Manipulation or mobilisation for neck pain: A Cochrane Review

Autonomic nervous system and endocrine system response to upper or lower cervical spine mobilization in males with persistent post-concussion symptoms: a proof-of-concept trial

INTRODUCTION

The peripheral stress response, consisting of the autonomic nervous system (ANS) and hypothalamic pituitary adrenal-axis (HPA-axis), functions to maintain homeostasis in response to stressors. Cervical spine manual therapy has been shown to differentially modulate the stress response in healthy populations. No study has investigated whether cervical spine mobilizations can differentially modulate the stress response in individuals with persistent post-concussion symptoms (PPCS), a population characterized by a dysfunctional stress response.

METHODS

A randomized, controlled, parallel design trial was performed to investigate whether upper or lower cervical spine mobilization can differentially modulate components of the stress response in individuals with PPCS. The outcomes were salivary cortisol (sCOR) concentration (primary) and the HRV metric, rMSSD, measured with a smartphone application (secondary). Nineteen males diagnosed with PPCS, aged 19-35, were included. Participants were randomly assigned into either intervention group, upper (n = 10) or lower (n = 9) cervical spine mobilization. Each outcome was collected at different time points, pre- and post-intervention. Statistical analyses were performed using the Friedman's Two-Way ANOVA, Mann-Whitney U test, and Wilcoxon Signed Rank Test.

RESULTS

There was a statistically significant within-group reduction in sCOR concentration 30 minutes following lower cervical spine mobilizations and statistically significant within-group increase in rMSSD 30 minutes following upper cervical spine mobilizations.

CONCLUSION

The results of this trial provide preliminary evidence for cervical spine mobilizations to differentially modulate components of the stress response at specific time points. Understanding the mechanisms of the effect of cervical spine mobilizations on the stress response provides a novel rationale for selecting cervical spine mobilizations to rehabilitate individuals with PPCS.

Cervical manipulation versus thoracic or cervicothoracic manipulations for the management of neck pain. A systematic review and meta-analysis

BACKGROUND

Cervical and thoracic thrust or non-thrust manipulations have shown to be effective in patients with neck pain, but there is a lack of studies comparing both interventions in patients with neck pain.

OBJECTIVE

To investigate the effects of cervical thrust or non-thrust manipulations compared to thoracic or cervicothoracic manipulations for improving pain, disability, and range of motion in patients with neck pain.

DESIGN

Systematic review and meta-analysis.

METHOD

Searches were performed in PubMed, PEDro, Cochrane Library, CINHAL, and Web of Science databases from inception to May 22, 2023. Randomized clinical trials comparing cervical thrust or non-thrust manipulations to thoracic or cervicothoracic manipulations were included. Methodological quality was assessed with PEDro scale, and the certainty of evidence was evaluated using GRADE guidelines.

RESULTS

Six studies were included. Meta-analyses revealed no differences between cervical thrust or non-thrust manipulations and thoracic or cervicothoracic manipulations in pain intensity, disability, or cervical range of motion in any plane. The certainty of evidence was downgraded to very low for pain intensity, to moderate or very low for disability and to low or very low for cervical range of motion.

CONCLUSION

There is moderate to very low certainty evidence that there is no difference in effectiveness between cervical thrust or non-thrust manipulations and thoracic or cervicothoracic manipulations for improving pain, disability, and range of motion in patients with neck pain.

PROSPERO REGISTRATION

CRD42023429933.

Changes in biochemical markers following a spinal manipulation - a systematic review update

OBJECTIVE

The aim of this systematic review was to update the current level of evidence for spinal manipulation in influencing various biochemical markers in healthy and/or symptomatic population.

METHODS

This is a systematic review update. Various databases were searched (inception till May 2023) and fifteen trials (737 participants) that met the inclusion criteria were included in the review. Two authors independently screened, extracted and assessed the risk of bias in included studies. Outcome measure data were synthesized using standard mean differences and meta-analysis for the primary outcome (biochemical markers). The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the quality of the body of evidence for each outcome of interest.

RESULTS

There was low-quality evidence that spinal manipulation influenced various biochemical markers (not pooled). There was low-quality evidence of significant difference that spinal manipulation is better (SMD -0.42, 95% CI - 0.74 to -0.1) than control in eliciting changes in cortisol levels immediately after intervention. Low-quality evidence further indicated (not pooled) that spinal manipulation can influence inflammatory markers such as interleukins levels post-intervention. There was also very low-quality evidence that spinal manipulation does not influence substance-P, neurotensin, oxytocin, orexin-A, testosterone and epinephrine/nor-epinephrine.

CONCLUSION

Spinal manipulation may influence inflammatory and cortisol post-intervention. However, the wider prediction intervals in most outcome measures point to the need for future research to clarify and establish the clinical relevance of these changes.

Effect of dynamic taping on neck pain, disability, and quality of life in patients with chronic non-specific neck pain: a randomized sham-control trial

Background

In 2020, 203 million people experienced neck pain, with a higher prevalence in women. By 2050, it is predicted that neck pain will affect 269 million people, representing a 32.5% increase. Physical rehabilitation is often employed for the treatment of chronic non-specific neck pain (CNSNP) and the associated functional loss. Taping is frequently used as an adjunct treatment alongside primary physical rehabilitation. Unlike kinesio tape (KT), the therapeutic benefits of dynamic tape (DT) have not been thoroughly explored and documented in non-athletic conditions. Therefore, the aim of this trial was to determine the effects of DT on pain, disability, and overall well-being in individuals experiencing CNSNP.

Methods

A prospective parallel-group active controlled trial was conducted at a single center, involving 136 patients with CNSNP, randomly allocated in a 1:1 ratio. The sham taping group (STC) received standard physiotherapy care (n = 67) alongside DT without tension, while the dynamic taping group (DTC) (n = 69) underwent standard cervical offloading technique with appropriate tension in addition to standard physiotherapy care. Demographic information and three patient-reported outcome measures (PROMs), namely the Neck Disability Index (NDI), Visual Analogue Scale (VAS), and the World Health Organization-Five Well-Being Index (WHO-5), were collected for each participant at three time points (baseline, four weeks post-taping, and four weeks follow-up).

Results

At baseline, no significant differences were observed between the STC and DTC for any outcome measure. Notably, all three PROMs exhibited a significant improvement from baseline to four weeks post-intervention, with moderate to small effect sizes (NDI ηp2 = 0.21, VAS ηp2 = 0.23, and WHO-55 ηp2 = 0.05). The WHO-5 scores for both groups demonstrated improvement from baseline through follow-up (p < 0.001). The NDI and VAS scores ameliorated from baseline to the four weeks post-taping period, with marginal improvements observed during the four weeks follow-up.

Conclusion

The incorporation of DT as an adjunct to standard physiotherapy care yielded enhancements in pain levels, functional disability, and well-being among patients with CNSNP when compared to the sham group. However, the sustainability of these improvements beyond the taping period lacks statistical significance and warrants further validation.

Comparative effectiveness of manual intermittent cervical longitudinal mobilization versus pain modalities in cervical radiculopathy: A double blinded randomized controlled study

BACKGROUND

Cervical radiculopathy is a common condition encountered in clinical practice and is characterized by compression or irritation of the nerve roots in the cervical spine.

OBJECTIVE

To compare the effectiveness of manual intermittent cervical longitudinal mobilization (mICLM) and therapeutic modalities in managing acute, sub-acute and chronic radiculopathy pain.

METHODS

This was a multicenter, double-blinded, randomized controlled trial. Individuals with radiculopathies were randomized into interventional; (IG, n= 18) receiving mICLM and control group; (CG, n= 17), receiving Microwave Diathermy (MWD) and transcutaneous electrical nerve stimulation (TENS) at the cervico-dorsal area daily for two weeks. The neck pain disability index (NPDI), numeric pain rating scale (NPRS), and global rating of change score (GRoC) were used as outcome measures. Statistical analysis was conducted using SPSS version 23.0.

RESULTS

Both mICLM and MWD with TENS were equally effective in reducing the pain and disability in either group. However, it was noted that mICLM had a better impact on acute, sub-acute and chronic cases of radiculopathy pain comparatively. Mean age was 42.3 (SD =± 10.9) years. 54.3% were between the age group of 40-60 years out of which 51.4% were male and 48.6% were female. 51.4% were in IG and 48.6% were in CG. The mean comparison of NPAD and NPRS within groups was significant with p< 0.01*. Post treatment mean comparison of NPAD outcomes in IG and CG remain significant with p= 0.004* and p< 0.01* respectively. The post NPAD and NPRS between IG and CG were found statistically insignificant with p= 0.75 and p= 0.57 respectively.

CONCLUSION

mICLM and therapeutic modalities showed similar outcomes in managing radiculopathy pain. The study highlights the need for further research to understand the effectiveness of these interventions in larger patient populations.

