Author Names
Jari Ylinen 1, Hannu Kautiainen, Kaija Wirén, Arja Häkkinen
Reviewer Name
Marc Moreno-Takegami, Doctor of Physical Therapy Student
Reviewer Affiliation(s)
Duke University
Paper Abstract
Objective: To compare the effects of manual therapy and stretching exercise on neck pain and disability. Design: An examiner-blinded randomized cross-over trial. Patients: A total of 125 women with non-specific neck pain. Methods: PATIENTS were randomized into 2 groups. Group 1 received manual therapy twice weekly and Group 2 performed stretching exercises 5 times a week. After 4 weeks the treatments were changed. The follow-up times were after 4 and 12 weeks. Neck pain (visual analogue scale) and disability indices were measured. Results: Mean value (standard deviation) for neck pain was 50 mm (22) and 49 mm (19) at baseline in Group 1 and Group 2, respectively, and decreased during the first 4 weeks by 26 mm (95% Confidence Interval 20-33) and 19 mm (12-27), respectively. There was no significant difference between groups. Neck and shoulder pain and disability index decreased significantly more in Group 1 after manual therapy (p=0.01) as well as neck stiffness (p=0.01). Conclusion: Both stretching exercise and manual therapy considerably decreased neck pain and disability in women with non-specific neck pain. The difference in effectiveness between the 2 treatments was minor. Low-cost stretching exercises can be recommended in the first instance as an appropriate therapy intervention to relieve pain, at least in the short-term.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
- Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
- Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
- Yes
- Were study participants and providers blinded to treatment group assignment?
- Yes
- Were the people assessing the outcomes blinded to the participants’ group assignments?
- Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
- Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
- Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
- Yes
- Was there high adherence to the intervention protocols for each treatment group?
- Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
- Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
- Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
- Yes
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
- Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
- Yes
Key Finding #1
Although the difference was not statistically different between the groups, there was a significantly greater benefit reported subjectively from the manual therapy group in comparison with the stretching exercise group.
Key Finding #2
The Neck and Shoulder Pain and Disability Index clearly favored manual therapy at the 4-week follow-up, while the Vernon Disability Index did not reach statistical significance.
Key Finding #3
Reduction in the occurrence of chronic neck pain was significantly more effective when stretching exercises were combined with either neck muscle endurance or strength training.
Please provide your summary of the paper
The objective of this randomized controlled trial was to compare the effects of manual therapy and stretching exercise on neck pain and disability. The patient population was 125 women with non-specific neck pain who were randomized into two groups, with one group receiving manual therapy twice a week and the other group stretching five times a week. For the manual therapy group, mobilization was based on an 8 osteopathic-type mobilization technique and no manipulations or high velocity thrusts with low amplitude were performed. For the stretching group, exercises were targeted towards lateral flexion of the upper part of the trapezius, ipsilateral flexion and rotation for the scalene and flexion for the extensor muscles, holding each movement for 30 seconds and repeating three times. After 4 weeks, the manual therapy group had a 52% decrease in neck pain and the stretching group had a 39% decrease in neck pain, with a more significant benefit being subjectively reported by the manual therapy group. The outcome measure of the Neck and Shoulder Pain Disability Index also clearly favored manual therapy at the 4-week follow up. However, in conclusion, both stretching exercises and manual therapy considerably decreased both neck pain and disability, and the difference between the two treatments was minor.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
One limitation of this study was the short-follow up time of 4 weeks. Nevertheless, the article acknowledges that there is not extensive evidence in support of manual therapy as a sole long-term treatment for chronic neck pain. Rather, manual therapy needs to be combined with neck muscle training and stretching exercises in order to have any significant long-term effects. Another interesting finding worth noting in this study was that only half of the patients in the study used medication to ease neck symptoms, and the patients that did you pharmacological treatment did not experience much pain relief from them. As a future physical therapist, I hope to use articles such as these in order to provide evidence-based support for physical therapy and active rehabilitation as opposed to pharmacological as a primary treatment option for my patients. Lastly, the article acknowledged that much of the benefit attributable to manual therapy has been suggested to be a placebo effect in the past. This raises the question of how effective some of these interventions really are. However, as future physical therapists, I think our responsibility is to inform patients of the potential benefits of different treatment options, and to do our best to increase patient confidence in treatments like manual therapy through a strong therapeutic alliance and comprehensive patient education.
