and coenzyme Q10), and physical therapies (specifically manual therapy). It appeared that any study depicting the benefit of manual therapy versus a control group for TTH resulted in significant positive effects, proving manual therapy to be a beneficial intervention for these individuals. They also found that individuals who received acupuncture noted a decrease in headache frequency. Researchers inspected the reasoning for why manual therapy is effective in this population, and they discussed the myofascial trigger release points (MTrPs). It was found that individual’s with TTH have an increased number of MTrPs and would benefit from increasing the pressure-pain threshold on these areas with manual therapy. In addition to the benefits on manual therapy on TTH, there may be adverse effects such as muscle stiffness, soreness, increased pain, fatigue, and weakness to be cognizant of while considering the patient’s presentation.

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

This review helped to guide clinicians on the path of choosing manual therapy as an intervention for patients who present with chronic tension-type headaches and provided data and reasoning to back up the positive effects of doing so. Since this review was focused on research with adults with TTH, the pediatric population was not included, warranting additional research to gain insight with varying populations. In addition, publication bias may have been a factor with this analysis and should be considered when implementing the results.

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