Is one better than another?: A randomized clinical trial of manual therapy for patients with chronic neck pain

Effects of upper thoracic Mulligan mobilization on pain, range of motion and function in patients with mechanical neck pain: A randomized placebo-controlled trial

OBJECTIVE

This study aimed to assess the impact of Mulligan Reverse Natural Apophyseal Glides (RNAGS) applied to the upper thoracic region on pain, movement limitation, and function in individuals with mechanical neck pain.

METHODS

Conducted between January 2021 and May 2021, the study involved 69 participants randomly assigned to a sham group, physiotherapy group, and Mulligan group. A two-week, 11-session treatment program was administered with shared physiotherapy interventions and stretching exercises to all groups. The Mulligan group received additional mobilization with the Mulligan RNAGS technique. The sham group received sub-standard Mulligan mobilization. Outcome measures included Range of Motion (ROM), Visual Analogue Scale (VAS), and Neck Disability Index (NDI).

RESULTS

No baseline differences were found in measurements among the groups. After the intervention, all groups showed increased ROM and decreased VAS and NDI scores (p<0.001). The Mulligan group exhibited significantly greater improvement in VAS, ROM, and NDI compared to other groups (p<0.001). The sham group demonstrated greater improvement in NDI and extension ROM compared to the physiotherapy group (p<0.001).

CONCLUSION

Mulligan RNAGS technique in the upper thoracic region proved beneficial for pain relief, range of motion, and functionality in mechanical neck pain. Long-term effects warrant further exploration through population-based studies.

A critical review of the role of manual therapy in the treatment of individuals with low back pain

The number of low back pain (LBP) cases is projected to increase to more than 800 million by 2050. To address the substantial burden of disease associated with this rise in prevalence, effective treatments are needed. While clinical practice guidelines (CPG) consistently recommend non-pharmacological therapies as first-line treatments, recommendations regarding manual therapy (MT) in treating low back pain vary. The goal of this narrative review was to critically summarize the available evidence for MT behind these recommendations, to scrutinize its mechanisms of action, and propose some actionable steps for clinicians on how this knowledge can be integrated into a person-centered approach. Despite disparate recommendations from CPG, MT is as effective as other available treatments and may be offered to patients with LBP, especially as part of a treatment package with exercise and education. Most of the effects of MT are not specific to the technique. MT and other interventions share several mechanisms of action that mediate treatment success. These mechanisms can encompass patients' expectations, prior experiences, beliefs and convictions, epistemic trust, and nonspecific contextual effects. Although MT is safer than opioids for patients with LBP, this alone is insufficient. Our goal is to encourage clinicians to shift away from outdated and refuted ideas in MT and embrace a person-centered approach rooted in a comprehensive biopsychosocial framework while incorporating patients' beliefs, addressing illness behaviors, and seeking to understand each patient's journey.

How to Evaluate the Efficacy of Manipulations in Spine Disorders-A Comprehensive Review of New and Traditional Outcome Measures

Spine pain (SP) is the most common musculoskeletal disorder that causes transitional forms of motor disability. Considering its affordability and safety, manipulative therapy (MT) stands as one of the primary therapeutic approaches for SP and the related dysfunctional consequences. However, it is still difficult to assess and quantify the results of this treatment since there is a lack of objective evaluation tools in the available scientific literature. Thus, the purpose of this comprehensive review is to summarize the main outcomes used to evaluate the effectiveness of spine manipulations, focusing on their strengths and weaknesses. An extensive review of the PubMed, Cochrane, and Embase databases was performed to identify the literature of the last ten years regarding MT and the related assessment tools. A total of 12 studies met the inclusion criteria. The analyzed literature indicates that a wide range of outcome measures have been used to assess the effectiveness of spine MT. Pain is the main aspect to be investigated but it remains difficult to elucidate since it is strongly linked to various dimensions such as self-perception and psychological aspects. Therefore, it seems necessary to include new tools for evaluating the effects of spine MT, with the aim of exploiting new technologies and taking into consideration the SP biomechanical and biopsychosocial aspects.

Immediate effect of craniocervical flexion exercise and Mulligan mobilisation in patients with mechanical neck pain - A randomised clinical trial

Background

Mechanical neck pain (MNP) is one of the most prevalent musculoskeletal pathologies in the present time. Physiotherapy management strategies comprising manual therapy and exercise therapy are routinely administered in patients with MNP.

Objective

To compare the immediate effect of craniocervical flexion (CCF) exercise and Mulligan mobilisation on pain, active cervical range of motion (CROM) and CCF test performance in patients with MNP.

Methods

This prospective, randomised, single-blinded study involved 26 patients with MNP (16 females; mean age; 31 . 12 ± 8 . 40 years) randomised to a single session of active CCF exercise (3 sets of 10 repetitions) or Mulligan mobilisation (3 sets of 6-10 repetitions). Pain intensity was measured on a numerical pain rating scale (NPRS), active CROM was measured using CROM device, and CCF test performance with surface electromyography (EMG) from bilateral sternocleidomastoid (SCM) and anterior scalene (AS) muscles recorded pre- and immediately post-intervention by an assessor blinded to the treatment groups. Mann-Whitney U test was used to analyse between groups and Wilcoxon signed rank test was used to analyse within-group significance for pain and CROM, Cochran-Mantel-Haenszel correlation test was used to analyse the CCF test performance on EMG from the bilateral SCM and AS muscles.

Results

Comparison between pre- and post-intervention readings revealed statistically significant within-group (p < 0 . 05 ) and no between-group significant difference for pain, ROM, and CCF test performance, indicating both interventions were equally effective.

Conclusion

Patients with MNP who received active CCF exercise or Mulligan mobilisation exhibited similar reduction in pain intensity and increased CROM and CCF test performance post-intervention. Surprisingly, AS surface EMG amplitudes were increased post-intervention in both groups warranting further exploration of its role in neck pain.

Benefits and Harms of Spinal Manipulative Therapy for Treating Recent and Persistent Nonspecific Neck Pain: A Systematic Review With Meta-analysis

OBJECTIVE: We aimed to estimate the benefits and harms of cervical spinal manipulative therapy (SMT) for treating neck pain. DESIGN: Intervention systematic review with meta-analysis of randomized controlled trials (RCTs). LITERATURE SEARCH: We searched the MEDLINE, Cochrane CENTRAL, Embase, CINAHL, PEDro, Chiropractic Literature Index bibliographic databases, and grey literature sources, up to June 6, 2022. STUDY SELECTION CRITERIA: RCTs evaluating SMT compared to guideline-recommended and nonrecommended interventions, sham SMT, and no intervention for adults with neck pain were eligible for our systematic review. Prespecified outcomes included pain, range of motion, disability, health-related quality of life. DATA SYNTHESIS: Random-effects meta-analysis for clinically homogenous RCTs at short-term and long-term outcomes. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 Tool. We used the Grading of Recommendations, Assessment, Development, and Evaluations approach to judge the certainty of evidence. RESULTS: We included 28 RCTs. There was very low to low certainty evidence that SMT was more effective than recommended interventions for improving pain at short term (standardized mean difference [SMD], 0.66; 95% confidence interval [CI]: 0.35, 0.97) and long term (SMD, 0.73; 95% CI: 0.31, 1.16), and for reducing disability at short-term (SMD, 0.95; 95% CI: 0.48, 1.42) and long term (SMD, 0.65; 95% CI: 0.23, 1.06). Transient side effects only were found (eg, muscle soreness). CONCLUSION: There was very low certainty evidence supporting cervical SMT as an intervention to reduce pain and improve disability in people with neck pain. J Orthop Sports Phys Ther 2023;53(9):510-528. Epub: 10 August 2023. doi:10.2519/jospt.2023.11708.