Effectiveness of Self-Care Education for Chronic Neck Pain: A Systematic Review and Meta-Analysis

Self-care programs for chronic neck pain are relevant to everyday life and can lead to long- term improvement. More studies on their effectiveness, key components and appropriate duration are needed. The aim of this study was to determine the effectiveness of self-care programs for patients with chronic neck pain. A systematic review and meta-analysis of randomized controlled trials was conducted according to the PRISMA guidelines. After searching in PubMed, Web of Science, Scopus and ScienceDirect, eleven studies met the inclusion criteria. Self-care education interventions typically consisted of education (i.e., pain neuro-science education or general educational concepts) accompanied by exercise or manual therapy. The most frequent components were addressing physical and psychological symptoms and engaging in self-care strategies. The least frequent ones were monitoring and recording symptoms and discussing with providers of medical care. The duration of the interventions ranged from three sessions to six months. Finally, individual and supervised modalities were the most frequent. After pooling the data, a meta-analysis was carried out according to four variables (i.e., pain, disability, kinesiophobia and catastrophization) and showed significant results (p < 0.05) in favor of self-care interventions. This systematic review and meta-analysis suggests that self-education interventions improve pain, psychological pain-related variables and disability in patients with chronic neck pain. The most frequently used components were addressing physical and psychological symptoms and engaging in self-care strategies. Future trials should focus on including other components, such as discussing symptoms with providers of medical care or self-monitoring symptoms. Additional areas of focus include more homogeneous doses and comparator treatments, as well as studies with better evidence to reach more solid conclusions.

Assessment of Long-term Effects of Adding Osteopathic Manipulative Treatment to Neck Exercises for Individuals With Non-specific Chronic Neck Pain: A Randomized Trial

Objective

The purpose of this study was to evaluate the long-term effects of adding osteopathic manipulative treatment (OMT) to neck exercises compared to exercises alone for individuals with non-specific chronic neck pain (NCNP).

Methods

A randomized controlled trial was conducted by assigning 90 individuals with NCNP into the following 2 groups: (1) exercises group (EG, n = 45) or (2) OMT plus exercises group (OMT/EG, n = 45). All participants received 4 weeks of treatment. The clinical outcomes were recorded at baseline and at 3 and 6 months after the treatment. The primary outcomes were pain and function-Numerical Pain Rating Scale (NPRS), Pressure Pain Threshold, and the Neck Disability Index (NDI). The secondary outcomes included range of motion for cervical spine rotation, Fear-Avoidance Beliefs Questionnaire, and Pain Self-Efficacy Questionnaire.

Results

In comparison to baseline data, both groups had a reduction of NPRS (P < .05) and NDI (P < .05) after the treatment. However, no statistically significant differences in pain intensity or disability were found when OMT/EG was compared to EG alone at 3 months (P = 0.1 and P = 0.2, respectively) and at 6 months (P = 0.4 and P = 0.9, respectively for pain and disability) and no difference was found between OMT/EG and the EG in the secondary outcomes during the same follow-up period (P > .05).

Conclusion

Outcomes of pain and functionality for patients in both groups were improved at 6 months. Our findings show that the combination of OMT and neck exercises for 4 weeks did not improve functionality and reduction of pain in patients with NCNP.

Valid and Invalid Indications for Osteopathic Interventions: A Systematic Review of Evidence-Based Practices and French Healthcare Society Recommendations

The main aim of this study was to determine the level of evidence in the literature for the main indications of osteopathy as recommended by the French osteopathy societies. This systematic review followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and evaluated articles published between January 2012 and January 2022 with one modification: when level one evidence studies were available, level two to five studies were excluded. Sources included PubMed, the Cochrane library, the French National Health Authority (HAS) and its affiliates. Inclusion criteria were level one published studies on the indications for osteopathic treatment in French and English, and level two to three studies when no level one studies were available. The level of evidence assessment was based on the Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence classification. The primary outcome was the level of evidence in the literature supporting osteopathic practices. The secondary outcome was to assess French professional osteopathy recommendations and French HAS guidelines in relation to the scientific literature. A total of 51 articles and nine recommendations from the HAS and its affiliates met the inclusion criteria for the systematic review. Analysis of the studies revealed 41 osteopathic indications from French osteopathy societies for musculoskeletal, neurosensory, psychological, pediatric, gynecological, digestive, and pulmonary disorders. High-level scientific evidence supported the use of osteopathy for low back pain, sciatica, cervical radiculopathy, and ankle sprain. There was moderate evidence for tension headache, temporomandibular joint disorder, endometriosis, and low back and pelvic pain in pregnant women. HAS recommended five indications, while nine indications were supported in the scientific literature. Osteopathy has been shown to have evidence-based benefits for a range of conditions, in particular for musculoskeletal and neurosensory disorders.

Effects of a Therapeutic Exercise Protocol for Patients with Chronic Non-Specific Back Pain in Primary Health Care: A Single-Group Retrospective Cohort Study

BACKGROUND

Back pain is highly prevalent; in Spain, it produces a very high economic cost and the scientific evidence supporting treatments shows low to moderate evidence for exercise. Therefore, the aim of this study was to assess the effectiveness of a therapeutic group exercise protocol in reducing pain intensity and disability in patients with back pain in primary health care setting.

METHODS

A total sample of 149 patients who suffered from chronic non-specific back pain was selected. Patients received a therapeutic exercise protocol, including auto-mobilization exercises for the neck and lumbar regions, as well as core stabilization exercises. Pain intensity and disability were evaluated before and after the therapeutic exercise protocol.

RESULTS

Statistically significant differences (p < 0.05) were shown in pain intensity and disability for patients with non-specific neck and low-back pain, with an effect size from moderate to large.

CONCLUSIONS

A therapeutic exercise protocol may provide beneficial effects upon disability and pain intensity in patients with chronic non-specific back pain, including neck and low-back pain conditions In addition, It could be considered for inclusion as a back-pain-approach program in primary healthcare.

Protocol for the development of a 'trustworthy' living systematic review and meta analyses of manual therapy interventions to treat neuromusculoskeletal impairments

BACKGROUND

Preprocessed research resources are believed to be highly 'trustworthy' when translating research to clinical practice. However, the overall 'trustworthiness' is unknown if this evidence contains randomized clinical trials (RCTs) where prospective has not been/cannot be verified, has low confidence in estimated effects, and if they are not up to date.

OBJECTIVES

This protocol will be used to create a baseline benchmark for a series of trustworthy living systematic reviews (SRs) regarding manual therapy interventions.

METHODS

Data will originate from RCTs related to manual therapy neuromusculoskeletal interventions, indexed in 6 search engines in English from 1 January 2010, to the present. Two blinded reviewers will identify the RCTs and extract data using Covidence. The data will be synthesized based on consensus and analyzed using the Cochrane collaboration's Review Manager.

EXPECTED OUTCOMES

It is expected that there will be a shortage of RCTs with at least a moderate confidence in estimated effects that will allow for strong practice recommendations.

DISCUSSION

Identifying evidence that can be translated into strong practice recommendations is essential to identify beneficial and harmful interventions, decrease practice variability, and identify neuromusculoskeletal manual therapy interventions that require further disciplined methodological focus.

Manual therapy for non-radicular cervical spine related impairments: establishing a 'Trustworthy' living systematic review and meta-analysis

OBJECTIVES

To establish a 'trustworthy' living systematic review (SR) with a meta-analysis of manual therapy for treating non-radicular cervical impairments.

DESIGN

SR with meta-analysis.

LITERATURE SEARCH

Articles published between January 2010 and September 2022 were included from: Cochrane Central Register of Controlled Trials (CENTRAL); CINAHL; MEDLINE; PubMed; PEDro, and ProQuest Nursing and Allied Health.

METHODS

This SR included English-language randomized clinical trials (RCTs) of manual therapy involving adults used to treat non-radicular cervical impairments. The primary outcomes were pain and region-specific outcome measures. Cervicogenic headaches and whiplash were excluded to improve homogeneity. Two reviewers independently assessed RCTs. The prospective plan was to synthesize results with high confidence in estimated effects using GRADE.

RESULTS

Thirty-five RCTs were screened for registration status. Twenty-eight were not registered or registered prospectively. In 5 studies, the discussion and conclusion did not match the registry, or this could not be determined. One study did not meet the external validity criterion, and another was rated as having a high risk of bias. One study met the inclusion and exclusion criteria, so practice recommendations could not be made. The remaining study did not identify any clinically meaningful group differences.

DISCUSSION

Only one prospectively registered RCT met this SR's strict, high-quality standards. The single identified paper provides initial high-quality evidence on this topic.

CONCLUSION

This SR establishes a foundation of trustworthiness and can be used to generate research agendas to determine the potential clinical utility of manual therapy directed at the cervical spine for non-radicular cervical complaints.

Manual Therapy Effects on Nonspecific Neck Pain Are Not Mediated by Mechanisms Related to Conditioned Pain Modulation: A Randomized Clinical Trial

BACKGROUND

Manual therapy (MT) is a treatment recommended by clinical practice guidelines in the management of patients with neck pain. However, the mechanisms through which MT works remain unknown. The aim of the present study is to investigate if MT is mediated by mechanisms related to conditioned pain modulation (CPM), comparing the effects of painful with a pain-free MT treatment.

METHODS

A two-arm, parallel, randomized controlled clinical trial with concealed allocation and blinding of the outcome assessor was conducted in university students with chronic or recurrent nonspecific neck pain (NSNP). Participants received either a painful or pain-free MT session. Psychophysical variables including pressure pain thresholds, CPM, temporal summation of pain and cold pain intensity were assessed before and immediately after treatment. In addition, changes in neck pain intensity over the following 7 days and self-perceived improvement immediately and 7 days after treatment were assessed.

