Research Review By Dr. Kent Stuber©


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Date Posted:

April 2012

Study Title:

Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: A multicenter randomized clinical trial


Dunning JR, Cleland JA, Waldrop MA, et al.

Author's Affiliations:

Nova Southeastern University, Ft. Lauderdale FL; Franklin Pierce University, Concord NH; University of South Carolina

Publication Information:

Journal of Orthopaedic & Sports Physical Therapy 2012; 42(1): 5-18.

Background Information:

A few years ago, The Neck Pain Task Force (see reference [1] and Related Reviews below) indicated that manual therapy may be one of the more useful treatments for neck pain, which is still an extremely common complaint. Some options available to manual therapists include non-thrust mobilizations and thrust based spinal manipulative therapy, either of which can be directed toward the thoracic spine, cervical spine, or both in combination.

However, which of these is most effective, and the correct dosage for neck pain patients in terms of short term and long term outcomes is still unclear. It is thought that dysfunction in the mobility of the upper thoracic spinal joints may contribute to neck pain and thus treatment for neck pain can be directed to the thoracic spine. A Clinical Prediction Rule for thoracic spinal manipulation and range of motion exercise for neck pain has been found invalid (2), although there is increasing evidence favoring thoracic spinal manipulation for neck pain, as well as a possible combination of thoracic and cervical spinal manipulation (again, see Related Reviews).

The purpose of this study was to look at the short-term effects on range of motion, motor performance of the cervical deep flexors and pain and disability of a single session of high velocity low amplitude spinal manipulation targeting the upper cervical and upper thoracic spinal joints when compared with non-thrust mobilization to the same areas.

Pertinent Results:

  • 107 patients completed the trial (56 in the manipulation group and 51 in the mobilization group)
  • Baseline characteristics between the two groups were not significantly different
  • At 48 hours post-treatment, the manipulation group was favoured to a statistically significant degree when compared with the mobilization group in terms of pain levels (on the NPRS), disability (on the NDI), global rating of change, C1-2 ranges of motion, and motor performance of the deep cervical flexors
  • The average NDI score change was 10.89 in the manipulation group compared with 2.84 in the mobilization group at 48 hours and the average percentage in disability reduction was 50.5% in the manipulation group and 12.8% in the mobilization group
  • 51.8% of the manipulation group had at least a 50% improvement in disability, compared with 7.8% of the mobilization group
  • The NPRS levels in the manipulation group were 2.3 at 48 hours on average compared with 4.4 on average in the mobilization group.
  • The manipulation group had an average pain reduction of 2.95 compared with 0.96 in the mobilization group, and the manipulation group averaged 58.5% reduction in pain compared with 12.6% in the mobilization group
  • Significantly more patients in the manipulation group had a successful outcome compared to the mobilization group with respect to perceived global rating of change and the average improvements in the manipulation group were significantly greater as well for this outcome measure
  • No major adverse events were reported

Clinical Application & Conclusions:

The authors concluded that, at least from a short term standpoint, combining upper cervical and upper thoracic spinal manipulation is more effective than mobilizations to the same regions in neck pain patients. There were greater improvements in the manipulation group in terms of pain and disability levels, as well as ranges of motion and motor performance of the deep cervical flexors.

The findings of this study could provide impetus for the use of upper cervical and upper thoracic spinal manipulation for mechanical neck pain to help with both subjective and objective outcome measures, particularly in the short term. However it should be noted that spinal manipulation should only be performed by those with suitable training, otherwise a referral would be more appropriate.

For manual therapists who are suitably trained to perform spinal manipulation, consideration of both the upper cervical and upper thoracic spinal regions in patients with mechanical neck pain may be warranted. Readers should keep the strengths and weaknesses of this study in mind when considering the results (see below).

Study Methods:

This was a multicenter randomized clinical trial for adult patients with localized neck pain and a Neck Disability Index score of greater than 20%. Pre-manipulative vertebral artery testing was not employed although subjects had to respond negatively to screening questions for cervical artery disease.

Experienced physical therapists who received standardized training in the examination and treatments involved were utilized with one in each centre providing treatment, and another blinded therapist who conducted examinations. Patients completed a numeric pain rating scale (NPRS) and Neck Disability Index (NDI) and were examined by a physical therapist blinded to group allocation with the flexion-rotation test, and the craniocervical flexion test serving as additional outcome measures, along with a global rating of change scale. Patients were then randomized (via computer-generated randomized number tables) to one of two groups:
  1. Group 1: received upper cervical (C1-2) and upper thoracic (T1-T2) HVLA thrust spinal manipulation (an anterior); and
  2. Group 2: received upper cervical and upper thoracic non-thrust (grade IV) mobilizations.
Both groups received home care advice to maintain usual activity within the limits of pain. During the treatment session the treating therapist would open an envelope informing them which treatment to employ. Patients were asked not to discuss treatments with the examining therapist. Patients received one treatment session and were then re-evaluated 48 hours later using the same outcome measures.

Appropriate power and sample size calculations were employed and data analysis consisted of descriptive statistics, independent t tests and chi square tests to compare baseline demographic data, and 2x2 mixed-model ANOVAs (analysis of variance) to compare the treatments for the various outcome measures. Finally, patients were placed in groups who either had a successful outcome based on improvement in the NDI or global rating of change scale.

Study Strengths / Weaknesses:

Among the strengths of this study are the overall randomized design and the assessor blinding. This was a well-conceived and executed short-term study. However, as is typical of RCTs involving manual therapy procedures there was no blinding of either patients or the treating therapist (this is a common problem in manual medicine research and often hard to overcome due to the nature of the interventions).

Also, as there was only one treatment visit and no further treatments or follow-up with the only follow-up being at 48 hours, we cannot state what kind of effect the single treatment would have in the long term for these patients or what effect multiple treatments would have on the multiple outcome measures utilized. This is an important point given the long term disability and pain that neck pain can impart on those affected.

The authors also point to the brief amount of time that the mobilizations were performed (only 30 seconds) as a limiting factor as therapists in clinical practice would likely perform the mobilizations over a longer period of time. Finally, a very standardized treatment was employed in both groups (as the same spinal manipulations or mobilizations were performed on all patients at the same segments) and as such it does not take into account the notion that different segments may be affected in different patients (for example C7-T1, or T2-3 in the upper thoracic region or Occ-C1, or C2-3 in the upper cervical) or if both regions actually need to be addressed in all neck pain patients, nor did it allow for different manipulations or mobilization maneuvers to be performed on patients based on the needs determined by the practitioner.

However as much research has shown, the validity and reliability of the findings of different forms of palpation is questionable, and some have argued that segmental specificity may not be as important as previously thought when performing spinal manipulation. It is also unknown whether different HVLA spinal manipulation maneuvers which target the same joints have the same or different effects on outcome measures.

Additional References:

  1. Hurwitz EL, Carragee EJ, van der Velde G et al. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. J Manipulative Physiol Ther 2009; 32(2 Suppl): S141-75.
  2. Cleland JA, Childs JA, Fritz JM et al. Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Phys Ther 2007; 87(1): 9-23.