Modernizing patient-centered manual therapy: Findings from a Delphi study on orthopaedic manual therapy application

BACKGROUND

Recent literature challenges the process by which orthopaedic manual therapy (OMT) has traditionally been applied. Progressive understanding of the complexities surrounding OMT analgesia and the decreased reliance on technique specific characteristics in determining treatment effectiveness promotes an update to training paradigms related to OMT.

OBJECTIVES

The purpose of this Delphi study was to establish consensus on what trainees should be focusing on when demonstrating OMT techniques and how candidates for OMT should be identified.

DESIGN

An international three-round Delphi study following recommended guidelines for conducting and reporting of Delphi studies (CREDES) was performed.

METHODS

One-hundred sixty-four expert manual therapy educators were identified for participation across four countries. Participants were asked to provide what concepts trainees should be focusing on when demonstrating OMT techniques and how candidates for OMT should be identified. Twenty-one themes were identified for each question.

RESULTS

Twenty-eight participants completed all three rounds of the Delphi. Consensus was reached on nineteen themes and eighteen themes respectively. Results from this Delphi stress patient-centered care within a biopsychosocial pain management model. Representation across all pillars of evidence-based practice were represented. Themes reaching consensus within this study favored the importance of neurophysiological, psychological, and biomechanical principles.

CONCLUSION

This Delphi presents consensus-based recommendations for what manual therapy trainees should focus on when demonstrating OMT techniques and on how candidates for OMT should be identified. These findings in collaboration with previous consensus recommendations on concepts to focus on within OMT education promote restructuring of OMT curriculum to evidence-based patient-centered care models.

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.

Comparison of an exercise program with and without manual therapy for patients with chronic neck pain and upper cervical rotation restriction. Randomized controlled trial

Background

Cervical exercise has been shown to be an effective treatment for neck pain, but there is still a need for more clinical trials evaluating the effectiveness of adding manual therapy to the exercise approach. There is a lack of evidence on the effect of these techniques in patients with neck pain and upper cervical rotation restriction.

Purpose

To compare the effectiveness of adding manual therapy to a cervical exercise protocol for the treatment of patients with chronic neck pain and upper cervical rotation restriction.

Methods

Single-blind randomized clinical trial. Fifty-eight subjects: 29 for the Manual Therapy+Exercise (MT+Exercise) Group and 29 for the Exercise group. Neck disability index, pain intensity (0–10), pressure pain threshold (kPa), flexion-rotation test (°), and cervical range of motion (°) were measured at the beginning and at the end of the intervention, and at 3-and 6-month follow-ups. The MT+Exercise Group received one 20-min session of manual therapy and exercise once a week for 4 weeks and home exercise. The Exercise Group received one 20-min session of exercise once a week for 4 weeks and home exercise.

Results

The MT+Exercise Group showed significant better values post-intervention in all variables: neck disability index: 0% patient with moderate, severe, or complete disability compared to 31% in the Exercise Group (p = 0.000) at 6-months; flexion-rotation test (p = 0.000) and pain intensity (p = 0.000) from the first follow-up to the end of the study; cervical flexion (p = 0.002), extension (p = 0.002), right lateral-flexion (p = 0.000), left lateral-flexion (p = 0.001), right rotation (p = 0.000) and left rotation (p = 0.005) at 6-months of the study, except for flexion, with significative changes from 3-months of follow up; pressure pain threshold from the first follow-up to the end of the study (p values range: 0.003–0.000).

Conclusion

Four 20-min sessions of manual therapy and exercise, along with a home-exercise program, was found to be more effective than an exercise protocol and a home-exercise program in improving the neck disability index, flexion-rotation test, pain intensity, and pressure pain threshold, in the short, medium, and medium-long term in patients with chronic neck pain and upper rotation restriction. Cervical range of motion improved with the addition of manual therapy in the medium and medium-long term. The high dropout rate may have compromised the external validity of the study.

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.

Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain

Spine pain is a highly prevalent condition affecting over 11% of the world's population. It is the single leading cause of activity limitation and ranks fourth in years lost to disability globally, representing a significant personal, social, and economic burden. For the vast majority of patients with back and neck pain, a specific pathology cannot be identified as the cause for their pain, which is then labeled as non-specific. In a growing proportion of these cases, pain persists beyond 3 months and is referred to as chronic primary back or neck pain. To decrease the global burden of spine pain, current data suggest that a conservative approach may be preferable. One of the conservative management options available is spinal manipulative therapy (SMT), the main intervention used by chiropractors and other manual therapists. The aim of this narrative review is to highlight the most relevant and up-to-date evidence on the effectiveness (as it compares to other interventions in more pragmatic settings) and efficacy (as it compares to inactive controls under highly controlled conditions) of SMT for the management of neck pain and low back pain. Additionally, a perspective on the current recommendations on SMT for spine pain and the needs for future research will be provided. In summary, SMT may be as effective as other recommended therapies for the management of non-specific and chronic primary spine pain, including standard medical care or physical therapy. Currently, SMT is recommended in combination with exercise for neck pain as part of a multimodal approach. It may also be recommended as a frontline intervention for low back pain. Despite some remaining discrepancies, current clinical practice guidelines almost universally recommend the use of SMT for spine pain. Due to the low quality of evidence, the efficacy of SMT compared with a placebo or no treatment remains uncertain. Therefore, future research is needed to clarify the specific effects of SMT to further validate this intervention. In addition, factors that predict these effects remain to be determined to target patients who are more likely to obtain positive outcomes from SMT.

Effect of manual therapy with exercise in patients with chronic cervical radiculopathy: a randomized clinical trial

BACKGROUND

Research that has examined the effects of cervical spine mobilization on hypoesthesia and hypersensitivity characteristics in patients with cervical radiculopathy is scarce. The aim of this study was to examine the short-term effects of vertebral mobilization on the sensory features in patients with cervical radiculopathy.

METHODS

Twenty-eight participants with chronic cervical radiculopathy were randomly allocated to (1) an experimental group [cervical vertebral mobilization technique and exercise] or (2) a comparison group [minimal superficial circular pressure on the skin and exercise]. Participants received a total of 6 sessions for 3-5 weeks. Numeric Pain Rating Scale (NPRS), Neck Disability Index (NDI), pressure pain threshold (PPT), heat/cold pain threshold (HPT/CPT), and active cervical range of motion (ROM) were measured at baseline immediately after the first session and after the sixth session.