RESULTS

No significant differences were found between groups in any of the psychophysical variables or in patients' self-perceived improvement. Only a significantly greater decrease in neck pain intensity immediately after treatment was found in the pain-free MT group compared to the painful MT group.

CONCLUSION

The results suggest that the immediate and short-term effects of MT on NSNP are not mediated by CPM-related mechanisms.

A Second Look at the Risks of Serious Adverse Events with Orthopaedic Manual Therapy, Paracetamol, and NSAID Treatment of Neck Pain

Letter to the Editor-in-Chief in response to JOSPT article "International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework" by Rushton A, Carlesso LC, Flynn T, et al. J Orthop Sports Phys Ther 2023;53(6):1-2. doi:10.2519/jospt.2023.0202.

Manual Therapy versus Localisation (Tactile, Sensory Training) in Patients with Non-Specific Neck Pain: A Randomised Clinical Pilot Trial

Manual therapy (MT) techniques typically incorporate localised touch on the skin with the application of specific kinetic forces. The contribution of localised touch to the effectiveness of MT techniques has not been evaluated. This study investigated the immediate effects of MT versus localisation training (LT) on pain intensity and range of movement (ROM) for neck pain. In this single-blind randomised controlled trial thirty eligible neck pain volunteers (23 females and 7 males), aged 28.63 ± 12.49 years, were randomly allocated to MT or to a motionless (LT) group. A single three-minute treatment session was delivered to each group's cervico-thoracic area. The LT involved tactile sensory stimulation applied randomly to one out of a nine-block grid. Subjects were asked to identify the number of the square being touched, reflecting a different location on the region of skin. MT involved three-minute anteroposterior (AP) glides and sustained natural apophyseal glides (SNAG) techniques. Pre- and post-intervention pain intensity were assessed using a pressure pain threshold (PPT) algometer and the numeric pain rating scale (NPRS). Neck ROM was recorded with a bubble inclinometer. Improvements in ROM and self-reported pain were recorded in both groups (p < 0.001) without differences in NPRS, ROM or PPT scores between groups (p > 0.05). Tactile sensory training (localisation) was as effective as MT in reducing neck pain, suggesting a component of MT's analgesic effect to be related with the element of localised touch rather than the forces induced during passive movements.

Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety

BACKGROUND

Safety incident (SI) reporting and learning via incident reporting systems (IRSs) is used to identify areas for patient safety improvement. The chiropractic patient incident reporting and learning system (CPiRLS) is an online IRS that was launched in the UK in 2009 and, from time to time, has been licensed for use by the national members of the European Chiropractors' Union (ECU), members of Chiropractic Australia and a Canada-based research group. The primary aim of this project was to analyse the SIs submitted to CPiRLS over a 10-year period to identify key areas for patient safety improvement.

METHOD

All SIs reported to CPiRLS between April 2009 and March 2019 were extracted and analysed. Descriptive statistics were used to describe: (1) the frequency of SI reporting and learning by the chiropractic profession, and (2) the character of reported SIs. Key areas for patient safety improvement were developed following a mixed methods approach.

RESULTS

A total of 268 SIs were recorded on the database over the 10-year period, 85% of which originated from the UK. Evidence of learning was documented in 143 (53.4%) SIs. The largest subcategory of SIs related to post-treatment distress or pain (n = 71, 26.5%). Seven key areas for patient improvement were developed including: (1) patient trip/fall, (2) post treatment distress/pain, (3) negative effects during treatment, (4) significant post-treatment effects, (5) syncope, (6) failure to recognize serious pathology, and (7) continuity of care.

CONCLUSION

The low number of SIs reported over a 10-year period suggests significant under-reporting, however, an upward trend was identified over the 10-year period. Several key areas for patient safety improvement have been identified for dissemination to the chiropractic profession. Improved reporting practice needs to be facilitated to improve the value and validity of reporting data. CPiRLS is important in identifying key areas for patient safety improvement.

High-dose cervical mobilization to improve central sensitization for a patient with post-fusion neck pain

BACKGROUND

Few studies have addressed the appropriate joint mobilization dosage for neck pain. Furthermore, the efficacy of manual therapy in patients with post-spinal fusion neck pain is unreported.

CASE DESCRIPTION

A 63-year-old man with a 2-year history of unresolved neck pain post-cervical fusion presented to therapy with an exacerbation of neck and left-shoulder pain. The patient presented with cervical impairments of intervertebral hypo-mobility above and below the fusion site. He exhibited a high Numeric Pain Rating Scale (NPRS) score of 8/10 related to his neck pain. Additionally, he demonstrated marked loss of cervical mobility. Indicators of central sensitization were present, including both hyperalgesia and allodynia. High-dose cervical joint mobilization was applied for durations of up to 10 minutes. Corrective exercises were added to improve muscle strength and endurance. Treatment was applied for 12 sessions over 4 months.

OUTCOMES

At the time of discharge, this patient reported a full recovery of neck function. This treatment reduced pain, improved passive joint accessory motion, and restored upper quarter function. The patient demonstrated a 33-point improvement in his Neck Disability Index (NDI) score and his pain was reduced to 0-1/10 on the NPRS. Markers of central sensitization were resolved. Intervertebral passive accessory joint mobility was pain free in addition to concurrent restoration of functional mobility.

CONCLUSION

A paucity of evidence exists for appropriate dosage with manual therapy interventions. This case report demonstrates marked improvement of pain and function with the use of high-dose joint mobilization. Improved cervical accessory joint mobility and central pain modulation were achieved with high-dose joint mobilization.

Identifying Patient Characteristics Associated With the Occurrence of Post Treatment Non-serious Adverse Events After Cervical Spine Manual Therapy Treatment in Patients With Neck Pain

OBJECTIVES

To compare prevalence rates of serious and non-serious adverse events after manipulation and mobilization and to identify risk factors of serious and non-serious adverse events following 4 types of manual therapy treatment in patients with neck pain.

DESIGN

A prospective cohort study in primary care manual therapy practice.

PARTICIPANTS

Patients with neck pain (N=686) provided data on adverse events after 1014 manipulation treatments, 829 mobilization treatments, 437 combined manipulation and mobilization treatments, and 891 treatments consisting of "other treatment modality".

INTERVENTIONS

Usual care manual therapy.

MAIN OUTCOME MEASURES

A chi-square test was performed to explore differences in prevalence rates. Logistic regression analysis was performed within the 4 treatment groups. A priori we defined associations between patient-characteristics and adverse events of odds ratio (OR)>2 or OR<0.5 as clinically relevant.

RESULTS

No serious adverse events, such as cervical artery dissection or stroke, were reported. With regard to non-serious adverse events, we found that these are common after manual therapy treatment: prevalence rates are ranging from 0.3% to 64.7%. We found a statistically significant difference between the 4 types of treatments, detrimental to mobilization treatment. Logistic regression analysis resulted in 3 main predictors related to non-serious adverse events after manual therapy treatment: smoking (OR ranges from 2.10 [95% confidence interval [CI] 1.37-3.11] to 3.33 [95% CI 1.83-5.93]), the presence of comorbidity (OR ranges from 2.32 [95% CI 1.22-4.44] to 3.88 [95% CI 1.62-9.26]), and female sex (OR ranges from 0.22 [95% CI 0.11-0.46] to 0.49 [95% CI 0.28-0.86]).

CONCLUSION

There is a significant difference in the occurrence of non-serious adverse events after mobilization compared with manipulation or a combination of manipulation and mobilization. Non-serious adverse events in manual therapy practice are common and are associated with smoking and the presence of comorbidity. In addition, women are more likely to report non-serious adverse events.

Are there differences between a real C0-C1 mobilization and a sham technique in function and pressure pain threshold in patients with chronic neck pain and upper cervical restriction? A randomised controlled clinical trial

BACKGROUND

Chronic neck pain is one of the main reasons for visiting a healthcare professional. In recent years, it has been shown that upper cervical restriction may be a factor involved in neck pain.

OBJECTIVE

To compare the immediate effects of a real cervical mobilization technique versus a sham cervical mobilization technique in patients with chronic neck pain and upper cervical restriction.

METHODS

This was a randomised, controlled, double-blind clinical trial. Twenty-eight patients with chronic neck pain were recruited and divided into two groups (14 = real cervical mobilization; 14 = sham mobilization). Both groups received a single 5-minute treatment session. Upper cervical range motion, flexion-rotation test, deep cervical activation and pressure pain threshold were measured.

RESULTS

In the between-groups comparison, statistically significant differences were found in favour of the real cervical mobilization group in upper cervical extension (p= 0.003), more restricted side of flexion-rotation test (p< 0.001) and less restricted side of flexion-rotation test (p= 0.007) and in the pressure pain threshold of the right trapezius (p= 0.040) and right splenius (p= 0.049). No differences in deep muscle activation were obtained.

CONCLUSION

The real cervical mobilization group generates improvements in upper cervical spine movement and pressure pain threshold of right trapezius and right splenius compared to the sham group in patients with chronic neck pain and upper cervical restriction.

