Research Review By Dr. Jeff Muir©


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Date Posted:

September 2013

Study Title:

Short-term effects of spinal thrust joint manipulation in patients with chronic neck pain: a randomized clinical trial


Saavedra-Hernandez M, Arroyo-Morales M, Cantarero-Villanueva I et al.

Author's Affiliations:

Department of Nursing and Physical Therapy, Universidad de Almeria, Spain; Department of Physical Therapy, Health Sciences School, Universidad Granada, Spain; Department of Physical Therapy, School of Allied Health Science, University of Nevada, Las Vegas, USA; Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation of Universidad Rey Juan Carlos, Spain; Esthesiology Laboratory of Universidad Alcorcon, Spain.

Publication Information:

Clinical Rehabilitation 2013; 27(6): 504–512.

Background Information:

Mechanical neck pain constitutes a significant societal burden (1, 2). It has been reported that the prevalence of neck pain is almost as high as that of low back pain (3), with one-year prevalence ranging from 16.7 to 75.1% depending on the study (4). Physical therapy and/or chiropractic care are often an initial approach for patients, with manual therapy regularly incorporated into treatment plans. Treatment is often directed at the source of the pain, although is also often expanded to include adjacent vertebral/spinal regions. This is partially justified by the fact that, as recent reviews have concluded, the quality of evidence for the use of cervical or thoracic manipulation in isolation is relatively low (5, 6). What is not known is whether the application of thrust joint manipulation to different spinal levels/regions would increase the effect of manipulation applied to only one region. Therefore, the purpose of this randomized controlled trial was to compare the effects of an isolated application of cervical spine thrust joint manipulation vs. the application of a full combination of cervical, cervico-thoracic and thoracic spine thrust joint manipulation on neck pain, disability and cervical range of motion (ROM) in individuals with chronic mechanical neck pain.

Pertinent Results:

Study Population:
Ninety consecutive individuals presenting at a local rehabilitation clinic with mechanical neck pain were screened for eligibility criteria. Eighty-two patients (mean ± SD age: 45 ± 9 years; 50% female) satisfied the eligibility criteria, agreed to participate, and were randomized into cervical manipulative (n = 41) or full manipulative (n = 41) groups.

Effect of treatment on neck pain:
Patients who received the full combination of spinal thrust joint manipulation exhibited greater reduction in disability than those who received only the cervical spine thrust joint manipulation, whereas both groups experienced similar decreases in neck pain (F = 5.450; p = 0.022). No effect of gender was observed for the Neck Disability Index (F = 0.355; p = 0.553) or neck pain (F = 0.219; p = 0.641).

Effect of treatment on cervical range of motion:
Patients who received cervical spine manipulation and those who received the full combination of manipulation experienced similar increases in cervical range of motion cervical flexion (F = 0.697, p = 0.406), extension (F = 0.275, p = 0.602), lateral-flexion (F = 0.485; p = 0.487) or rotation (F = 0.297; p = 0.587). Again, no effect of gender was observed for any cervical ROM.

Clinical Application & Conclusions:

Cervical spine manipulation alone was found to be equally effective at reducing neck pain and improving cervical spine ROM as cervico-thoracic manipulation. Cervico-thoracic (or, multi-region) treatment, though, was superior in providing patients with decreased self-reported disability. The authors suggest that this finding represents a cumulative effect on outcomes. It is also possible that consecutive applications of spinal thrust joint manipulation would induce greater reduction in disability.

The authors propose that the improved self-reported disability scores associated with multi-region treatment may be related to the neurophysiological sequelae that are associated with SMT. They also suggest that the multi-level treatment is not required to induce biomechanical changes (increased ROM). These ideas require further research, but for now, addressing mobility issues in the cervico-thoracic and thoracic spine regions (in addition to the cervical spine) remains an evidence-informed and reasonable option for your patients with neck pain.

Study Methods:

This was a randomized, single-blind clinical trial. Patients were selected for inclusion if they had a primary complaint of bilateral chronic mechanical neck pain. Patients were recruited from those who were referred for physical therapy at a private clinic in Almeria (Spain).

Exclusion Criteria:
  • Contraindication to cervical thrust joint manipulation (e.g. fracture, osteoporosis, positive extension-rotation test or any symptom of vertebrobasilar insufficiency)
  • History of whiplash
  • History of cervical spine surgery
  • Diagnosis of cervical radiculopathy or myelopathy
  • Diagnosis of fibromyalgia syndrome
  • Having previously undergone spinal manipulative therapy
  • Being less than 18 or more than 55 years of age
Study Groups:
  1. Cervical manipulative group (n = 41): this group received SMT directed only at the cervical spine.
  2. Full manipulative group (n = 41): this group received SMT to the cervical, cervico-thoracic and thoracic regions as determined by the treating clinician.
Treatment Protocol:
High-velocity, low-amplitude thrust manipulation was performed in the following patient positions (in all cases, a maximum of 2 attempts were made):
  • Thoracic spine: anterior adjustment (patient supine with arms crossed, etc.)
  • Cervico-thoracic spine: prone C7/T1 adjustment (known to many as a ‘combination adjustment’) – this was applied bilaterally.
  • Cervical spine: patient supine, mid-cervical rotary adjustment directed to C3
The authors wanted to mimic clinical practice, so the treating clinicians chose which levels of the spine to manipulate in the cervical, cervico-thoracic or thoracic spine based on the following clinical findings: hypomobility (abnormal end-feel and increased tissue resistance) combined with pain provocation during palpation. Each region of the spine (cervical, cervico-thoracic or thoracic) was manipulated only at the most symptomatic level, to standardize the number of thrust manipulations received by each patient.

Outcome Measures:
Pain was measured on a visual analogue scale (VAS). Subjects also completed the Neck Disability Index (NDI) and underwent cervical spine range of motion evaluation.

Study Strengths / Weaknesses:

  • A sample of convenience from only one clinic was utilized, which may not be representative of the general population of patients with chronic mechanical neck pain.
  • Only the short-term effects (one week) of spinal thrust joint manipulation were investigated. The authors cannot infer that the benefits observed would be maintained in the long term.
  • Management of patients with mechanical neck pain usually involves a multimodal approach and not only the use of spinal thrust joint manipulation as isolated interventions, which may also limit the ability to extrapolate the findings to the general patient population.
  • The authors provide recommendations for addressing each limitation discussed above.
  • Regarding treatment (in this case, SMT), the authors provide a detailed explanation of their protocols and the method. This is a component that many authors neglect, even though it is a valuable addition for practitioners reading research studies (or reviewing them!).

Additional References:

  • Borghouts JA, Koes BW, Vondeling H et al. Cost-of-illness of neck pain in The Netherlands in 1996. Pain 1999; 80: 629–636.
  • Cote P, Cassidy J and Carroll L. The factors associated with neck pain and its related disability in the Saskatchewan population. Spine 2000; 25: 1109–1117.
  • Martin BI, Deyo RA, Mirza SK et al. Expenditures and health status among adults with back and neck problems. JAMA 2008; 299: 656–664.
  • Fejer R, Ohm-Kyvik K and Hartvigsen J. The prevalence of neck pain in the world population: a systematic critical review of the literature. Eur Spine J 2006; 15: 834–848.
  • Gross A, Miller J, D’Sylva J et al. Manipulation or mobilisation for neck pain: a Cochrane Review. Man Ther 2010; 15: 315–333.
  • Cross KM, Kuenze C, Grindastaff TL & Hertel J. Thoracic spine thrust manipulation improves pain, range of motion, and self-reported function in patients with mechanical neck pain: a systematic review. J Orthop Sports Phys Ther 2011; 41: 633–642.