Original articleImmediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial☆
Introduction
Approximately 54% of individuals have experienced neck pain within the last six months (Cote et al., 1998, Cote et al., 2000), and the incidence appears to be rising (Nygren et al., 1995). The economic burden due to neck disorders is high, second only to low back pain in annual workers’ compensation costs in the United States (Wright et al., 1999). Patients with neck pain are frequently encountered in outpatient physical therapy practice, consisting of approximately 25% of all patients (Jette et al., 1994). Manual therapy interventions are one treatment strategy appropriate for patients with neck pain (American Physical Therapy Association, 2001). The Guide to Physical Therapist Practice (American Physical Therapy Association, 2001) uses the term “mobilization/manipulation” to refer to a “manual therapy technique comprising a continuum of skilled passive movements to the joints and/or related soft tissues that are applied at varying speeds and amplitudes, including a small-amplitude/high-velocity therapeutic movement.” To be more specific, the term “manipulation” in this paper refers specifically to techniques involving a high-velocity low-amplitude thrust, whereas mobilization refers to techniques performed as lower velocity, passive movements of a joint. Approximately 37% of therapists who routinely perform manual therapy interventions for patients with spinal disorders in their clinical practice perform manipulation and/or mobilization to the cervical spine in patients with neck pain (Hurley et al., 2002). The effectiveness of these interventions in patients with neck pain and cervicogenic headaches has been recently supported by an increasing number of high quality randomized clinical trials (RCT) (Bronfort et al., 2001b; Evans et al., 2002; Hoving et al., 2002; Jull et al., 2002), and systematic reviews (Bronfort et al., 2001a; Gross et al., 2002) suggesting both forms of manual therapy are effective.
The benefits of manual therapy interventions directed to the cervical spine must be considered in the context of the potential risks. The risk of serious complications such as vertebrobaslilar insufficiency (VBI) has been estimated to be extremely low (approximately six in 10 million; 0.00006%) (Hurwitz et al., 1996). However, studies to date have largely failed to substantiate the ability of currently available screening procedures to identify at-risk patients prior to treatment (DiFabio, 1999). Therefore, it has been suggested that cervical manipulation interventions be abandoned altogether (Bolton et al., 1989; Cote et al., 1996; DiFabio, 1999; Haldeman et al., 1999, Haldeman et al., 2002a, Haldeman et al., 2002b). In one survey of physical therapists in Canada, 88% of respondents strongly agreed that all available screening tests should be performed prior to cervical manipulation (Hurley et al., 2002), suggesting that therapists are indeed concerned about the risks. Therefore, some therapists may conclude the benefits achieved from manual therapy interventions directed to the cervical spine are not worth even the small risks associated with these interventions.
Clinical experts have suggested that a thorough examination of the thoracic spine be included in the evaluation of patients with primary complaints of neck pain (Porterfield and DeRosa, 1995; Greenman, 1996). Due to the biomechanical relationship between the cervical and thoracic spine, perhaps disturbances in joint mobility in the thoracic spine serve as an underlying contributor to the development of neck disorders. It has also been demonstrated that mobilization/manipulation of joints remote to the patient's pain results in an immediate hypoalgesic effect (Vicenzino et al., 1996, Vicenzino et al., 1998, Vicenzino et al., 2001; Paungmali et al., 2003). This is speculated to occur through the stimulation of descending inhibitory mechanisms (Vicenzino et al., 1998; Skyba et al., 2003). For these reasons it has been suggested that perhaps the incorporation of thoracic spine manipulation interventions in lieu of manipulation or mobilization interventions directed to the cervical spine may avoid even the small inherent risks associated with manual therapy interventions directed to the cervical spine, while achieving similar therapeutic benefits (Erhard and Piva, 2000).
Only scant evidence exists regarding the use of thoracic spine manipulation in patients with neck pain. Flynn and colleagues have reported preliminary data suggesting that thoracic spine manipulation results in an immediate reduction in pain and increases in cervical range of motion in individuals presenting with primary neck dysfunction (Flynn et al., 2004). However, the lack of a comparison group in this study precludes establishing that a cause-and-effect relationship exists. In addition, Parkin-Smith (Parkin-Smith and Penter, 1998) and colleagues demonstrated that thoracic manipulation in addition to cervical manipulation in patients with neck pain was no more advantageous than cervical manipulation alone. Therefore, the purpose of this study was to further investigate the immediate effects of thoracic manipulation on neck pain in a randomized clinical trial.
Section snippets
Methods
Potential participants were patients between 18 and 60 years of age with a primary complaint of mechanical neck pain referred by their primary care physician to an outpatient orthopaedic physical therapy clinic. Mechanical neck pain was defined as nonspecific pain in the area of the cervicothoracic junction that is exacerbated by neck movements (Bogduk, 1984; Childs et al., 2003). The study was approved by the Institutional Review Board at Franklin Pierce College (Rindge, NH) before recruitment
Results
Sixty-eight patients were screened for eligibility during a six-month period from January 2003 to June 2003. Sixteen patients (24%) did not satisfy the inclusion and exclusion criteria for the study. Sixteen eligible patients (31%) elected not to participate because of preferring not to receive manipulation interventions (n=11) or specifically requesting manipulation (n=5). The remaining 36 patients, mean age equal to 36 (SD=9.8) (27 female), were randomized to receive thoracic spine
Discussion
The results of this study suggest that thoracic spine manipulation in patients with a primary complaint of neck pain results in immediate improvements in their neck pain. Patients receiving thoracic spine manipulation demonstrated a mean change of 15.5 mm (95% CI: 11.8–19.2) on the VAS, compared to only a 4.2 mm (95% CI: 1.9–6.6) change among patients in the placebo group. Even if one presumes the lower bound of the 95% CI of 11.8 to be the point estimate for patients receiving thoracic spine
Conclusion
Thoracic spine manipulation results in immediate improvements in perceived levels of cervical pain in patients with mechanical neck pain. Given the concern regarding the risks of cervical spine manipulation, perhaps thoracic spine manipulation is a reasonable alternative, or supplement to, cervical manipulation and mobilization to maximize the patient's outcome at a reasonably low level of risk. This study was limited to an immediate follow-up and the patient's perceived levels of pain, thus
Disclaimer
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force or Department of Defense.
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Work should be attributed to the Physical Therapy Program, Franklin Pierce College, Concord, NH.