RESULTS

The experimental group showed improvements from baseline to session 6 in NPRS [mean difference 2.6; 95% confidence interval: -4.6, -0.7], NDI [14; -23.3, -4.3], and active cervical ROM in extension [14°; 2.3, 25.5], rotation [16°; 8.8, 22.5], and lateral flexion to the affected side [10°; 2.3, 16.8]. Improvements were also found in PPT at the neck [124 kPa; 57, 191.1] and C7 level at the hand [99 kPa; 3.6, 194.9]. There were no changes in the HPT and CPT at any tested area (P>0.050).

CONCLUSIONS

Cervical vertebral mobilization for patients with chronic cervical radiculopathy reduced localized mechanical, but not thermal, pain hypersensitivity.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT03328351 ). Registered on November 1, 2017, retrospectively registered.

Immediate effects of thoracic manipulation on cervical joint position sense in individuals with mechanical neck pain: A randomized controlled trial

BACKGROUND

Performing thoracic manipulations for neck pain can result in immediate improvements in neck function.

OBJECTIVE

The aim of this study was to investigate the immediate effects of thoracic manipulation on cervical joint position sense and cervical range of motion in individuals with chronic mechanical neck pain.

METHODS

Eighty male volunteers between 18-25 years and having chronic or recurrent neck or shoulder pain of at least 3 months duration with or without arm pain were randomized into two groups: Thoracic Manipulation Group (TMG:50) and Control Group (CG:30), with a pretest-posttest experimental design. The TMG was treated with thoracic extension manipulation while the CG received no intervention. Cervical joint position error and cervical range of motion of the individuals were assessed at baseline and 5 minutes later.

RESULTS

There was no difference in demographic variables such as age (p= 0.764), Body Mass Index (p= 0.917) and Neck Pain Disability Scale (NPDS) scores (p= 0.436) at baseline outcomes between TMG and CGs. Joint position error outcomes between the two groups following intervention were similar in all directions at 30 and 50 degrees. Differences in range of motion following intervention in neck flexion (p< 0.001) and right rotation (p= 0.004) were higher in TMG compared to CG.

CONCLUSIONS

A single session of thoracic manipulation seems to be inefficient on joint position sense in individuals with mild mechanical neck pain. However, thoracic manipulation might be an effective option to increase flexion and rotation of the cervical region as an adjunctive to treatment.

Efficacy of manual therapy on psychological status and pain in patients with neck pain. A randomized clinical trial

Objectives:

To compare the effectiveness of Maitland versus Mulligan mobilization techniques on pain, functional disability, and psychological status in patients with neck pain.

Methods:

Forty-four patients with nonspecific neck pain were randomly assigned to the Maitland group (n=22 patients received Maitland therapy [central or unilateral postero-anterior pressure] for 2 sessions/week for 3 weeks) and Mulligan group (n=22 patients received Mulligan sustained natural apophyseal glides for 2 sessions/week for 3 weeks). This study was conducted at the Rehabilitation Clinic, King Abdulaziz Hospital, Jeddah, Kingdom of Saudi Arabia between December 2016 to May 2017. The outcome measures were the numeric pain rating scale score, neck disability index score, beck depression inventory score, State-trait anxiety inventory score, fear avoidance beliefs questionnaire, and pain catastrophic scale results. The independent t-test, Shapiro-Wilk test, and paired t-test were used in data analysis.

Results:

There were significant improvements in mean values of the numeric pain rating scale, neck disability index, beck depression inventory, state-trait anxiety inventory scores, and pain catastrophic scale results after the interventions in both groups (p<0.05, all except fear avoidance beliefs results in mulligan group p>0.05), and there were no significant differences in mean values between the groups (p>0.05).

Conclusion:

In patients with nonspecific neck pain, Maitland and Mulligan mobilization techniques have positive effects on neck pain, functional disability, and selected psychological features with no significant difference between them.

Effects of the Manual Therapy Approach of Segments C0-1 and C2-3 in the Flexion-Rotation Test in Patients with Chronic Neck Pain: A Randomized Controlled Trial

Background: Flexion-rotation test predominantly measures rotation in C1-2 segment. Restriction in flexion-rotation may be due to direct limitation in C1-2, but also to a premature tightening of the alar ligament as a result of lack of movement in C0-1 or C2-3. The aim of this study was to compare the effect of a 20-min single cervical exercise session, with or without manual therapy of C0-1 and C2-3 segment in flexion-rotation test, in patients with chronic neck pain and positive flexion-rotation test. Methods: Randomized controlled clinical trial in 48 subjects (24 manual therapy+exercise/24 exercise). Range of motion and pain during flexion-rotation test, neck pain intensity and active cervical range of motion were measured before and after the intervention. Results: Significant differences were found in favour of the manual therapy group in the flexion-rotation test: right (p < 0.001) and left rotation (p < 0.001); pain during the flexion-rotation test: right (p < 0.001) and left rotation (p < 0.001); neck pain intensity: (p < 0.001); cervical flexion (p < 0.038), extension (p < 0.010), right side-bending (p < 0.035), left side-bending (p < 0.002), right rotation (p < 0.001), and left rotation (p < 0.006). Conclusions: Addition of one C0-C1 and C2-C3 manual therapy session to cervical exercise can immediately improve flexion-rotation test and cervical range of motion and reduce pain intensity.

Does Upper Cervical Manual Therapy Provide Additional Benefit in Disability and Mobility over a Physiotherapy Primary Care Program for Chronic Cervicalgia? A Randomized Controlled Trial

Introduction: Neck pain is a condition with a high incidence in primary care. Patients with chronic neck pain often experience reduction in neck mobility. However, no study to date has investigated the effects of manual mobilization of the upper cervical spine in patients with chronic mechanical neck pain and restricted upper cervical rotation. Objective: To evaluate the effect of adding an upper cervical translatoric mobilization or an inhibitory suboccipital technique to a conventional physical therapy protocol in patients with chronic neck pain test on disability and cervical range of motion. Design: Randomized controlled trial. Methods: Seventy-eight patients with chronic neck pain and restricted upper cervical rotation were randomized in three groups: Upper cervical translatoric mobilization group, inhibitory suboccipital technique group, or control group. The neck disability index, active cervical mobility, and the flexion-rotation test were assessed at baseline (T0), after the treatment (T1), and at three-month follow-up (T2). Results: There were no statistically significant differences between groups in neck disability index. The upper cervical translatoric mobilization group showed a significant increase in the flexion-rotation test to the more restricted side at T1 (F = 5.992; p < 0.004) and T2 (F = 5.212; p < 0.007) compared to the control group. The inhibitory suboccipital technique group showed a significant increase in the flexion-rotation test to the less restricted side at T1 (F = 3.590; p < 0.027). All groups presented high percentages of negative flexion-rotation tests. (T1: 69.2% upper neck translator mobilization group; 38.5% suboccipital inhibition technique group, 19.2% control group; at T2: 80.8%; 46.2% and 26.9% respectively). No significant differences in the active cervical mobility were found between groups. Conclusion: Adding manual therapy to a conventional physical therapy protocol for the upper cervical spine increased the flexion-rotation test in the short- and mid-term in patients with chronic neck pain. No changes were found in the neck disability index and the global active cervical range of motion.