Effectiveness of Thoracic Spine Manipulation on the Management of Neck Pain: A Systematic Review and Meta-Analysis of Randomized Control Trials

There are contradicting findings regarding the effect of thoracic spine manipulation in decreasing pain and disability in patients with chronic mechanical neck pain. Hence, the purpose of this review was to evaluate the current evidence on the effectiveness of thoracic spine thrust manipulation in decreasing pain intensity, and neck disability among subjects with chronic mechanical neck pain. We made a comprehensive search of literature published between 2010 and 2020 from the electronic databases of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, and Physiotherapy Evidence Database (PEDro). We adhered to Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA). The methodological quality was assessed by the PEDro scale, and the level of evidence rated by Grading of Recommendations Assessment, Development, and Evaluation (GRADE) software. Finally, a meta-analysis was done using RevMan 5.3 with a random-effects model to calculate the mean difference (MD) and 95% confidence intervals for pain and disability. Eight eligible randomized controlled trials were identified with a total of 457 participants. The quality assessment of the included studies was found to be fair in quality (mean PEDro score of 6.63/10). The overall GRADE of the review showed low to moderate level of evidence. Effect size estimates of the studies showed modest differences in pain reduction, as it revealed a significant effect in Visual Analog Scale ((VAS) 0-100mm) (MD -12.46; 95% CI: -17.29, -7.64), and Pain Numeric Rating Scale ((PNRS) 0-10 pts) (MD -0.8; 95% CI: -1.60, -0.10). The thoracic manipulation also resulted in a significant effect in decreasing neck disability, in which the mean difference in Neck disability index (NDI) showed (MD -6.46; 95% CI: -10.43 -2.50). This review suggested that thoracic spine manipulation was effective in reducing pain and neck disability in all adults with chronic mechanical neck pain compared to other interventions.

Effects of an exercise program plus manual therapy in a patient with failed neck surgery syndrome: A case report

BACKGROUND

Patients who have undergone cervical surgery may present pain and dysfunction in the upper limb, which is often referred to as failed neck surgery syndrome. Little is known about the effects of an exercise program plus manual therapy in the treatment of prolonged neuropathic pain of the upper quadrant in a patient with failed neck surgery.

CASE DESCRIPTION

A 66-year-old woman consulted for neuropathic pain and dysfunction during grasping activities, as a result of failed neck surgery after 12 months. Clinical, functional, and electromyographic measurements were recorded at baseline and after treatment. The patient underwent a treatment for six weeks based on manual therapy for the upper limb and cervical spine and an exercise program for the scapular muscles, rotator cuff and wrist extensor muscles.

OUTCOMES

Positive clinically significant changes were observed in the Neuropathic Pain Questionnaire (DN4) (baseline = 7 points; post-treatment = 4 points), Neck Disability Index (NDI) (baseline = 36; post-treatment = 18 points), QuickDASH (baseline = 78; post- treatment = 32 points), Upper Limb Neurodynamic Test 1 (ULNT-1) (baseline = 75°; post- treatment = 42°) and grip strength (GS) (baseline = 23 kgf; post-treatment = to 32 kgf). Improvements in the surface electromyographic (sEMG) activity of the upper trapezius (UT), infraspinatus (IS) and radial wrist extensors (RWE) muscles also seemed to occur after treatment.

CONCLUSION

Treatment helped relieve neuropathic pain, decrease neck disability, and improve general upper limb function.

The effect of lumbar spinal manipulation on biomechanical factors and perceived transient pain during prolonged sitting: a laboratory-controlled cross-sectional study

BACKGROUND

Spinal manipulation has been shown to affect muscle activity, posture, and pain. To date, no studies have examined the effect of manipulation on biomechanical factors during sitting. Therefore, the purpose of this study was to investigate the immediate effect of lumbar spinal manipulation on trunk muscle activation, spine posture and movements, and perceived ratings of transient pain in asymptomatic adults during prolonged office sitting.

METHODS

Twenty healthy adults were recruited for a single laboratory session that included a standardized office sitting/data entry protocol (120 min total, 3 blocks of 40 min). Data were collected between July and August 2012. The first block (baseline) was immediately followed by two experimental blocks. Prior to the start of each experimental block, participants were transferred to a therapy plinth and placed side lying (right side down), and a random presentation of either a control or high velocity low amplitude thrust directed at L4/L5 was delivered. Continuous measures of muscle activity, spine posture, and spine movements were recorded throughout the sitting trials. Perceived transient pain was measured by visual analogue scale at 10-min intervals (including immediately before and after the randomized maneuvers).

RESULTS

There were no significant differences in spine or pelvic posture or perceived back pain following either the manipulation or control maneuvers. Significantly reduced muscle activity and increased shifts of the lumbar spine angle were identified in the block following manipulation compared to both baseline and post control blocks.

CONCLUSIONS

Spinal manipulation does not appear to have an immediate impact on spine or pelvic posture in healthy adults but does appear to reduce muscle activity and increase spine movement during sitting. Future work should replicate this study with a larger population in a field setting. It may be worthwhile to explore the implication of reduced muscle activation and increased spine movements during prolonged sitting for office workers that receive manipulations or mobilizations during their workday.

Analysis of cervical and upper thoracic spinal segmental rotation angles during end-range neck rotation: Comparison with and without neck pain

BACKGROUND

Neck pain is a common manifestation of musculoskeletal disorders of the cervical and thoracic spine. Manual therapy interventions to the thoracic spine are recommended for treating patients with several types of neck pain. However, only a few studies have investigated the thoracic spine mobility associated with neck movement.

OBJECTIVES

Compare cervical and upper thoracic rotation angles in subjects with and without neck pain.

METHODS

The subjects included nine individuals who experienced neck pain (pain, Group P) and 11 who did not (non-pain, Group N). The rotation angle was measured using MRI. The imaging limb position was at 90% of the maximum neck rotation. The MR images were analyzed using image analysis software to calculate the rotation angle of C1 to Th3. The rotation angle of the segment was then calculated by subtracting the rotation angle corresponding to the lower vertebra from that corresponding to the upper vertebra. The total rotation of each segment was calculated as the sum of the right and left rotation angle. Then, the segmental rotation angles were compared between groups.

RESULTS/FINDINGS

The rotation angles of C3-C4, C7-Th1, and Th1-Th2 were significantly smaller in Group P than in Group N, and C5-C6 and C6-C7 were significantly larger in Group P than in Group N. There was no statistical difference in rotational angle at all other spinal levels measured.

CONCLUSIONS

The results of this study indicate subjects with neck pain had hypermobility of the lower cervical spine and hypomobility of the cervico-thoracic junction and upper thoracic spine compared with subjects without neck pain. These results add to current understanding of biomechanical factors that may be related to neck pain.

The effects of osteopathic manipulative treatment on pain and disability in patients with chronic neck pain: A single-blinded randomized controlled trial

BACKGROUND

Neck pain (NP) affects up to 70% of individuals at some point in their lives. Systematic reviews indicate that manual treatments can be moderately effective in the management of chronic, nonspecific NP. However, there is a paucity of studies specifically evaluating the efficacy of osteopathic manipulative treatment (OMT).

OBJECTIVE

To evaluate the efficacy of OMT in reducing pain and disability in patients with chronic NP.

DESIGN

Single-blinded, cross-over, randomized-controlled trial.

SETTING

University-based, osteopathic manipulative medicine outpatient clinic.

PARTICIPANTS

Ninety-seven participants, 21 to 65 years of age, with chronic, nonspecific NP.

INTERVENTIONS

Participants were randomized to two trial arms: immediate OMT intervention or waiting period first. The intervention consisted of three to four OMT sessions over 4 to 6 weeks, after which the participants switched groups.

MAIN OUTCOME MEASURES

Primary outcome measures were pain intensity (average and current) on the numerical rating scale and Neck Disability Index. Secondary outcomes included Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) health domains and Fear Avoidance Beliefs Questionnaire. Outcomes obtained prior to the cross-over allocation were evaluated using general linear models and after adjusting for baseline values.

RESULTS

A total of 38 and 37 participants were available for the analysis in the OMT and waiting period groups, respectively. The results showed significantly better primary outcomes in the immediate OMT group for reductions in average pain (-1.02, 95% confidence interval [CI] -1.72, -0.32; p = .005), current pain (-1.02, 95% CI -1.75, -0.30; p = .006), disability (-5.30%, 95% CI -9.2%, -1.3%; p = .010) and improved secondary outcomes (PROMIS) related to sleep (-3.25, 95% CI -6.95, -1.54; p = .003), fatigue (-3.26, 95% CI -6.04, -0.48; p = .022), and depression (-2.59, 95% CI -4.73, -0.45; p = .018). The effect sizes were in the clinically meaningful range between 0.5 and 1 standard deviation. No study-related serious adverse events were reported.

CONCLUSIONS

OMT is relatively safe and effective in reducing pain and disability along with improving sleep, fatigue, and depression in patients with chronic NP immediately following treatment delivered over approximately 4 to 6 weeks.

Short-Term Effects of Dry Needling with a Standard Exercise Program on Pain and Quality of Life in Patients with Chronic Mechanical Neck Pain

Background: This study aimed to determine the short-term effects of dry needling (DN) combined with a standard exercise program on pain and quality of life in patients with chronic mechanical neck pain (CMNP). Methods: Thirty-one patients with CMNP were randomly allocated to the experimental and control groups. The experimental group received DN and underwent a standard exercise program (one DN session and six exercise sessions) for two weeks, whereas the control group underwent the same exercise program alone for two weeks. The participants’ scores in the Numeric Pain Rating Scale (NPRS), Neck Disability Index (NDI), Short Form-36 Quality of Life Scale (SF-36 QOLS), and Beck Depression Inventory (BDI) before and after the intervention were assessed. Results: The control and experimental groups’ post-test NDI, NPRS, SF-36 QOLS, and BDI scores significantly differed from their baseline scores (p ≤ 0.05). The between-group comparison of the post-test scores using Wilcoxon rank-sum test revealed no significant differences between the NDI, NPRS, BDI, and SF-36 QOLS scores of both groups (p ≥ 0.05). Conclusions: One session of trigger point DN (TrP-DN) with exercise and exercise alone showed the same pain and quality-of-life outcomes after a two-week intervention. We did not recognise TrP-DN as an efficient intervention, not because we obtained evidence that it is ineffective, but because there were inadequate high-quality studies on the subject and unavailable data on the minimum quantity of injections required for better DN outcomes in CMNP patients.

