Research Review By Dr. Jeff Muir©


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Date Posted:

May 2019

Study Title:

Immediate Effects of Thoracic Spine Thrust Manipulation on Neurodynamic Mobility


Hartstein AJ, Lievre AJ, Grimes JK, Hale SA

Author's Affiliations:

Division of Physical Therapy, Shenandoah University, Winchester, Virginia; College of Health Professions, Sacred Heart University, Fairfield, Connecticut, USA.

Publication Information:

Journal of Manipulative and Physiological Therapeutics 2018; 41(4): 332–341.

Background Information:

The benefits of manual therapies for musculoskeletal conditions are widely known (1-3). The mechanism(s) of action, however, remain largely unknown. A combination of biomechanical and neurophysiological effects has been suggested as being responsible for the observed improvements (4), as have psychological effects (5). In addition, the influence of the patient-therapist relationship and patient expectation may also impact the effectiveness (or ineffectiveness) of a given manual therapy (6).

Manual treatment for the thoracic spine has shown considerable variability in effectiveness between thrust manipulations and mobilization. While effective for treatment of mechanical neck pain, disability and lower trapezius muscle activation (7-9), there is less evidence supporting the effect of thoracic spine manipulation (TSM) on peripheral nervous system tissue and mechanosensitivity during investigations such as neurodynamic tests. Specifically, while previous studies have investigated the response of upper quarter neurodynamic mobility to cervical spine treatment (10, 11), no studies have investigated the effects of TSM on upper or lower quarter neurodynamic mobility.

Therefore, the purpose of this study was to evaluate the immediate effects of TSM on the upper limb provocation test (ULPT) and seated slump test (SST) in patients diagnosed with neurodynamic mobility impairments.

Pertinent Results:

43 patients with 130 limbs (including arms and legs) determined to have impaired neurodynamic mobility were randomized to 2 treatment groups (TSM: n = 64; mobilization: n = 66). No significant differences were noted in demographic variables between the two study groups. Patients allocated to the mobilization group who experienced a cavitation were not included in the final analysis (5 patients, 17 limbs). A total of 113 limbs were included in the final analysis.

Upper Limb Provocation Test (ULPT):
51 limbs were considered for upper quarter neurodynamic impairment (TSM: n = 30; mobilization: n = 21). ANOVA revealed a significant effect (F1, 49 = 42.56, p < 0.001) but no significant interaction (F1, 49 = 1.55, p = 0.218) between groups. Neurodynamic mobility improved significantly in both groups; effect size for both groups was medium (TSM: d = 0.70, mobilization: d = 0.69).

Seated Slump Test (SST):
62 limbs were considered for lower quarter neurodynamic impairment (TSM: n = 34, mobilization: n = 28). A significant effect was noted for the SST (F1, 59 = 21.56, p < 0.001), but (again) no significant interaction was noted between groups (F1, 59 = 1.17, p = 0.285). Both groups exhibited significant improvements in neurodynamic mobility. SST effect size for TSM was medium (d = 0.53), while that for the mobilization group was small (d = 0.26).

Perceived Effects of Treatment:
No significant differences were noted between the perceived effects in the TSM and mobilization groups (p = 0.14). A significant difference was noted between those with a positive vs. negative perception of effect (p < 0.05) in the mean neurodynamic mobility change between participants with a positive (10.80°) and a negative (3.12°) perception of effect. Effect size for those with a positive perception approached medium (d = 0.46), while in those with a negative perception, it approached small (d = 0.17).

Clinical Application & Conclusions:

The results indicate that peripheral neurodynamic mobility improved regardless of intervention (thoracic manipulation or mobilization). While manipulation resulted in a greater effect in lower quarter neurodynamic mobility, the effect of both manipulation and mobilization was similar in upper quarter neurodynamic mobility. When considering perception, those who perceived a positive effect from manipulation demonstrated greater neurodynamic mobility changes when compared with those who perceived treatment negatively. The authors concluded that these observations support previous research that manipulation and mobilization may yield similar results, although these results can be influenced by patient perception or expectation.

Study Methods:

Design: Randomized, pre-test/post-test design

Participants: Sample size was calculated at 126 limbs. 48 asymptomatic patients aged 18-63 years (mean: 24.35, SD: 6.61) with 192 limbs were recruited.