"Short- and mid-term effects of adding upper cervical manual therapy to a conventional physical therapy program in patients with chronic mechanical neck pain. Randomized controlled clinical trial."

OBJECTIVE

To evaluate the effect of adding an Upper Cervical Translatoric Mobilization (UCTM) or an Inhibitory Suboccipital Technique (IST) to a physiotherapy treatment in the symptomatology and function of mechanical chronic neck pain patients.

DESIGN

Randomized controlled trial.

SETTING

Primary Care Center in Cornellà, Spain.

SUBJECTS

78 patients (64 women), with mean age (SD) of 59.96 (13.30) years with mechanical chronic neck pain were divided in three groups: control, IST and UCTM groups.

INTERVENTIONS

All groups received 15 physiotherapy sessions for three weeks. The UCTM and IST groups added 5 minutes of the assigned technique during six sessions.

MAIN MEASURES

Neck disability index (NDI) and numeric pain rating scale (NPRS) for neck pain were measured baseline, three-weeks and 15-weeks follow-up.

RESULTS

NDI (SD) at baseline, three-weeks and 15-weeks were 11.62 (7.08), 9.65 (6.25), 7.58 (5.64) for the control group, 14.38 (6.92), 8.50 (6.11), 7.12 (4.98) for the IST group and 13.19(7.23), 5.35(6.10), 4.35(2.76) for the UCTM group. NPRS (SD) at baseline, three-weeks and 15-weeks were 58.69 (19.46), 45.19 (23.43), 44.58 (24.08) for the control group; 64.08 (19.26), 42.19 (19.69), 34 (21.14) for the IST group; and 67.65 (20.65), 36.23 (20.10), 39.85 (25.44) for the UCTM group.

CONCLUSIONS

Compared with no treatment, both forms of mobilization were associated with reduced disability at three weeks, and UCTM remained better than control at 15 weeks; there were no significant differences between the two mobilization groups.

TRIAL REGISTRATION

This study was registered in Clinicaltrials.gov (NCT02832232).

Does the Addition of Manual Therapy Approach to a Cervical Exercise Program Improve Clinical Outcomes for Patients with Chronic Neck Pain in Short- and Mid-Term? A Randomized Controlled Trial

Chronic neck pain is one of today’s most prevalent pathologies. The International Classification of Diseases categorizes four subgroups based on patients’ associated symptoms. However, this classification does not encompass upper cervical spine dysfunction. The aim is to compare the short- and mid-term effectiveness of adding a manual therapy approach to a cervical exercise protocol in patients with chronic neck pain and upper cervical spine dysfunction. Fifty-eight subjects with chronic neck pain and upper cervical spine dysfunction were recruited (29 = Manual therapy + Exercise; 29 = Exercise). Each group received four 20-min sessions, one per week during four consecutive weeks, and a home exercise regime. Upper flexion and flexion-rotation test range of motion, neck disability index, craniocervical flexion test, visual analogue scale, pressure pain threshold, global rating of change scale, and adherence to self-treatment were assessed at the beginning, end of the intervention and at 3- and 6-month follow-ups. The Manual therapy + Exercise group statistically improved short- and medium-term in all variables compared to the Exercise group. Four 20-min sessions of Manual therapy + Exercise along with a home-exercise program is more effective in the short- to mid-term than an exercise protocol and a home-exercise program for patients with chronic neck pain and upper cervical dysfunction.

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.

Association between sympathoexcitatory changes and symptomatic improvement following cervical mobilisations in participants with neck pain. A double blind placebo controlled trial

BACKGROUND

sympathoexcitation observed with passive cervical mobilisations may imply activation of an endogenous pain inhibition system resulting in hypoalgesia. However, research is mostly in asymptomatic participants and there is very limited evidence of a relationship between sympathoexcitation and symptomatic improvement in people with clinical pain.

OBJECTIVE

to investigate the effects of cervical mobilisations on the sympathetic nervous system in participants with neck pain, and to explore the relationship between symptomatic improvement and sympathoexcitation.

DESIGN

double-blind randomised controlled trial.

METHOD

40 participants with neck pain (aged 20-69 years, 25 female) were randomly allocated to either cervical mobilisations or motionless placebo. Skin conductance was measured before, during, and after intervention. After interventions were completed, their credibility was assessed. Participants were classified as responders or non-responders according to global symptom change.

RESULTS

participants receiving mobilisations were more likely to be classified as responders (odds ratio: 4.33, p = 0.03) and demonstrated greater change in most outcome measures of sympathoexcitation from baseline to during the intervention but not from during to after the intervention. There was no association between sympathoexcitation and symptomatic improvement. Mobilisations and placebo were equally credible.

CONCLUSIONS

These findings suggest sympathoexcitatory changes may be caused by an orienting response unrelated to the activation of an endogenous pain inhibition system Alternatively, the observed lack of an association may be explained by the existence of various mechanisms for pain relief. This study used single outcome measures of sympathoexcitation and symptomatic improvement and other measures may reveal different things. CLINICALTRIALS.

GOV NUMBER

M10/2016/095.

Concussion part II: Rehabilitation - The need for a multifaceted approach

INTRODUCTION

While most individuals recover in the initial days to weeks following a concussion, in up to 30% of cases symptoms and functional limitations may persist beyond the initial four weeks. There is emerging evidence that multifaceted physiotherapy techniques for individuals who have ongoing symptoms following concussion may be of benefit.

PURPOSE

The purpose of this masterclass article is to summarize the evidence for rehabilitation, describe treatment techniques and multifaceted interventions following concussion.

IMPLICATIONS

Concussion is a heterogenous injury and multiple types of rehabilitation may be required to address ongoing alterations in function. A greater understanding of evidence based rehabilitative techniques will enable the clinician to direct treatment and facilitate recovery for individuals who have ongoing symptoms following concussion.

The efficacy and fidelity of clinical interventions used to reduce posterior shoulder tightness: a systematic review with meta-analysis

BACKGROUND

Posterior shoulder tightness (PST) has been implicated in the etiology of numerous shoulder disorders and is a source of stiffness in both postoperative and nonsurgical cohorts. Identifying efficacious interventions to address PST has the potential to impact patient outcomes in both operative and nonoperative cohorts. Our purpose was to analyze the efficacy of nonoperative clinician-assisted interventions used to mitigate PST.

METHODS

We performed a systematic review and meta-analysis. Relevant studies were assessed for inclusion, and selected studies were identified from the PubMed, Embase, Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases by a biomedical librarian. Data extracted from the selected studies underwent quality appraisal using Grading of Recommendations, Assessment, Development, and Evaluation analysis; fidelity assessment; and meta-analysis.

RESULTS

The search identified 374 studies, with 13 ultimately retained. Grading of Recommendations, Assessment, Development, and Evaluation analysis revealed areas of concern regarding consistency and imprecision of reporting within the included studies overall. Treatment fidelity assessment showed that only 3 of the 13 studies received a rating of good to excellent, indicating a high risk of bias. When clinician-assisted interventions were compared with no treatment, meta-analysis showed a moderate effect size in favor of clinician-assisted interventions for improving range of motion. When a multimodal treatment approach for PST was compared with active comparator interventions, a small effect size was present for improving range of motion in favor of the multimodal approach.