Responsiveness of the German version of the Neck Disability Index in chronic neck pain patients: a prospective cohort study with a seven-week follow-up

Background

The need for an efficient and feasible strategy to deal with neck pain has a high priority for many countries. Validated assessment tools like the Neck Disability Index (NDI) to evaluate the functional status of a neck pain patient are urgently needed to treat and to follow-up patients purposefully. A German version (NDI-G) was shown to be valid and reliable, but has so far not been tested for responsiveness. The aim of this study was to evaluate the NDI-G`s responsiveness.

Methods

This was a prospective cohort study with a seven-week follow-up. Fifty chronic neck pain patients filled out NDI-G twice. Additionally, the Patients’ Global Impression of Change score (PGIC) was assessed at follow-up. Wilcoxon and Spearman tests were used to assess direction and strength of the association between the change in NDI-G and PGIC. The receiver operating characteristics method and the area under the curve (AUC) were calculated to assess sensitivity and specificity of the NDI-G change over time.

Results

The Wilcoxon test showed statistically significant differences for NDI-G at baseline and follow-up in the total sample, the “clinically improved” and “clinically not improved” subgroups as indicated in the PGIC. Spearman test resulted in a moderate correlation between the NDI-G and the PGIC (rS = -0.53, p = 0.01) at follow-up. AUC showed an acceptable discrimination [AUC = 0.78 (95% confidence interval 0.64 – 0.91)] of the NDI-G, with a cutoff score of 1.5, between clinically improved and clinically not improved patients, based on the PGIC.

Conclusions

The NDI-G is responsive to change in chronic neck pain. Together with the results of a previous study on its validity and reliability, the NDI-G can be recommended for research and clinical settings in patients with neck pain in German speaking countries.

Trial registration

NCT02676141. February 8, 2016.

Evidence (-based medicine) in manual medicine/manual therapy—a summary review

Objective

The aim of this summary review is to analyse the current state of evidence in manual medicine or manual therapy.

Methods

The literature search focussed on systematic reviews listed in PubMed referring to manual medicine treatment until the beginning of 2022, limited to publications in English or German. The search concentrates on (1) manipulation, (2) mobilization, (3) functional/musculoskeletal and (4) fascia. The CASP Checklist for Systematic Reviews was used to present the included reviews in a clear way.

Results

A total of 67 publications were included and herewith five categories: low back pain, neck pain, extremities, temporomandibular disorders and additional effects. The results were grouped in accordance with study questions.

Conclusion

Based on the current systematic reviews, a general evidence-based medicine level III is available, with individual studies reaching level II or Ib. This allows manual medicine treatment or manual therapy to be used in a valid manner.

Some conservative interventions are more effective than others for people with chronic non-specific neck pain: a systematic review and network meta-analysis

QUESTION

Which is the most effective conservative intervention for patients with non-specific chronic neck pain (CNSNP)?

DESIGN

A systematic review and network meta-analysis of randomised clinical trials.

PARTICIPANTS

Adults with CNSNP of at least 3 months duration.

INTERVENTIONS

All available pharmacological and non-pharmacological interventions.

OUTCOME MEASURES

The primary outcomes were pain intensity and disability. The secondary outcome was adverse events.

RESULTS

Overall, 119 RCTs (12,496 patients; 32 interventions) were included. Risk of bias was low in 50.4% of trials, unclear in 22.7% and high in 26.9%. Compared with inert treatment, a combination of active and/or passive multimodal non-pharmacological inventions (eg, exercise and manual therapy) were effective for pain on a 0-to-10 scale at 1 month (MD range 0.84 to 3.74) and at 3 to 6 months (MD range 1.06 to 1.49), and effective on disability on a 0-to-100 scale at 1 month (MD range 10.26 to 14.09) and 3 to 6 months (MD range 5.60 to 16.46). These effects ranged from possible to definite clinical relevance. Compared with inert treatment, anti-inflammatory drugs alone or in combination with another non-pharmacological treatment did not reduce pain at 1 month or 3 to 6 months. At 12 months, no superiority was found over inert treatment on both outcomes. Most mild adverse events were experienced following acupuncture/dry needling intervention. On average, the evidence varied from low to very low certainty.

CONCLUSIONS

While multimodal non-pharmacological interventions may reduce pain and disability for up to 3 to 6 months of follow-up when compared with inert treatment, the evidence was very uncertain about their effects. Better quality and larger trials are needed to improve the certainty of evidence.

REGISTRATION

PROSPERO CRD42019124501.

Cervical and scapula-focused resistance exercise program versus trapezius massage in patients with chronic neck pain: A randomized controlled trial

OBJECTIVE

The purpose of this study was to investigate the effects of resistance exercise in comparison with those of common exercise on chronic neck pain (CNP) to provide useful clinical guidelines for reducing pain or increasing cervical range of motion (ROM), upper trapezius tone, disability level, and quality of life (QOL).

METHODS

The subjects were randomized into a cervical and scapula-focused resistance exercise group (CSREG, n = 21) or trapezius massage group (TMG, n = 20). All groups received a 4-week, five times per week CSRE or TM program for CNP. The visual analogue scale (VAS) score, cervical ROM, myotonometer measures (upper trapezius tone, stiffness, and elasticity), neck disability index (NDI), and short form-36 (SF-36) were identified as the primary outcomes.

RESULTS

Within-group changes in VAS, cervical ROM, myotonometer measures, NDI, and SF-36 were significant in the CSREG and TMG (P < .05). The between-group changes in VAS, cervical rotation, myotonometer (upper trapezius tone and stiffness), NDI, and SF-36 after intervention showed significant differences between the CSREG and TMG (P < .05).

CONCLUSION

These results suggest that the CSRE program is effective in improving pain, cervical ROM, upper trapezius tone, disability level, and QOL in patients with CNP. More comprehensive studies with longer follow-up durations are needed to better understand the potential effects of the CSRE program in patients with CNP.

A Single-Center Study Comparing the Effects of Thoracic Spine Manipulation vs Mobility Exercises in 26 Office Workers with Chronic Neck Pain: A Randomized Controlled Clinical Study

Background

Neck pain is associated with computer work, poor posture, imbalanced neck muscles, and fatigue, particularly in office workers. This study from a single center aimed to compare the effects of thoracic spine mobility exercise and thoracic spine manipulation to improve cervical spine range of motion in 26 office workers who had chronic neck pain for more than 12 weeks.

Material/Methods

The participants were 26 office workers with neck pain lasting >12 weeks. These participants were randomly assigned to undergo TSME (n=13) or TSM (n=13). Both groups underwent cervical joint mobilization and deep cervical flexor muscle exercises for 25 min a day, twice weekly, for 6 weeks. The TSME group additionally performed TSME 15 min a day, twice a week, for 6 weeks, while the TSM group received TSM 2 times a day, twice a week, for 6 weeks. Cervical and thoracic spine ROM, numeric pain rating scale (NPRS), and neck disability index (NDI) were measured before and after interventions. The ROM of cervical and thoracic spine was measured using a dual inclinometer.

Results

Both groups showed significant changes in cervical spine ROM, thoracic spine ROM, NPRS, and NDI after intervention compared to before intervention (P<0.05). Cervical spine right lateral flexion and right rotation differed significantly between the groups (P<0.05), while thoracic spine ROM, NPRS, and NDI did not.

Conclusions

TSME and TSM have similar effects in improving pain and disability in office workers with non-specific chronic neck pain.

Effectiveness of interventions for middle-aged and ageing population with neck pain: a systematic review and network meta-analysis protocol

INTRODUCTION

Neck pain (NP) is a common musculoskeletal complaint and is increasing in prevalence. Current clinical practice guidelines and systematic reviews recommended conservative, pharmacological and invasive interventions for individuals with NP. However, optimal management specifically for those who are middle-aged or older adults (≥45 years) is not available; and important considering our ageing population.

METHODS AND ANALYSIS

A systematic review with network meta-analysis (NMA) will be conducted following the Cochrane guidelines. Eligibility criteria include randomised controlled/clinical trials evaluating any of acute (<3 months) or chronic (≥3 months) non-specific NP, whiplash associated disorders, cervical radiculopathy and cervicogenic headache. Any interventions and outcome measures detailed within The International Classification of Functioning, Disability and Health domains will be included. Two independent reviewers will search key databases (AMED, CENTRAL, CINAHL, Embase, MEDLINE, PEDro and PsycINFO), grey literature, key journals and reference lists in May 2022. Two reviewers will decide eligibility and assess risk of bias (ROB) of included studies. The kappa statistic will be used to evaluate agreement between the reviewers at each stage. Data will be extracted by one reviewer and checked for accuracy by a second reviewer. Descriptive data and ROB will be summarised and tabulated. Traditional pairwise meta-analysis using random-effect model will be performed for all direct comparisons, and NMA using a frequentist random-effect model then performed based on NP classification where possible. A network of traditional pairwise meta-analysis allows comparisons of multiple interventions from both direct and indirect evidence to provide a hierarchal establishment for enhancing decision making of clinical practitioners.

