Research Review by Dr. Rob Rodine©

Date:

Oct. 2008

Study Title:

The Immediate Effects of Upper Thoracic Translatoric Spinal Manipulation on Cervical Pain and Range of Motion: A Randomized Clinical Trial

Authors:

Krauss J, Creighton D, Ely JD, Podlewska-Ely J

Authors’ Affiliations: School of Health Science, Oakland University, Michigan, USA

Publication Information:

The Journal of Manual & Manipulative Therapy, 2008: 16(2): 93-99.

Summary:

Mechanical neck pain is highly prevalent, affecting 40-50% of the population. In addition, restricted and painful cervical range of motion is present in approximately 25% of mechanical neck pain outpatients. Cervical provocative discography and facet joint blocks have thoroughly demonstrated the anatomical relationship of these structures to neck pain. However, the pathoanatomical contribution of the thoracic spine to neck pain has not been as thoroughly studied.

Biomechanical studies have pointed towards hypomobility augmenting symptomatology in adjacent hypermobile segments, while cohort studies and RCT’s have demonstrated the presence of thoracic dysfunction in neck pain patients. From here, research has led to examining the relationship of manual therapy in the thoracic spine with cervical spine outcome measures. These outcome measures have included range of motion, the NDI (Neck Disability Index), VAS (Visual Analogue Scale), NPRS (Numeric Pain Rating Scale) and GROC (Global Rate of Change). Previous reviews from RRS have examined some of this research, which suggests not only that upper thoracic spinal manipulation decrease mechanical neck pain and disability, but that thrust manipulation achieves greater results versus non-thrust manipulation (links to these reviews below).

The purpose of the current investigation was to examine the effect of a translatoric spinal manipulation of hypomobile upper thoracic segments on cervical ROM and scores on the 9-point Faces Pain Scale (FPS). Participants in this study included a convenience sample of 32 patients across three clinics. Patients were included if they demonstrated signs of lower cervical mechanical pain of insidious onset, were between 19-50 years of age, were asymptomatic in the thoracic spine, and did not demonstrate red flags or have an autoimmune disease. Cervical pain had to be provoked by palpation, but absent of neurological or vascular origin.

Following physical examination, patient qualification and consent to participate, subjects returned two days later and were randomly assigned to either the experimental or control group:
  1. Experimental Group (n=22): received translatoric spinal manipulation, described as “a short, passive linear movement performed in a dorsal direction approximately perpendicular to the plane of the facet joints and approximately parallel to the plane of the UT intervertebral disc joints at each level.” (This manipulative technique is quite similar to the frequently performed ‘anterior’ style of diversified thoracic manipulation performed by many chiropractors.)
  2. Control Group (n=10): received no treatment - subjects remained seated on the treatment table for a comparable amount of time that the experimental group would have been receiving their allocated intervention.
Outcome measures were collected by physical therapy assistants who were not associated with the intervention and blinded to group allocation. Outcome measures were collected pre- and post-intervention:
  • ROM was measured via motion inclinometry (validation studies have shown this device to have high inter- and intra-tester reliability)
  • The FPS was used as a primary outcome measure – it offers patients 9 facial expressions all associated with a different severity of pain (this tool has been validated in children, adolescents and adults, and has demonstrated validity and reliability when compared with the NPRS)
  • Segmental hypomobility in the thoracic spine was determined by the treating therapist. While the authors relay that previous studies have shown high accuracy of cervical palpation compared with controlled diagnostic blocks, comparable data for the thoracic spine as well as inter- and intra-tester reliability is not offered.
Results were evaluated for both with-in group and between group differences. Subjects were sub-divided into those suffering from decreased ROM on right rotation or left. As well, they were sub-divided into those experiencing pain at the end of right rotation, left rotation or bilaterally.

Pertinent results of this study include:
  • Subjects were predominantly female (26 with only 6 males, 3 in each group).
  • 10 subjects had pain with bilateral rotation, 11 with left rotation and 11 with right rotation.
  • Those receiving upper thoracic manipulation experienced significant improvement in ROM compared to controls. This improvement demonstrated a mean of 8.23 degrees on the right and 7.09 on the left.
  • Subjects experiencing pain at end range of either left or right rotation only showed no significant difference in FPS scores, and therefore pain scores, with-in allocated groups.
  • However, subjects experiencing pain on both left and right rotation showed decreased pain levels on both left and right rotation following manipulation. This was not found within the control group.

Conclusions & Practical Application:

While this is not an overly strong study, it can be included in a body of literature that demonstrates a relationship between thoracic spinal manipulation and improvements in cervical spine pain. With continued contribution to this area and with improved methodology, this clinical hypothesis held by many manual therapists may be confirmed scientifically.

This study does have some significant limitations. The study’s major flaws include the convenience sampling, small number of included subjects and unequal distribution of subjects between the experimental and control group. However, this study did use a true control group, in which no therapy was received. This is a methodological strength, as sham/placebo interventions are difficult to perform in manual therapy, and are still likely to influence results.

This study was therefore comparing its manipulative group to a true natural history of the condition. Lastly, the results of this study are centered on a one-time intervention. This aspect is not mentioned by the authors, however is pertinent to manual therapists, as one could expect range of motion improvements within one treatment.