CONCLUSION

The efficacy of clinician-assisted interventions for reducing PST was identified when using both a single treatment and multimodal treatments. Current evidence focuses mostly on populations with PST who were not seeking care and the immediate- to short-term effects of clinician-assisted interventions, which may limit generalization of findings.

A randomized clinical trial comparing non-thrust manipulation with segmental and distal dry needling on pain, disability, and rate of recovery for patients with non-specific low back pain

Objective: The purpose of this study was to examine the within and between-group effects of segmental and distal dry needling (DN) without needle manipulation to a semi-standardized non-thrust manipulation (NTM) targeting the symptomatic spinal level for patients with non-specific low back pain (NSLBP). Methods: Sixty-five patients with NSLBP were randomized to receive either DN (n = 30) or NTM (n = 35) for six sessions over 3 weeks. Outcomes collected included the oswestry disability index (ODI), patient specific functional scale (PSFS), numeric pain rating scale (NPRS), and pain pressure thresholds (PPT). At discharge, patients perceived recovery was assessed. Results: A two-way mixed model ANOVA demonstrated that there was no group*time interaction for PSFS (p = 0.26), ODI (p = 0.57), NPRS (p = 0.69), and PPT (p = 0.51). There was significant within group effects for PSFS (3.1 [2.4, 3.8], p = 0.018), ODI (14.5% [10.0%, 19.0%], p = 0.015), NPRS (2.2 [1.5, 2.8], p = 0.009), but not for PPT (3.3 [0.5, 6.0], p = 0.20). Discussion: The between-group effects were neither clinically nor statistically significant. The within group effects were both significant and exceeded the reported minimum clinically important differences for the outcomes tools except the PPT. DN and NTM produced comparable outcomes in this sample of patients with NSLBP. Level of evidence: 1b.

Immediate effects of cervical mobilisations on global perceived effect, movement associated pain and neck kinematics in patients with non-specific neck pain. A double blind placebo randomised controlled trial

BACKGROUND

Neck pain is prevalent, costly and disabling. Cervical mobilisations are frequently used to treat it but their effectiveness has been questioned by several systematic reviews. Evidence suggests that better outcomes are achieved with mobilisations when they are applied to specific patient subgroups. A criteria for patients suitable for neck mobilisations has been proposed, but the effectiveness on this patient subgroup has not been tested.

OBJECTIVE

To assess the effectiveness of cervical mobilisations applied to a subgroup of patients with neck pain who fulfil specific criteria.

DESIGN

Randomised controlled trial.

METHOD

40 patients with neck pain attending a Physiotherapy clinic were recruited and randomised to a single session of either cervical mobilisations or motionless manual contact placebo. The immediate effects on global perceived effect, range of movement (ROM), movement velocity and movement associated pain were assessed.

RESULTS

mobilisation participants reported significantly better global perceived effect (p˂0.001) and improvements in movement associated pain (p = 0.041). Mobilisations produced a significant increase in ROM in side flexion (p = 0.006) and rotation (p = 0.044) when compared with placebo, but only in patients with pre-intervention ROM restriction. 29-47% of all movement associated pains were resolved following mobilisations and 11-27% following placebo. Patients in both groups showed a significant (p < 0.05) increase in movement velocity, but only in those who had a velocity restriction pre-intervention.

CONCLUSIONS

Cervical mobilisations are effective in improving movement-associated pain, increasing ROM and velocity, and patient perceived improvement when applied to patients with neck pain that fulfil a criteria. Their use should be advocated.

Immediate and short-term effects of mulligan concept positional sustained natural apophyseal glides on an athletic young-adult population classified with mechanical neck pain: an exploratory investigation

Objectives: Mechanical neck pain (MNP) is common in the athletic population. While symptoms may present at the cervical spine for patients complaining of MNP, thoracic spinal alignment or dysfunction may influence cervical positioning and overall cervical function. Clinicians often employ cervical high-velocity low-amplitude (HVLA) thrust manipulations to treat MNP, albeit with a small level of inherent risk. Mulligan Concept positional sustained natural apophyseal glides (SNAGs) directed at the cervicothoracic region are emerging to treat patients with cervical pain and dysfunction, as evidence supporting an interdependent relationship between the thoracic and cervical spine grows. The purpose of this a priori study was to evaluate outcome measures of patients classified with MNP treated with the Mulligan Concept Positional SNAGs. Methods: Ten consecutive young-adult patients, ages ranging from 15 to 18 years (mean = 16.5 ± 1.78), classified with MNP were treated utilizing Mulligan Concept Positional SNAGs. The Numeric Rating Scale (NRS), Patient-Specific Functional Scale (PSFS), Neck Disability Index (NDI), Disablement in the Physically Active (DPAS), and Fear-Avoidance Based Questionnaire-Physical Activity (FABQPA) were collected for inclusion criteria and to identify patient-reported pain and dysfunction. Results: Patients reported decreases in pain on the NRS [5.4 to .16, p = .001], increases in function on the PSFS [5.2 to 10, p = .001], and increases in cervical range of motion (CROM) [ext p = .003, flex p = .009, left rot p = .001, right rot p = .002] immediately post-treatment and between treatments. Discussion: Positional SNAGs directed at the cervicothoracic region may address a variety of patient reported symptoms for MNP, and the number of treatment sessions needed for symptom resolution may be closer to a single session rather than multiple treatments. Level of Evidence: 4.

The clinical reasoning process in randomized clinical trials with patients with non-specific neck pain is incomplete: A systematic review

OBJECTIVE

Primarily to evaluate the completeness of the description of the clinical reasoning process in RCTs with patients with non-specific neck pain with an argued or diagnosed cause i.e. an impairment or activity limitation. Secondly, to determine the association between the completeness of the clinical reasoning process and the degree of risk of bias.

DATA SOURCES

Pubmed, Cinahl and PEDro were systematically searched from inception to July 2016.

STUDY SELECTION

RCTs (n = 122) with patients with non-specific neck pain receiving physiotherapy treatment published in English were included.

DATA EXTRACTION

Data extraction included study characteristics and important features of the clinical reasoning process based on the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II)].

DATA SYNTHESIS

Thirty-seven studies (30%) had a complete clinical reasoning process of which 8 (6%) had a 'diagnosed cause' and 29 (24%) had an 'argued cause'. The Spearmans rho association between the extent of the clinical reasoning process and the risk of bias was -0.2.

CONCLUSIONS

In the majority of studies (70%) the described clinical reasoning process was incomplete. A very small proportion (6%) had a 'diagnosed cause'. Therefore, a better methodological quality does not necessarily imply a better described clinical reasoning process.