ETHICS AND DISSEMINATION

Ethic approval is not required as the study is a literature review. The findings will be shared with the national and international researchers, healthcare professionals and the general public through publishing in a peer-reviewed journal and presentations at conferences.

PROSPERO REGISTRATION NUMBER

CRD42021284618.

Kinematics of the head and associated vertebral artery length changes during high-velocity, low-amplitude cervical spine manipulation

Background

Cervical spine manipulation (CSM) is a frequently used treatment for neck pain. Despite its demonstrated efficacy, concerns regarding the potential of stretch damage to vertebral arteries (VA) during CSM remain. The purpose of this study was to quantify the angular displacements of the head relative to the sternum and the associated VA length changes during the thrust phase of CSM.

Methods

Rotation and lateral flexion CSM procedures were delivered bilaterally from C1 to C7 to three male cadaveric donors (Jan 2016–Dec 2019). For each CSM the force–time profile was recorded using a thin, flexible pressure pad (100–200 Hz), to determine the timing of the thrust. Three dimensional displacements of the head relative to the sternum were recorded using an eight-camera motion analysis system (120–240 Hz) and angular displacements of the head relative to the sternum were computed in Matlab. Positive kinematic values indicate flexion, left lateral flexion, and left rotation. Ipsilateral refers to the same side as the clinician's contact and contralateral, the opposite. Length changes of the VA were recorded using eight piezoelectric ultrasound crystals (260–557 Hz), inserted along the entire vessel. VA length changes were calculated as D = (L₁− L₀)/L₀, where L₀ = length of the whole VA (sum of segmental lengths) or the V3 segment at CSM thrust onset; L₁ = whole VA or V3 length at peak force during the CSM thrust.

Results

Irrespective of the type of CSM, the side or level of CSM application, angular displacements of the head and associated VA length changes during the thrust phase of CSM were small. VA length changes during the thrust phase were largest with ipsilateral rotation CSM (producing contralateral head rotation): [mean ± SD (range)] whole artery [1.3 ± 1.0 (− 0.4 to 3.3%)]; and V3 segment [2.6 ± 3.6 (− 0.4 to 11.6%)].

Conclusions

Mean head angular displacements and VA length changes were small during CSM thrusts. Of the four different CSM measured, mean VA length changes were largest during rotation procedures. This suggests that if clinicians wish to limit VA length changes during the thrust phase of CSM, consideration should be given to the type of CSM used.

Manual therapy versus advice to stay active for nonspecific back and/or neck pain: a cost-effectiveness analysis

BACKGROUND

Low back and neck pain are the most common musculoskeletal disorders worldwide, and imply suffering and substantial societal costs, hence effective interventions are crucial. The aim of this study was to evaluate the cost-effectiveness of manual therapy compared with advice to stay active for working age persons with nonspecific back and/or neck pain.

METHODS

The two interventions were: a maximum of 6 manual therapy sessions within 6 weeks, including spinal manipulation/mobilization, massage and stretching, performed by a naprapath (index group), respectively information from a physician on the importance to stay active and on how to cope with pain, according to evidence-based advice, at 2 occasions within 3 weeks (control group). A cost-effectiveness analysis with a societal perspective was performed alongside a randomized controlled trial including 409 persons followed for one year, in 2005. The outcomes were health-related Quality of Life (QoL) encoded from the SF-36 and pain intensity. Direct and indirect costs were calculated based on intervention and medication costs and sickness absence data. An incremental cost per health related QoL was calculated, and sensitivity analyses were performed.

RESULTS

The difference in QoL gains was 0.007 (95% CI - 0.010 to 0.023) and the mean improvement in pain intensity was 0.6 (95% CI 0.068-1.065) in favor of manual therapy after one year. Concerning the QoL outcome, the differences in mean cost per person was estimated at - 437 EUR (95% CI - 1302 to 371) and for the pain outcome the difference was - 635 EUR (95% CI - 1587 to 246) in favor of manual therapy. The results indicate that manual therapy achieves better outcomes at lower costs compared with advice to stay active. The sensitivity analyses were consistent with the main results.

CONCLUSIONS

Our results indicate that manual therapy for nonspecific back and/or neck pain is slightly less costly and more beneficial than advice to stay active for this sample of working age persons. Since manual therapy treatment is at least as cost-effective as evidence-based advice from a physician, it may be recommended for neck and low back pain. Further health economic studies that may confirm those findings are warranted. Trial registration Current Controlled Trials ISRCTN56954776. Retrospectively registered 12 September 2006, http://www.isrctn.com/ISRCTN56954776 .

Comparisons of cervical and thoracic spine kinematic joint and body segment angles, timing, and velocity between individuals with and without chronic idiopathic neck pain during functional tasks

BACKGROUND

Few studies comprehensively analyse 3D neck kinematics in individuals with chronic idiopathic neck pain during functional tasks considered challenging. This critical knowledge is needed to assist clinicians to recognise and address how altered movement strategies might contribute to pain.

RESEARCH QUESTION

Are there differences in 3D neck kinematics (angles, timing, velocity) during functional tasks in people with chronic neck pain compared to matched asymptomatic control participants?

METHODS

Participants with chronic idiopathic neck pain (n = 33) and matched asymptomatic controls (n = 30) performed four functional tasks (overhead reach forward, right and left, and putting on a seatbelt) while evaluated using 3D motion capture. Kinematic variables included joint angles, range of motion (ROM,°), velocity (m s^-1) and timing (% of movement phase) for joint angles (head-neck [HN joint], head+neck-upper trunk [HNT], and thoracolumbar) and segments (head, neck, head+neck [HN segment], upper trunk, and trunk. Generalised linear mixed models examined between-group differences.

RESULTS

There were few between-group differences. The neck pain group had less HN segment extension that controls (mean difference [MD] left -2.06°; 95% CI -3.82, -0.29; p = .023; and right reach -2.52°; -4.67, -0.37; P = .022), and had less total sagittal HNT ROM across all tasks (-1.28; 95% CI -2.25, -0.31; p = .010). Approaching significance was the pain group having less thoracolumbar left rotation than controls (MD -2.14, 95% CI -4.41 to 0.13, p = .064). The pain group had higher neck segment peak flexion velocity than controls across all tasks (MD -3.09; 95% CI -5.21 to -0.10; P = .004). Timing of joint angle peaks did not differ between groups.

SIGNIFICANCE

When performing an overhead reach task to the left and right and putting on a seatbelt, people with neck pain maintain a more flexed HN segment, use less sagittal ROM and have higher velocity peaks. These findings can assist clinicians in their assessment of patients by identifying possible underlying contributors to neck pain.

Intersegmental Kinematics of the Upper Cervical Spine: Normal Range of Motion and Its Alteration After Alar Ligament Transection

STUDY DESIGN

Biomechanical study using cadaveric cervical spines.

OBJECTIVE

To evaluate joint mobility and stiffness at the craniovertebral junction.

SUMMARY OF BACKGROUND DATA

Data on the intersegmental kinematics of the craniovertebral joints are available in the literature with a widespread range of values. The effect that alar ligament injuries have on intersegmental kinematics remains unclear and requires further biomechanical investigation.

METHODS

Ten occipito-atlanto-axial (C0-C1-C2) human specimens were articulated to flexion, extension, bilateral lateral bending, and bilateral axial rotation. The moment-rotation response was continuously tracked through the entire range of motion before and after unilateral alar ligament transection of the right side.

RESULTS

The intersegmental (C0-C1/C1-C2) moment-rotation response was continuously quantified in full flexion (7.2 ± 6.6°/12.1 ± 5.8°), extension (11.1 ± 6.4°/3.0 ± 2.8°), lateral bending to the right (3.1 ± 2.2°/1.6 ± 1.2°) and left sides (3.3 ± 1.6°/2.1 ± 1.5°), and axial rotation to the right (1.2 ± 3.5°/32.3 ± 9.3°) and left sides (2.7 ± 2.6°/25.3 ± 8.3°). Unilateral alar ligament transection increased the range of motion of C0-C2 in the three planes of movement; however, intersegmental motion alterations were not always observed.

CONCLUSION

Increases in the range of extension and lateral bending at C0-C1, which had not been reported previously, were observed. Further, the range of rotation on the right and left sides increased, in conjunction with the increased ranges at C0-C1 and C1-C2.Level of Evidence: N/A.

Fascial treatment versus manual therapy (HVLA) in patients with chronic neck pain: A randomized controlled trial

BACKGROUND

Chronic neck pain (CNP) is a common health problem in western industrialized nations. In recent years, the fascial tissue has attracted the attention of therapists, and a treatment of the fasciae promises to be a meaningful approach in the therapy of patients with CNP.

OBJECTIVE

The aim of this study was to investigate the effectiveness of a fascial treatment (FT) compared to manual therapy (MT) and to no intervention (control group, CG) in patients with CNP.