Procedures: Patients were randomized to one of two groups: thoracic thrust manipulation (TSM) (n = 64) or thoracic mobilization (n = 66). Treatment was delivered to participants who had at least 1 limb with positive neurodynamic findings. Assessing clinicians were blinded to treatment allocation. Participants were asked post-treatment about their perception of the effects of treatment and were retested with the upper limb provocation test (ULPT) and/or seated slump test (SST).

Measurements: The ULPT was completed as described by Davis et al. (12), with patients in the supine position. Ipsilateral cervical spine side bending was used to differentiate between a neurodynamic limitation and other soft-tissue issues. Elbow extension was measured using a standard goniometer. Measurements were made bilaterally during pre-test measurements. Post-test measurements were taken only on limbs lacking at least 60° of elbow extension.

The seated slump test (SST) was also completed per Davis et al. (12). Knee extension was measured using an inclinometer placed at the tibial tuberosity. Pre-test measurements were taken on both legs; post-test measurements were taken only on limbs lacking at least 22° of knee extension.

Perceived effects of treatment were assessed using methods similar to Michener et al. (13). Post-treatment, patients were asked if they felt that the treatment they had received would increase their (arm/leg) flexibility.

Interventions: Patients received either a high-velocity, low-amplitude thoracic spine manipulation via a supine, antero-posterior thrust, or mobilization, which was identical to the TSM, but with different hand positioning (flat hand vs. loose-fist grip used for TSM) to reduce the likelihood of cavitation. In this group, cavitation resulted in exclusion from the study.

Study Strengths / Weaknesses:

  • This was a novel, well-designed pre-test/post-test study with clinically relevant treatment options.
  • Testing and outcomes were both relevant and readily available to those in clinical practice (no special equipment required).
  • The young, healthy cohort included in this study may not represent the true patient population (for example, those with degenerative radiculopathies).
  • Confidence intervals of mean values were wide (particularly for the mobilization intervention). Follow-up studies may be required to further evaluate the findings.
  • The sample size was relatively low.

Additional References:

  1. Licciardone JC, Stoll ST, Fulda KG, et al. Osteopathic manipulative treatment for chronic low back pain: randomized controlled trial. Spine 2003; 28(13):1355-1362.
  2. Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med 2004; 141(12): 920-928.
  3. Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med 2000; 132(3): 173-181.
  4. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther 2009; 14(5): 531-538.
  5. Lopez-Lopez A, Alonso Perez JL, González Gutierez JL, et al. Mobilization versus manipulations versus sustain apophyseal natural glide techniques and interaction with psychological factors for patients with chronic neck pain: randomized controlled trial. Eur J Phys Rehabil Med 2015; 51(2): 121-132.
  6. Whyte J, Hart T. It’s more than a black box; it’s a Russian doll: defining rehabilitation treatments. Am J Phys Med Rehabil 2003; 82(8): 639-652.
  7. Salom-Moreno J, Ortega-Santiago R, Cleland JA, Palacios- Ceña M, Truyols-Domínguez S, Fernández-de-las-Peñas C. Immediate changes in neck pain intensity and widespread pressure pain sensitivity in patients with bilateral chronic mechanical neck pain: a randomized controlled trial of thoracic thrust manipulation vs non-thrust mobilization. J Manip Physiol Ther 2014; 37(5): 312-319.
  8. Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Man Ther 2005; 10(2): 127-135.
  9. Cleland JA, Glynn P, Whitman JM, Eberhart SL, MacDonald C, Childs JD. Short-term effects of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial. Phys Ther 2007; 87(4): 431-440.
  10. Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain 1996; 68(1): 69-74.
  11. Saranga J, Green A, Lewis J, Worsfold C. Effect of a Cervical Lateral Glide on the Upper Limb Neurodynamic Test 1: a blinded placebo-controlled investigation. Physiotherapy 2003; 89(11): 678-684.
  12. Davis DS, Anderson IB, Carson MG, Elkins CL, Stuckey LB. Upper limb neural tension and seated slump tests: the false positive rate among healthy young adults without cervical or lumbar symptoms. J Man Manip Ther 2008; 16(3): 136-141.
  13. Michener LA, Kardouni JR, Sousa CO, Ely JM. Validation of a sham comparator for thoracic spinal manipulation in patients with shoulder pain. Man Ther 2015; 20(1): 171-175.