Immediate Effects of Thoracic Spine Thrust Manipulation on Neurodynamic Mobility

OBJECTIVE

The purpose of this study was to investigate the immediate effects of thoracic spine thrust manipulation (TSM) on the upper limb provocation test (ULPT) and seated slump test (SST) in individuals with identified neurodynamic mobility impairments. A secondary aim was to determine if correlation existed between the perception of effect and improvements in neurodynamic mobility following a thrust manipulation compared with mobilization.

METHODS

A pretest-posttest experimental design randomized 48 adults into 2 groups: TSM or mobilization. Participants with identified neurodynamic mobility impairment as assessed with the ULPT or SST received a pre-assigned intervention (TSM, n = 64 limbs; mobilization, n = 66 limbs). Perception of effect was assessed to determine its influence on outcome. Repeated-measures analysis of variance was used to examine the effects of intervention, and Fisher's exact test and independent t tests were used to determine the influence of perception.

RESULTS

Both the ULPT (P < .001) and SST (P < .001) revealed improvements at posttest regardless of intervention. The ULPT effect sizes for TSM (d = 0.70) and mobilization (d = 0.69) groups were medium. For the SST, the effect size for the TSM group (d = 0.53) was medium, whereas that for the mobilization group (d = 0.26) was small. Participants in the mobilization group with positive perception had significantly greater (P < .05) mean neurodynamic mobility changes than those with a negative perception.

CONCLUSIONS

Neurodynamic mobility impairment improved regardless of intervention. The magnitude of change was greater in the ULPT than SST. Although both interventions appeared to yield similar outcomes, individuals who received mobilization and expressed a positive perception of effect exhibited significantly greater changes in neurodynamic mobility than those without a positive perception.

Unraveling the Mechanisms of Manual Therapy: Modeling an Approach

Synopsis Manual therapy interventions are popular among individual health care providers and their patients; however, systematic reviews do not strongly support their effectiveness. Small treatment effect sizes of manual therapy interventions may result from a "one-size-fits-all" approach to treatment. Mechanistic-based treatment approaches to manual therapy offer an intriguing alternative for identifying patients likely to respond to manual therapy. However, the current lack of knowledge of the mechanisms through which manual therapy interventions inhibit pain limits such an approach. The nature of manual therapy interventions further confounds such an approach, as the related mechanisms are likely a complex interaction of factors related to the patient, the provider, and the environment in which the intervention occurs. Therefore, a model to guide both study design and the interpretation of findings is necessary. We have previously proposed a model suggesting that the mechanical force from a manual therapy intervention results in systemic neurophysiological responses leading to pain inhibition. In this clinical commentary, we provide a narrative appraisal of the model and recommendations to advance the study of manual therapy mechanisms. J Orthop Sports Phys Ther 2018;48(1):8-18. doi:10.2519/jospt.2018.7476.

The impact of pragmatic vs. prescriptive study designs on the outcomes of low back and neck pain when using mobilization or manipulation techniques: a systematic review and meta-analysis

Objective

The purpose of this systematic review and meta-analysis was to examine the impact of pragmatic versus prescriptive study designs on the outcomes of low back and neck pain when using mobilization or manipulation techniques.

Methods

This study design was a systematic review and meta-analysis, which was performed according to the PRISMA guidelines. A search of MEDLINE and CINAHL complete databases was performed. Article titles and abstracts were reviewed to identify studies comparing mobilization and manipulation in low back or neck pain that met eligibility criteria. Validity of studies was examined using the Cochrane Risk of Bias tool. Data analysis was performed using RevMan 5.3. Forest plots were constructed after data were analyzed to determine effect sizes.

Results

Thirteen studies with a total of 1313 participants were included in the systematic review, and 12 studies with 977 participants in the meta-analysis. For most time-points prescriptive studies found manipulation to be superior to mobilization for both pain and disability. At no time-point did pragmatic designs find a difference between mobilization and manipulation for either pain or disability.

Discussion

When a pragmatic design was used, representing actual clinical practice, patients improved with both techniques with no difference between mobilization and manipulation. When clinicians were prescribed techniques, not representing true clinical practice, manipulation showed better outcomes than mobilization for pain and disability.

Level of Evidence

1a.

The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review

OBJECTIVE

To review and update the evidence for different forms of manual therapy (MT) and exercise for patients with different stages of non-specific neck pain (NP).

DATA SOURCES

MEDLINE, Cochrane-Register-of-Controlled-Trials, PEDro, EMBASE.

METHOD

A qualitative systematic review covering a period from January 2000 to December 2015 was conducted according to updated-guidelines. Specific inclusion criteria only on RCTs were used; including differentiation according to stages of NP (acute - subacute [ASNP] or chronic [CNP]), as well as sub-classification based on type of MT interventions: MT1 (HVLA manipulation); MT2 (mobilization and/or soft-tissue-techniques); MT3 (MT1 + MT2); and MT4 (Mobilization-with-Movement). In each sub-category, MT could be combined or not with exercise and/or usual medical care.

RESULTS

Initially 121 studies were identified for potential inclusion. Based on qualitative and quantitative evaluation criteria, 23 RCTs were identified for review. Evidence for ASNP: MODERATE-evidence: In favour of (i) MT1 to the cervical spine (Cx) combined with exercises when compared to MT1 to the thoracic spine (Tx) combined with exercises; (ii) MT3 to the Cx and Tx combined with exercise compared to MT2 to the Cx with exercise or compared to usual medical care for pain and satisfaction with care from short to long-term. Evidence for CNP: STRONG-evidence: Of no difference of efficacy between MT2 at the symptomatic Cx level(s) in comparison to MT2 on asymptomatic Cx level(s) for pain and function. MODERATE to STRONG-evidence: In favour of MT1 and MT3 on Cx and Tx with exercise in comparison to exercise or MT alone for pain, function, satisfaction with care and general-health from short to moderate-terms. MODERATE-evidence: In favour (i) of MT1 as compared to MT2 and MT4, all applied to the Cx, for neck mobility, and pain in the very short term; (ii) of MT2 using sof-tissue-techniques to the Cx and Tx or MT3 to the Cx and Tx in comparison to no-treatment in the short-term for pain and disability.

CONCLUSION

This systematic review updates the evidence for MT combined or not with exercise and/or usual medical care for different stages of NP and provides recommendations for future studies. Two majors points could be highlighted, the first one is that combining different forms of MT with exercise is better than MT or exercise alone, and the second one is that mobilization need not be applied at the symptomatic level(s) for improvements of NP patients. These both points may have clinical implications for reducing the risk involved with some MT techniques applied to the cervical spine.

Effectiveness of a specific manual approach to the suboccipital region in patients with chronic mechanical neck pain and rotation deficit in the upper cervical spine: study protocol for a randomized controlled trial

BACKGROUND

Mechanical neck pain is a highly prevalent problem in primary healthcare settings. Many of these patients have restricted mobility of the cervical spine. Several manual techniques have been recommended for restoring cervical mobility, but their effectiveness in these patients is unknown. The aim of the present study is to compare the effectiveness of two types of specific techniques of the upper neck region: the pressure maintained suboccipital inhibition technique (PMSIT) and the translatory dorsal glide mobilization (TDGM) C0-C1 technique, as adjuncts to a protocolized physiotherapy treatment of the neck region in subjects with chronic mechanical neck pain and rotation deficit in the upper cervical spine.