METHODS

Sixty participants with CNP were randomized into three groups. Primary outcome parameters were pain intensity as measured by the visual analogue scale (VAS), and severity of illness as measured by the Neck Pain and Disability Scale (NPAD). Secondary outcome parameter was the range of motion (ROM) of the cervical spine.

RESULTS

Repeated measures t-tests demonstrated significant decreases with medium to large effect sizes for the FT (VAS: dR⁢M= 1.14; NPAD: dR⁢M= 0.51) and for the MT (VAS: dR⁢M= 1.15; NPAD: dR⁢M= 0.72).

CONCLUSION

Our results confirmed the effectiveness of MT on pain and severity of illness in the treatment of patients suffering from CNP. Furthermore, the results demonstrated the effectiveness and clinical relevance of FT for this population.

A Systematic Review of Musculoskeletal Mobilization and Manipulation Techniques Used in Veterinary Medicine

Simple Summary

Neck and back pain are common ailments in animals. While there are medical and surgical treatment options available for select patients, conservative care is the most common form of management of pain, stiffness and muscle spasms. Physical therapists, osteopaths and chiropractors use mobilization and manipulation techniques to evaluate and treat muscle and joint problems in both humans and animals, but there seems to be little scientific evidence available to support their use in veterinary medicine. This study reviews the scientific literature with the goal of identifying the clinical indications, dosages, outcome parameters, and efficacy of mobilization and manipulation techniques in dogs and horses. Fourteen articles were included in this review of which 13 were equine and one was a canine study. There was a large variability in the quality of evidence that supports the use of joint mobilization or manipulation in treating pain, stiffness and muscle hypertonicity in horses. Therefore, it was difficult to draw firm conclusions despite all studies reporting positive effects. Future studies need to establish standardized methods to evaluate the optimal dosages of mobilization and manipulation for use in animals.

Abstract

Mobilization and manipulation techniques are often used in small animal and equine practice; however, questions remain concerning indications, dosing and efficacy. A bibliographic search was performed to identify peer-reviewed publications from 1980 to 2020 that evaluated the clinical effects of musculoskeletal mobilization and manipulation techniques in dogs, cats and horses. The search strategy identified 883 papers for review. Inclusion and exclusion criteria were applied. The clinical indications, dosages, outcome parameters, and reported efficacy within each publication were recorded and categorized for comparison with scientific quality assessed according to a standardized grading system. Fourteen articles were included in this systematic review of which 13 were equine and one was a canine study. Seven of these were cohort studies and seven were randomized controlled clinical trials. The canine study involved carpal immobilization-remobilization and all equine studies focused on the effects of passive mobilization (n = 5) or manipulation (n = 8) of the axial skeleton. Study quality was low (n = 4), moderate (n = 7), and high (n = 3) and included a wide array of outcome parameters with varying levels of efficacy and duration of therapeutic effects, which prevented further meta-analysis. Therefore, it was difficult to draw firm conclusions despite all studies reporting positive effects. Optimal technique indications and dosages need to be determined to improve the standardization of these treatment options.

Effects of sling-based manual therapy on cervicothoracic junction in patients with neck pain and forward head posture: A randomized clinical trial

OBJECTIVE

The purpose of this study was to investigate the effect of 4 weeks of sling-based manual therapy on the cervicothoracic junction (CTJ) area in patients with neck pain and forward head posture.

DESIGN

Single-blind randomized controlled trial.

SETTING

Outpatient, Chonbuk National University hospital, Republic of Korea.

SUBJECTS

A total of 22 participants with neck pain (Numeric Pain Rating Scale >3) and forward head posture (craniovertebral angle <51) were randomly assigned to a CTJ group or a control group (n = 11 each).

INTERVENTION

In the control group, joint mobilization and motor control training was applied for the upper cervical spine (C0-C1). The CTJ group applied the same intervention to the upper cervical spine and cervicothoracic junction (C7-T3).

MAIN MEASURES

Numeric pain rating scale and neck disability index, craniovertebral angle, active range of motion, and muscle activity were evaluated before and after 4 weeks of intervention.

RESULT

The CTJ group participants showed significant improvement in the craniovertebral angle and cervical extension range after the intervention than the control group (P = 0.025, P = 0.001). While both groups presented significant differences after the intervention regarding Numeric pain rating scale, neck disability index, and muscle activity (sternocleidomastoid and anterior scalene muscle), there were no statistically significant differences between the groups (P > 0.05).

CONCLUSION

Our results suggest that the CTJ and the upper cervical region in patients with neck pain and forward head posture represent an area which if approached by manual therapy, improves cervical mobility and posture.

Teaching and use of cervical high-velocity, low-amplitude manipulation at colleges of osteopathic medicine

Context

Despite the documented effectiveness of high-velocity, low-amplitude (HVLA) treatment of the cervical spine, concerns about patient safety potentially limit didactic instruction and use in clinical practice. Understanding how cervical HVLA is taught and employed is of interest to osteopathic educators and clinicians.

Objectives

To characterize the perspectives of osteopathic manipulative medicine/osteopathic principles and practices (OMM/OPP) departments within colleges of osteopathic medicine (COMs) in the US regarding patterns of teaching and practice of HVLA treatment of the cervical spine.

Methods

A questionnaire was distributed on April 11, 2019 in paper format to OMM/OPP department chairs or designated faculty member attendees at the Educational Council on Osteopathic Principles biannual meeting. If the department chair was not available, the survey was provided to the faculty member designated to represent the Chair of the institution at ECOP. All respondents in this category returned the survey in paper before they left the meeting. The OMM/OPP department chairs who did not attend or send representatives to the ECOP meeting were sent the survey by email on April 11, 2019 and given three opportunities over 6 weeks at 2-week intervals to reply to this voluntary online survey. The survey was given or sent to a total of 51 OMM/OPP department chairs or representatives. Six questions elicited demographic information pertaining to status, age, gender, ethnicity, board-certified specialty, and COM affiliation. Nine questions examined perspectives related to the instruction of cervical HVLA manipulation and treatment.

Results

Of the 51 OMM/OPP department chairs surveyed, 38 (74.5%) responded, 32 to the paper survey at the ECOP meeting and six to the digital survey. Respondents were primarily dual Board-certified in Family Medicine and Neuromuscular Medicine (55.3%). At over 90% (35) of the COMs for which department chairs responded to the survey, cervical HVLA instruction occurs in the curriculum primarily during program years 1 and 2. Instruction in cervical HVLA to the 2nd through 7th cervical vertebral levels occurred in 97% (37), while 11% (4) of the COMs excluded the occipital-atlanto (OA) and atlanto-axial (AA) joints. A high percentage (81.6%; 31) of the OMM/OPP department chairs or representatives reported employing cervical HVLA techniques within their practice. Among the respondents, 40.5% (15) reported that 0-25% of their school's medical school class could perform cervical HVLA competently upon graduation, whereas 27% (10) said that 51-75% of their class could perform cervical HVLA.

Conclusions

A majority of COMs provide education in their curricula related to cervical HVLA primarily in the first 2 years of medical education. However, instruction often excludes cervical HVLA to the upper regions of the cervical spine. At COMs where HVLA to the cervical spine is not taught, that decision is because the techniques are thought to be too difficult and the attendant medicolegal risk perceived to be too high. OMM/OPP department chairs expressed confidence in only a small proportion of their graduates having the ability to competently apply HVLA to the cervical spine immediately after completing their predoctoral medical training.

The Effects of Therapeutic Exercise With and Without Mobilization in Participants With Chronic Ankle Instability: A Randomized Controlled Trial

Context: Manual therapy (MT) is reported to increase range of motion (ROM), improve balance, and decrease pain in individuals with chronic ankle instability (CAI). Additional literature is needed to examine the effectiveness of the addition of MT to a therapeutic exercise regimen in individuals with CAI. Objective: To examine the combined effects of thrust joint manipulation (TJM) and exercise on function in participants reporting CAI. Design: Randomized controlled trial. Setting: Research laboratory. Participants: A convenience sample of 30 participants (mean age 23.7 [3.65] y; mean height 169.50 [9.50] cm; mean mass 66.48 [10.64] kg). Intervention: Participants were randomly allocated to the exercise (n = 15) or exercise + TJM group (n = 20) and completed an exercise program. The exercise + TJM group also received MT at the talocrural, proximal, and distal tibiofibular joints in the first 3 sessions. Main Outcome Measures: Self-reported outcomes were recorded at baseline and follow-up using the Foot and Ankle Ability Measure (FAAM), the FAAM-Sport (FAAM-S) subscale, and the Ankle Joint Functional Assessment Tool (AJFAT). The side-hop test, figure-of-8 hop test, 3 directions of the Star Excursion Balance Test, and dorsiflexion ROM were also assessed at baseline and follow-up. Results: Only the exercise + TJM group demonstrated an improvement in weight-bearing dorsiflexion with the knee flexed following treatment (P = .02). For all outcome measures, except ROM, subjects improved significantly at follow-up regardless of group assignment (P ≤ .01). Conclusions: Our data suggest that rehabilitation of patients with CAI is related to improved ROM, function, and self-reported outcomes. This provides evidence that the addition of MT to exercise may enhance improvements in ROM as compared with exercise alone. Additional research is needed to identify optimal parameters to maximize therapeutic benefit.

The Effect of Spinal Manipulation on the Electrophysiological and Metabolic Properties of the Tibialis Anterior Muscle

There is growing evidence showing that spinal manipulation increases muscle strength in healthy individuals as well as in people with some musculoskeletal and neurological disorders. However, the underlying mechanism by which spinal manipulation changes muscle strength is less clear. This study aimed to assess the effects of a single spinal manipulation session on the electrophysiological and metabolic properties of the tibialis anterior (TA) muscle. Maximum voluntary contractions (MVC) of the ankle dorsiflexors, high-density electromyography (HDsEMG), intramuscular EMG, and near-infrared spectroscopy (NIRS) were recorded from the TA muscle in 25 participants with low level recurring spinal dysfunction using a randomized controlled crossover design. The following outcomes: motor unit discharge rate (MUDR), strength (force at MVC), muscle conduction velocity (CV), relative changes in oxy- and deoxyhemoglobin were assessed pre and post a spinal manipulation intervention and passive movement control. Repeated measures ANOVA was used to assess within and between-group differences. Following the spinal manipulation intervention, there was a significant increase in MVC (p = 0.02; avg 18.87 ± 28.35%) and a significant increase in CV in both the isometric steady-state (10% of MVC) contractions (p < 0.01; avg 22.11 ± 11.69%) and during the isometric ramp (10% of MVC) contractions (p < 0.01; avg 4.52 ± 4.58%) compared to the control intervention. There were no other significant findings. The observed TA strength and CV increase, without changes in MUDR, suggests that the strength changes observed following spinal manipulation are, in part, due to increased recruitment of larger, higher threshold motor units. Further research needs to investigate the longer term and potential functional effects of spinal manipulation in various patients who may benefit from improved muscle function and greater motor unit recruitment.

Is Myofascial Release Therapy Cost-Effective When Compared With Manual Therapy to Treat Workers' Mechanical Neck Pains?

OBJECTIVE

The aim of this study was to do a cost-benefit analysis of myofascial release therapy (MRT) compared to manual therapy (MT) for treating occupational mechanical neck pain.

METHODS

Variables regarding the outcomes of the intervention were intensity of neck pain, cervical disability, quality of life, craniovertebral angle, and ranges of cervical motion. Costs were assessed based on a social perspective using diary costs. Between-groups differences in average cost, cost-effectiveness, and cost-utility ratios were assessed using bootstrap parametric techniques. The economic cost-benefit evaluation was with regard to an experimental parallel group study design. There were 59 participants.

RESULTS

Myofascial released therapy showed significant improvement over MT for cervical mobility (side bending, rotation, and craniovertebral angle). The total cost of MRT was approximately 20% less (-$519.81; 95% confidence interval, -$1193.67 to $100.31) than that of MT, although this was not statistically significant. Cost-effectiveness and cost-utility ratios showed that MRT could be associated with lower economic costs.

CONCLUSION

With probabilities of 93.9% and 95.8%, MRT seems to be cost-effective for treating mechanical neck pain without the need to add any additional cost to obtain a better clinical benefit. Consequently, we believe it could be included in the clinical practice guidelines of different Spanish health care institutions.

Spinal manipulation for the management of cervicogenic headache: A systematic review and meta-analysis

BACKGROUND

Spinal manipulative therapy (SMT) is frequently used to manage cervicogenic headache (CGHA). No meta-analysis has investigated the effectiveness of SMT exclusively for CGHA.

OBJECTIVE

To evaluate the effectiveness of SMT for CGHA.

DATABASES AND DATA TREATMENT

Five databases identified randomized controlled trials comparing SMT with other manual therapies. The PEDro scale assessed the risk-of-bias. Pain and disability data were extracted and converted to a common scale. A random effects model was used for several follow-up periods. GRADE described the quality of evidence.

RESULTS

Seven trials were eligible. At short-term follow-up, there was a significant, small effect favouring SMT for pain intensity (mean difference [MD] -10.88 [95% CI, -17.94, -3.82]) and small effects for pain frequency (standardized mean difference [SMD] -0.35 [95% CI, -0.66, -0.04]). There was no effect for pain duration (SMD - 0.08 [95% CI, -0.47, 0.32]). There was a significant, small effect favouring SMT for disability (MD - 13.31 [95% CI, -18.07, -8.56]). At intermediate follow-up, there was no significant effects for pain intensity (MD - 9.77 [-24.21 to 4.68]) and a significant, small effect favouring SMT for pain frequency (SMD - 0.32 [-0.63 to - 0.00]). At long-term follow-up, there was no significant effects for pain intensity (MD - 0.76 [-5.89 to 4.37]) and for pain frequency (SMD - 0.37 [-0.84 to 0.10]).

CONCLUSION

For CGHA, SMT provides small, superior short-term benefits for pain intensity, frequency and disability, but not pain duration, however, high-quality evidence in this field is lacking. The long-term impact is not significant.

SIGNIFICANCE

CGHA are a common headache disorder. SMT can be considered an effective treatment modality, with this review suggesting it providing superior, small, short-term effects for pain intensity, frequency and disability when compared with other manual therapies. These findings may help clinicians in practice better understand the treatment effects of SMT alone for CGHA.

Osteopathic manipulative treatment combined with exercise improves pain and disability in individuals with non-specific chronic neck pain: A pragmatic randomized controlled trial

PURPOSE

To determine effectiveness of osteopathic manipulative treatment combined with stretching and strengthening exercises in the cervical region on pain and disability in individuals with non-specific chronic neck pain.

METHODS

90 adults with non-specific chronic neck pain were randomized to either exercises group (EG, n = 45) or osteopathic manipulative treatment associated with exercises group (OMT/EG, n = 45). The primary outcomes were obtained by the use of Numeric Pain-Rating Scale (NPRS), Pressure Pain Threshold (PPT) and Neck Disability Index (NDI). Secondary outcomes included range of motion (ROM) for cervical spine rotation, Fear-Avoidance Beliefs Questionnaire Work/Physical Activity (FABQ-W/PA) and Pain-self efficacy at two different moments: baseline and 4 weeks after the first treatment. Techniques and dosages of OMT were selected pragmatically by a registered osteopath. Generalized Estimating Equations model (GEE), complemented by the Least Significant Difference (LSD) and the intention-to-treat analysis, was used to assess the clinical outcomes.

RESULTS

Analysis with GEE indicated that OMT/EG reduced pain and disability more than the EG alone after 4 weeks of treatment with statistically significant difference (p < 0,05), as well as cervical active rotation was significantly improved (p = 0.03). There were no between-group differences observed in Pressure Pain Threshold (PPT) measure, Fear-Avoidance Beliefs Questionnaire and Pain-self efficacy.

CONCLUSION

The association between OMT and exercises reduces pain and improves functional disability more than only exercise for individuals with non-specific chronic neck pain.

Effect of alar ligament transection in side-bending stress test: A cadaveric study

BACKGROUND

The side-bending stress test is a pre-manipulative screening test for assessing upper cervical instability. To our knowledge, there is no study that simulates the clinical application of side bending stress test before and after alar ligament transection with fixation of C2.

OBJECTIVE

To simulate the effect of alar ligament transection in the side bending stress test for an in vitro validation.

DESIGN

In vitro study.

METHODS

After the dissection of the superficial structures to the alar ligament and the fixation of C2, ten cryopreserved upper cervical spines were manually mobilized in right and left lateral flexion with and without right alar ligament transection. Upper cervical lateral flexion range of motion and mobilization force were measured with the Vicon motion capture system and a load cell respectively.

RESULTS

The right alar ligament transection increased the upper cervical spine (UCS) range of motion (ROM) in both side bendings (1.30°±1.54° and 1.88°±1.51° increase for right and left side bending respectively). As an average, with standardized forces of 2N, 4N and 6N, right alar ligament transection increased both right and left lateral flexion UCS ROM.

CONCLUSION

This in vitro study simulates the clinical application of the side bending stress test with intact and right transected alar ligament. Unilateral transection of the alar ligament revealed a predominantly bilateral increase in upper cervical side bending and variability in the mobilization force applied during the test.

Completeness of the description of manipulation and mobilisation techniques in randomized controlled trials in neck pain; A review using the TiDieR checklist

STUDY DESIGN

A secondary analysis of a systematic review.

BACKGROUND

Manipulations or mobilizations are commonly used interventions in patients with mechanical neck pain. The treatment effects have often been studied in randomized controlled trials (RCT) which are generally considered the gold standard in evaluating the treatment effects, mainly due to its high internal validity. External validity is defined as the extent to which the effects can be generalised to clinical practice. An important prerequisite for this is that interventions used in clinical trials can be replicated in clinical practice. It can be questioned if interventions utilized in randomized controlled trials can be translated into clinical practice.

OBJECTIVES

The overall aim of this study is to examine whether the quality of the description of manipulation and mobilization interventions is sufficient for to replication of these interventions in clinical practice.

METHODS

A comprehensive literature search was performed. Two independent researchers used the Template for Intervention Description and Replication (TIDieR) which is a 12-item checklist for describing the completeness of the interventions.

RESULTS

Sixty-seven articles were included that used manipulation and/or mobilization interventions for patients with mechanical neck pain. None of the articles describe the intervention e.g. all the items on the TIDieR list. Considering item 8 (a-f) of the TIDieR checklist only one article described the used techniques completely.

CONCLUSION

Manipulation or a mobilization interventions are poorly reported in RCTs, which jeopardize the external validity of RCTs, making it difficult for clinicians and researchers to replicate these interventions.