METHODS

A randomized, prospective, double-blind (patient and evaluator) clinical trial. The participants (n = 78) will be randomly distributed into three groups. The Control Group will receive a protocolized treatment for 3 weeks, the Mobilization Group will receive the same protocolized treatment and 6 sessions (2 per week) of the TDGM C0-C1 technique, and the Pressure Group will receive the same protocolized treatment and 6 sessions (2 per week) of the PMSIT technique. The intensity of pain (VAS), neck disability (NDI), the cervical range of motion (CROM), headache intensity (HIT-6) and the rating of clinical change (GROC scale) will be measured. The measurements will be performed at baseline, post-treatment and 3 months after the end of treatment, by the same physiotherapist blinded to the group assigned to the subject.

DISCUSSION

We believe that an approach including manual treatment to upper cervical dysfunction will be more effective in these patients. Furthermore, the PMSIT technique acts mostly on the musculature, while the TDGM technique acts on the joint. We expect to clarify which component is more effective in improving the upper cervical mobility.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02832232 . Registered on July 13th, 2016.

Predictive factors for reporting adverse events following spinal manipulation in randomized clinical trials - secondary analysis of a systematic review

While spinal manipulative therapy (SMT) is recommended for the treatment of spinal disorders, concerns exist about adverse events associated with the intervention. Adequate reporting of adverse events in clinical trials would allow for more accurate estimations of incidence statistics through meta-analysis. However, it is not currently known if there are factors influencing adverse events reporting following SMT in randomized clinical trials (RCTs). Thus our objective was to investigate predictive factors for the reporting of adverse events in published RCTs involving SMT. The Physiotherapy Evidence Database (PEDro) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for RCTs involving SMT. Domains of interest included: sample size; publication date relative to the 2010 CONSORT statement; risk of bias; the region treated; and number of intervention sessions. 7398 records were identified, of which 368 articles were eligible for inclusion. A total of 140 (38.0%) articles reported on adverse events. Articles were more likely to report on adverse events if they possessed larger sample sizes, were published after the 2010 CONSORT statement, had a low risk of bias and involved multiple intervention sessions. The region treated was not a significant predictor for reporting on adverse events. Predictors for reporting on adverse events included larger sample size, publication after the 2010 CONSORT statement, low risk of bias and trials involving multiple intervention sessions. We recommend that researchers focus on developing robust methodologies and participant follow-up regimens for RCTs involving SMT.

The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial

OBJECTIVE

To determine the effect of mobilization and routine physiotherapy on pain, disability, neck range of motion (ROM) and neck muscle endurance (NME) in patients having chronic mechanical neck pain (NP).

METHODS

Sixty eight patients with chronic mechanical NP were randomly allocated into two groups by using a computer generated random sequence table with 34 patients in the multi-modal mobilization group and 34 patients in the routine physiotherapy group. Baseline values for pain, disability, NME, and neck ROM were recorded using visual analogue scale (VAS), neck disability index (NDI), neck flexor muscle endurance test and universal goniometer respectively, before the treatment. Each patient received 10 treatment sessions over a period of four weeks and at the end of four weeks all the outcome measures were recorded again.

RESULTS

A paired t-test revealed significant pre to post treatment differences for all outcome measures in both groups (p ≤ 0.001 in all instances). An independent t-test revealed statistically significant differences for pain, disability, NME, and neck ROM in favor of the multi-modal mobilization group with a between group difference of 1.57 cm for VAS (p < 0.001), 11.74 points for NDI (p = 0.001), 18.45 s for NME (p < 0.001) and 6.06-8.24° for neck ROM (p < 0.05).

CONCLUSION

The results suggest that a combination of cervical mobilization with routine physiotherapy is more effective for reducing pain and disability and improving NME and neck ROM in patients with chronic mechanical NP compared to routine physiotherapy alone.

Influence of the actions observed on cervical motion in patients with chronic neck pain: a pilot study

The aim of the present pilot study was to prove if the action-observation (AOb) improved the cervical range of motion (CROM) in patients with nonspecific chronic neck pain (CNP). Double blind pilot study. A total of 28 subjects were randomly assigned to an effective-movement group (n=14) and an ineffective-movement group (n=14). The follow-up consisted of: pretreatment, posttreatment and 10 min after second measurement (motor imagery). Outcome measures were CROM, and pres-sure pain detection thresholds (PPDTs). No statistical differences were found in baseline on CROM and on the PPDT. Test for independent groups revealed significant changes in cervical rotation movement. Both groups in posttreatment (P=0.042; Cohen d=0.81) and after 10 min (P=0.019; Cohen d=0.9). For intragroup PPDT, the Wilcoxon test revealed significant effects in the effective movement at C2 of the pre to 10-min post (P=0.040). However, the ineffective movement revealed a significant reduction in PPDT in zygapophyseal joint of C5-C6 as the pre to post (P=0.010) as the pre to 10-min post (P=0.041) periods. In conclusions this pilot study demonstrated that the effective AOb produced significant changes versus ineffective AOb in the CROM and it could influences in PPT in subject with CNP immediately.

Strategies to overcome size and mechanical disadvantages in manual therapy

The practice of manual therapy (MT) is often difficult when providing care for large patients and for practitioners small in stature or with other physical limitations. Many MT techniques can be modified using simple principles to require less exertion, permitting consistency with standards of practice even in the presence of physical challenges. Commonly used MT techniques are herein described and demonstrated with alternative preparatory and movement methods, which can also be adopted for use in other techniques. These alternative techniques and the procedures used to adapt them warrant discussion among practitioners and educators in order to implement care, consistent with the best treatment evidence for many common musculoskeletal (MSK) conditions. The inclusion in educational curricula and MT training programs is recommended to enrich skill development in physical therapists (PTs), spanning entry-level practitioners to those pursuing advanced manual skills.

Using the template for intervention description and replication (TIDieR) as a tool for improving the design and reporting of manual therapy interventions

The detailed reporting of any research intervention is crucial to evaluate its applicability into a routinely practice-based context. However, it has been estimated that, especially in non-pharmacological interventions, the published literature typically includes incomplete intervention details. In the field of manual medicine, where interventions are delivered with a high degree of individualization and variability, poorly reported studies could compromise internal and external validity of the results. Among the various initiatives that have been undertaken to improve the intervention description, the Template for Intervention Description and Replication (TIDieR) has to be highlighted as the most promising. TIDieR offers both to researchers and clinicians a helpful and comprehensive guidance on how manual therapy interventions have to be designed and reported, taking into account the clinical complexity of manual therapy and the need to satisfy research gold standards.

A Comparison of the Effects of Stabilization Exercises Plus Manual Therapy to Those of Stabilization Exercises Alone in Patients With Nonspecific Mechanical Neck Pain: A Randomized Clinical Trial

STUDY DESIGN

Randomized clinical trial.

BACKGROUND

Little is known about the efficacy of providing manual therapy in addition to cervical and scapulothoracic stabilization exercises in people with mechanical neck pain (MNP). Objectives To compare the effects of stabilization exercises plus manual therapy to those of stabilization exercises alone on disability, pain, range of motion (ROM), and quality of life in patients with MNP.

METHODS

One hundred two patients with MNP (18-65 years of age) were recruited and randomly allocated into 2 groups: stabilization exercise without (n = 51) and with (n = 51) manual therapy. The program was carried out 3 days per week for 4 weeks. The Neck Disability Index, visual analog pain scale, digital algometry of pressure pain threshold, goniometric measurements, and Medical Outcomes Study 36-Item Short-Form Health Survey were used to assess participants at baseline and after 4 weeks.

RESULTS

Improvements in Neck Disability Index score, night pain, rotation ROM, and the Medical Outcomes Study 36-Item Short-Form Health Survey score were greater in the group that received stabilization exercise with manual therapy compared to the group that only received stabilization exercise. Between-group differences (95% confidence interval) were 2.2 (0.1, 4.3) points for the Neck Disability Index, 1.1 (0.0, 2.3) cm for pain at night measured on the visual analog scale, -4.3° (-8.1°, -0.5°) and -5.0° (-8.2°, -1.7°) for right and left rotation ROM, respectively, and -2.9 (-5.4, -0.4) points and -3.1 (-6.2, 0.0) points for the Medical Outcomes Study 36-Item Short-Form Health Survey physical and mental components, respectively. Changes in resting and activity pain, pressure pain threshold, and cervical extension or lateral flexion ROM did not differ significantly between the groups. Pressure pain threshold increased only in those who received stabilization exercise with manual therapy (P<.05).

CONCLUSION

The results of this study suggest that stabilization exercises with manual therapy may be superior to stabilization exercises alone for improving disability, pain intensity at night, cervical rotation motion, and quality of life in patients with MNP.

LEVEL OF EVIDENCE

Therapy, level 1b.

Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment

BACKGROUND

Manipulation and mobilisation are commonly used to treat neck pain. This is an update of a Cochrane review first published in 2003, and previously updated in 2010.

OBJECTIVES

To assess the effects of manipulation or mobilisation alone compared wiith those of an inactive control or another active treatment on pain, function, disability, patient satisfaction, quality of life and global perceived effect in adults experiencing neck pain with or without radicular symptoms and cervicogenic headache (CGH) at immediate- to long-term follow-up. When appropriate, to assess the influence of treatment characteristics (i.e. technique, dosage), methodological quality, symptom duration and subtypes of neck disorder on treatment outcomes.

SEARCH METHODS

Review authors searched the following computerised databases to November 2014 to identify additional studies: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We also searched ClinicalTrials.gov, checked references, searched citations and contacted study authors to find relevant studies. We updated this search in June 2015, but these results have not yet been incorporated.

SELECTION CRITERIA

Randomised controlled trials (RCTs) undertaken to assess whether manipulation or mobilisation improves clinical outcomes for adults with acute/subacute/chronic neck pain.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, abstracted data, assessed risk of bias and applied Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methods (very low, low, moderate, high quality). We calculated pooled risk ratios (RRs) and standardised mean differences (SMDs).

MAIN RESULTS

We included 51 trials (2920 participants, 18 trials of manipulation/mobilisation versus control; 34 trials of manipulation/mobilisation versus another treatment, 1 trial had two comparisons). Cervical manipulation versus inactive control: For subacute and chronic neck pain, a single manipulation (three trials, no meta-analysis, 154 participants, ranged from very low to low quality) relieved pain at immediate- but not short-term follow-up. Cervical manipulation versus another active treatment: For acute and chronic neck pain, multiple sessions of cervical manipulation (two trials, 446 participants, ranged from moderate to high quality) produced similar changes in pain, function, quality of life (QoL), global perceived effect (GPE) and patient satisfaction when compared with multiple sessions of cervical mobilisation at immediate-, short- and intermediate-term follow-up. For acute and subacute neck pain, multiple sessions of cervical manipulation were more effective than certain medications in improving pain and function at immediate- (one trial, 182 participants, moderate quality) and long-term follow-up (one trial, 181 participants, moderate quality). These findings are consistent for function at intermediate-term follow-up (one trial, 182 participants, moderate quality). For chronic CGH, multiple sessions of cervical manipulation (two trials, 125 participants, low quality) may be more effective than massage in improving pain and function at short/intermediate-term follow-up. Multiple sessions of cervical manipulation (one trial, 65 participants, very low quality) may be favoured over transcutaneous electrical nerve stimulation (TENS) for pain reduction at short-term follow-up. For acute neck pain, multiple sessions of cervical manipulation (one trial, 20 participants, very low quality) may be more effective than thoracic manipulation in improving pain and function at short/intermediate-term follow-up. Thoracic manipulation versus inactive control: Three trials (150 participants) using a single session were assessed at immediate-, short- and intermediate-term follow-up. At short-term follow-up, manipulation improved pain in participants with acute and subacute neck pain (five trials, 346 participants, moderate quality, pooled SMD -1.26, 95% confidence interval (CI) -1.86 to -0.66) and improved function (four trials, 258 participants, moderate quality, pooled SMD -1.40, 95% CI -2.24 to -0.55) in participants with acute and chronic neck pain. A funnel plot of these data suggests publication bias. These findings were consistent at intermediate follow-up for pain/function/quality of life (one trial, 111 participants, low quality). Thoracic manipulation versus another active treatment: No studies provided sufficient data for statistical analyses. A single session of thoracic manipulation (one trial, 100 participants, moderate quality) was comparable with thoracic mobilisation for pain relief at immediate-term follow-up for chronic neck pain. Mobilisation versus inactive control: Mobilisation as a stand-alone intervention (two trials, 57 participants, ranged from very low to low quality) may not reduce pain more than an inactive control. Mobilisation versus another active treatment: For acute and subacute neck pain, anterior-posterior mobilisation (one trial, 95 participants, very low quality) may favour pain reduction over rotatory or transverse mobilisations at immediate-term follow-up. For chronic CGH with temporomandibular joint (TMJ) dysfunction, multiple sessions of TMJ manual therapy (one trial, 38 participants, very low quality) may be more effective than cervical mobilisation in improving pain/function at immediate- and intermediate-term follow-up. For subacute and chronic neck pain, cervical mobilisation alone (four trials, 165 participants, ranged from low to very low quality) may not be different from ultrasound, TENS, acupuncture and massage in improving pain, function, QoL and participant satisfaction at immediate- and intermediate-term follow-up. Additionally, combining laser with manipulation may be superior to using manipulation or laser alone (one trial, 56 participants, very low quality).

AUTHORS' CONCLUSIONS

Although support can be found for use of thoracic manipulation versus control for neck pain, function and QoL, results for cervical manipulation and mobilisation versus control are few and diverse. Publication bias cannot be ruled out. Research designed to protect against various biases is needed. Findings suggest that manipulation and mobilisation present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up. Since the risk of rare but serious adverse events for manipulation exists, further high-quality research focusing on mobilisation and comparing mobilisation or manipulation versus other treatment options is needed to guide clinicians in their optimal treatment choices.